OCS in severe asthma care: Time to end over-reliance

WRITTEN BY

Professor Andrew Menzies-Gow

This article is authored by Professor Andrew Menzies-Gow, Consultant in Respiratory Medicine and Director of the Lung Division at Royal Brompton Hospital, Deputy Medical Director of the Royal Brompton and Harefield NHS Trust and Professor of Practice in Respiratory Medicine at Imperial College, London

In my role, running one of the largest severe asthma clinics in the UK, I’m all too familiar with the complicated relationship many people with severe asthma have with oral corticosteroids (OCS).

OCS are an effective treatment for acute asthma attacks and improve symptom control, however, they also have significant acute and long-term side effects.1-4 As a consequence, chronic and cumulative OCS exposure should be minimised whenever possible. Invariably, when my patients first come to see me their number one concern is their OCS use, and their number one question is – “How can I get off these medicines?”

The time has come to fundamentally change the role of OCS in severe asthma care.

Oral corticosteroids have been the mainstay of severe asthma treatment for over 60 years5

Severe asthma is a heterogenous and complex disease, with multiple underlying drivers.6,7 34 million people are affected worldwide,1,8 experiencing frequent exacerbations and significant limitations on their lung function and quality of life.1-4

For over 60 years we have relied on OCS as a mainstay of severe asthma treatment to help people manage their exacerbations.5 More than 13.5 million people worldwide with severe asthma currently rely on OCS to control exacerbations and prevent hospitalisations.1-3,9 This cumulative, long-term use of OCS is associated with debilitating side effects for patients and can place further burden on their quality of life.2,3,10 Chronic OCS use carries the potential for serious health risks, including diabetes, osteoporosis and heart disease.4,11,12 In fact, potential OCS-induced morbidities have been identified in 93 percent of people with severe asthma.11

OCS reduction in other disease areas gives us hope to replicate this success in severe asthma

In other disease areas we have seen a recent decline in the use of OCS, for example rheumatology, in which they were once the commonplace standard of care.5,13 For decades, steroids were used to help control symptoms for people with rheumatoid arthritis. 5,13 Now with earlier diagnosis, alongside the advent of novel treatments, rheumatologists have been able to revolutionise patient care and substantially reduce OCS use. 5,13

We must embrace learnings from other disease areas like rheumatology where clinicians have found success in reducing OCS use.5,13 When coupled with clear evidence on how to safely, effectively achieve this in severe asthma, we have the potential to dramatically change patient outcomes for the better.

Embracing evidence to inform guideline changes and adoption of OCS-sparing strategies

A growing body of evidence is emerging that could further inform guidelines to drive greater adoption of OCS-sparing strategies and enable physicians to safely and effectively taper their patients from OCS.14,15 This presents an important opportunity for those of us in the respiratory community to collaborate to ensure both physicians and patients understand the risks of OCS and why change is needed.

The medical community must embrace emerging evidence and put it into practice as quickly, but responsibly, as possible. As new, targeted therapies continue to emerge, alongside evidence supporting safe OCS-sparing strategies, I’m incredibly hopeful that we can achieve an improved approach to severe asthma treatment, which truly relegates OCS use to last resort.

Learn more about this important issue on the recently launched A Complicated Relationship: OCS and Asthma Care campaign, including a roadmap for improving care in severe asthma and the key responsibilities physicians hold alongside policy makers, clinical leaders, patient advocates and industry to ensure severe asthma patients are no longer reliant on OCS.




References

1. Wenzel S. Severe Asthma in Adults. Am J Respir Crit Care Med. 2005;172(2);149-60.

2. Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014;43:343-73. 

3. Peters SP, Ferguson G, Deniz Y, et al. Uncontrolled asthma: a review of the prevalence, disease burden and options for treatment. Respir Med. 2006:100 (7):1139-51. 

4. Sullivan PW, et al. Oral corticosteroid exposure and adverse effects in asthmatic patients. Journal of Allergy and Clinical Immunology. 2017;141(1):110–6.e7.

5. Chung LP, et al. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology. 2020;25:161-72. 

6. Borish L, Culp JA. Asthma: a syndrome composed of heterogeneous diseases. Ann Allergy Asthma Immunol. 2008;101(1):1-8.

7. Carr, TF. Bleecker, E. Asthma heterogeneity and severity. World Allergy Organ J. 2016;9:41.

8. The Global Asthma Network. The Global Asthma Report 2018. Available at: http://www.globalasthmareport.org/. [Last accessed: October 2020].

9. Voorham J, Xu X, Price D, Golam S, Davis J, et al. Health care resource utilization and costs associated with incremental systemic corticosteroid exposure in asthma. Allergy. 2019, 74;273-283.

10. Fernandes AG, Souza-Machado C, Coelho RC, et al. Risk factors for death in patients with severe asthma. J Bras Pneumol. 2014; 40 (4): 364-372.

11. Sweeney J, Patterson CC, Menzies-Gow A, et al. Comorbidity in severe asthma requiring systemic corticosteroid therapy: cross-sectional data from the Optimum Patient Care Research Database and the British Thoracic Difficult Asthma Registry. Thorax. 2016; 71 (4): 339-346.

12. Hyland ME, Whalley B, Jones RC, et al. A qualitative study of the impact of severe asthma and its treatment showing that treatment burden is neglected in existing asthma assessment.Quality of Life Research. 2015; 24 (3) 631-619.

13. Menzies-Gow A, Canonica G, Winders TA. et al. A Charter to Improve Patient Care in Severe Asthma. Adv Ther. 2018;35:1485-9.

14. Menzies-Gow A, Corren J, Bel E, et al. Oral Corticosteroid Tapering During Benralizumab Treatment of Severe, Uncontrolled Eosinophilic Asthma: PONENTE Phase IIIb Clinical Trial. Presented at the American Thoracic Society (ATS) International conference, 17-22 May 2019, Dallas, Texas. 

15. Clinicaltrials.gov. Study to Evaluate Efficacy and Safety of Benralizumab in Reducing Oral Corticosteroid Use in Adult Patients with Severe Asthma (PONENTE). Available at: https://clinicaltrials.gov/ct2/show/NCT03557307. [Last accessed: October 2020].

 

Veeva ID: Z4-28124
Date of Preparation: October 2020