14 October 2021

Don’t prescribe steroids lightly: TSANZ

Asthma Clinical Respiratory

The Thoracic Society of Australia and New Zealand has released a position statement outlining how doctors can responsibly manage oral corticosteroid prescribing in asthma.

The paper, published in Respirology in September, brought together the latest evidence from Australian and international research showing that oral corticosteroids have damaging effects on patients long-term and should be used sparingly.

“We thought that it was a good time to publish this stewardship statement because more and more evidence is suggesting that the steroids use in asthma is clearly excessive,” Professor Philip Bardin, a respiratory physician and co-author of the paper, told The Medical Republic.

“Recent research has shown that if you take more than 1,000 milligrams, or one gram, of prednisolone over a lifetime, then the incidence of really nasty adverse events starts to build,” he said.

Chronic dependence on oral corticosteroids in asthma causes a range of serious side effects – including weight gain, osteoporosis, hypertension, glucose intolerance and increased risk of infections. These side effects can occur even at a lifetime cumulative dose as low as 500 milligrams.

Prednisone and prednisolone also cause short-term negative outcomes such as dyspepsia, insomnia, fluid retention and mood changes.

Australian patients with asthma who rely on oral corticosteroids are often not taking their preventer medication regularly, have poor inhaler technique or are continuing to smoke – all of which exacerbate their asthma, said Professor Bardin.

Australian research published in 2020 in the MJA (led by Professor Mark Hew, the head of allergy, asthma and clinical immunology at The Alfred) found that more than a quarter of patients prescribed oral corticosteroids were dispensed a cumulative dose more than 1000mg within five years. 

Half of the patients who were on high doses of prednisolone long-term had poor adherence with treatment based on evidence of infrequent dispensing of preventer medications.

The stewardship statement urges GPs to question why their patients need ongoing oral corticosteroids and to check inhaler technique or refer to a specialist to see whether a biologic might be a viable alternative.

Dr Russell Wiseman, a Queensland GP and the founder of the General Practitioner Asthma Group, said the issue of OCS side effects had been raised at respiratory conferences in the past few years. But we shouldn’t use this issue “as a stick to beat general practice”, he said.

While most oral corticosteroids were prescribed in general practice, most GPs were following the guidelines, he said.

The Australian Asthma Handbook currently recommends the use of oral prednisolone to treat severe exacerbations at 37.5–50mg per day for five to ten days and does not routinely recommend tapering doses except if treatment has continued for more than two weeks.

While GPs will check inhaler technique and refer to a specialist where needed, there wasn’t always an alternative to steroids for patients with severe asthma, he said.

“This idea that biologics are the answer is not exactly true,” said Dr Wiseman.

Only one of the four biologics on the market has “impressive data” for being able to get patients off oral steroids, he said. “The other three have got good data for decreasing exacerbations, and maybe getting people off OCS.”

Even if biologics do work for a particular patient with asthma, there is a long wait – six to 12 months to become eligible, he said.

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