With new guidelines for the treatment of moderate to severe asthma, experts noted a shift toward increasing caution in corticosteroid use.
"I think the shift from the guidelines and from all the data that we're accumulating over time is that minimizing oral corticosteroids or systemic corticosteroids is going to be a focus," said Jay Lieberman, MD, of the University of Tennessee Health Science Center in Memphis, who spoke as part of a panel discussing the upcoming guideline update at the American College of Allergy, Asthma & Immunology (ACAAI) meeting.
A network analysis by the joint ACAAI/American Academy of Allergy, Asthma & Immunology practice parameter task force comparing data across biologics for this patient population is also underway, but not yet ready, said panelist Giselle S. Mosnaim, MD, of Endeavor Health in Glenview, Illinois.
"The guidelines clearly are going to have recommendations to use the biologics in that frame -- reducing exacerbations," Lieberman told MedPage Today. "The question will be, as they develop more of the analysis, are there going to be certain scenarios where one biologic [gets preference] versus another or how to use those biologics a little more clearly. But definitely the goal will be to minimize oral corticosteroid use."
"We used to think, oh, you know, a couple steroid bursts a year, who cares? Like that's okay. But I think more and more data are saying every little bit matters and we really need to tighten the screws to try to minimize it as much as possible," he said.
John Oppenheimer, MD, of UMDNJ Rutgers University School of Medicine in Newark, New Jersey, presented the case on corticosteroid risks, which include increased appetite, mood swings, hyperglycemia, so-called moon face, reflux, osteoporosis, diabetes, cataracts, thinning of skin, adrenal suppression, and slower growth in children.
About a third of U.S. patients get a typically 5- to 7-day burst of steroids to treat acute exacerbation in a given year, Oppenheimer noted. "But it was only recently, in 2018, that we begin seeing literature that even intermittent bursts may have long-term side effects."
That systematic review of adverse events from systemic corticosteroids showed that a lifetime cumulative dose of 0.5 to 1.0 g of prednisolone equivalent, which represents three to four bursts, was linked to deleterious effects. A subsequent analysis of 11 U.K.-based cohorts subsequently showed very similar data: most oral corticosteroid-associated adverse events increased with 0.5 g or more over a lifetime.
"Together, these highlight the fact that oral corticosteroids contribute to burden, even intermittently used," Oppenheimer noted. "But despite the side effects, oral corticosteroids continue to be used in asthma management, largely because they're beneficial, they have efficacy, and we often don't think about the side effects."
His group's analysis of the evidence to inform the new guideline turned up clear evidence of risk from add-on systemic corticosteroid use compared with standard care alone but low or very low certainty that it may improve asthma control and asthma quality of life or reduce severe exacerbations. And compared to low-dose oral corticosteroid monotherapy, high-dose inhaled corticosteroid monotherapy had the same low or very low certainty of improving those outcomes.
The impact of more aggressive use of biologics and other maintenance therapies to better prevent some of these exacerbations and cut down on corticosteroid use could be huge, Lieberman said. "If you look at the studies for biologics, patients typically were required to get enrolled into the study to have at least two bursts in the year prior. So two per year in that patient population, that moderate to severe asthma group that we're talking about ... And you're not talking lifetime, you're talking year."
In addition, patients place a high value on preventing severe exacerbations and avoiding adverse events, although the evidence is moderate on the latter, Flavia Hoyte, MD, of National Jewish Health in Denver, noted at the session, pointing to the recently published data from their systematic review.
The data reviews on systemic corticosteroids and biologics will be published in the next few months. The joint task force is starting this week on formulating the final recommendations for the new guidelines.
Disclosures
Lieberman disclosed no relevant relationships with industry.
Oppenheimer reported relationships with GSK, Aquestive, AstraZeneca/Amgen, Chiesi, DBV, ARS, Teva, Novartis, Sanofi, AbbVie, the Annals of Allergy, Asthma and Immunology, UpToDate, and WebMD.
Hoyte reported relationships with AstraZeneca, Genentech, GSK, Sanofi, and Teva. She has family members who own stock in Amgen.
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