Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study

Adverse consequences of systemic corticosteroids use among a broad population of US adults with asthma: a real-world analysis

AIMS

Systemic corticosteroids (SCS) are used to manage asthma exacerbations. Among the broad population of patients with asthma, SCS-related risk of adverse events (AEs), health care resource utilization (HCRU), and costs remain unclear.

MATERIALS AND METHODS

This retrospective cohort study used the Optum Research Database claims to identify adults with asthma from 1/1/2017 to 6/30/2022. The index date was the earliest SCS claim for SCS users; non-SCS users were randomly selected and adjusted proportionally to SCS users by index year. SCS use was measured during the first 12 months of follow-up. Inverse probability of treatment weighting balanced the two cohorts for selected baseline demographic and clinical characteristics. SCS users were further stratified into low, medium, and high dose sub-cohorts. SCS-related AEs were assessed up to 48 months, while HCRU and costs were assessed during the first 12 months of follow-up. A generalized linear model (GLM) analyzed follow-up costs by SCS exposure.

RESULTS

The 130,739 patients included 55,363 non-SCS users (42.3%), while 75,376 were SCS users stratified into 60,319 low-, 12,235 medium-, and 2,822 high-dose users. The mean age was 49.6 years; 61.8% were female and 68.9% were non-Hispanic White. SCS users had a significantly greater risk of new-onset acute and chronic SCS-related AEs, increasing incrementally with dose exposure (all p < .001) across numerous physiological systems. Follow-up HCRU and costs also rose incrementally with dose exposure (all p < .001). Compared with non-users, SCS-related costs were 1.43, 1.97, and 3.21 times higher among low-, medium-, and high-dose users, respectively. The adjusted GLM predicted a 9.9% cost increase per 100 mg of prednisone equivalents.

LIMITATIONS

Retrospective administrative claims studies cannot randomize patients and may not capture all patient events.

CONCLUSIONS

Among a broad population of adults with asthma, even low doses of SCS were associated with significantly increased risk of new-onset AEs, HCRU, and costs.

Efficacy and safety of phytotherapy and anthroposophic medicine in bronchial asthma: A systematic review

BACKGROUND

Bronchial asthma is a highly prevalent health condition associated with low quality of life and high economic costs. Treatments from traditional, complementary and integrative medicine (TCIM) are commonly used by individuals with bronchial asthma. However, a synthesis of the evidence on plant-derived medications is lacking.

OBJECTIVE

This review aims to systematically summarize the evidence on the efficacy, effectiveness and safety of European/Western phytotherapy (PT) and medications from anthroposophic medicine (AM) in individuals with bronchial asthma.

METHODS

Four electronic databases and additional references were screened for clinical trials published between 1990 and 2023. The findings of the included studies were qualitatively synthesized and study quality was assessed.

RESULTS

Of 23 included studies, 19 examined European/Western PT and four investigated AM medications. Nine studies of sufficient quality reported beneficial effects of various plants (e.g., Nigella sativa) on asthma symptoms, pulmonary function and immunological parameters. The medications were considered safe in studies that reported on safety.

CONCLUSION

This systematic review suggests several medications from European/Western PT and AM that may be beneficial and appear to be safe in the treatment of bronchial asthma. However, further rigorous studies are needed to provide evidence-based guidance on add-on treatment options for individuals with bronchial asthma.

Real-world mepolizumab treatment in patients with severe asthma decreased exacerbations, oral corticosteroid use, and healthcare resource utilization and costs over 4 years: a retrospective analysis

OBJECTIVE

Although the efficacy of mepolizumab in reducing exacerbations and oral corticosteroid (OCS) use in severe asthma is well-established, real-world long-term effectiveness data are limited. This study evaluated the real-world impact of mepolizumab treatment in patients with severe asthma over a 4-year follow-up period.

METHODS

This was a retrospective cohort study of patients with asthma initiating mepolizumab (index date: first claim, November 2015-September 2019) using the Merative MarketScan Commercial and Medicare Databases. Outcomes included asthma exacerbations, OCS use, and exacerbation-related healthcare resource utilization (HCRU) and costs, assessed 12-months pre-index (baseline) and annually during the 4-year follow-up period.

RESULTS

Among 189 eligible patients, mean asthma exacerbation rate (AER) declined progressively from baseline during follow-up: AER decreased by 53.8% at Year 1 and 73.8% by Year 4 (p < 0.001). The annual OCS prescription rate reduced from baseline by 41.1% at Year 1 and 62.2% at Year 4 (p < 0.001). The proportion of patients with both no exacerbations and no OCS use progressively increased from 6.4% at baseline to 18.5% at Year 1 and 41.8% at Year 4. Exacerbation-related HCRU including inpatient, emergency room, and outpatient office visits decreased from baseline (9.0%, 21.7%, and 78.8%, respectively), at Year 1 (3.2%, 12.2%, and 49.2%), and Year 4 (0.0%, 4.8%, and 31.8%). Exacerbation-related healthcare costs declined from $4,635 at baseline to $1,487 at Year 1 and $217 at Year 4 (p < 0.001).

CONCLUSION

Patients treated with mepolizumab demonstrated progressive and sustained long-term, real-world reductions in exacerbation frequency, OCS dependency, and exacerbation-related HCRU and costs over 4 years.

Corticosteroid Use in Randomized Clinical Trials of Biologics and Small Molecules in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND AND AIMS

This systematic review aims to elucidate the use of corticosteroids in randomized clinical trials (RCTs) evaluating biologics and small molecules for inflammatory bowel disease (IBD). We analyzed corticosteroid use during both the induction and maintenance phases, highlighting areas needing standardization and improvement in clinical research.

METHODS

We selected placebo-controlled phase 3 RCTs involving adults with moderate to severe IBD. These studies included detailed reports on corticosteroid use during induction and maintenance phases, with clinical remission and/or corticosteroid-free clinical remission (CSF-CR) as primary endpoints.

RESULTS

Initially, 324 studies were identified and refined to 26 RCTs after screening. Analysis revealed variability in corticosteroid administration. Over time, corticosteroid use showed a decreasing trend (Spearman ρ = -0.42, P = .045). Studies allowing higher corticosteroid doses (up to 40 mg/day of prednisone or equivalent) reported a higher proportion of corticosteroid users (51.8%, range: 42.9%-61%) compared to those excluding patients on doses >20 mg/day (37.5%, range: 31.6%-51.8%; P = .007) or >30 mg/day (41.1%, range: 29.6%-53.7%; P = .023). Trials with mandatory tapering protocols showed a narrower gap between overall clinical remission and CSF-CR rates, with an average difference of 6% in the group without mandatory tapering and 1.2% in the group with forced tapering (T-test P = .038; Cohen's d ≈ 1.1).

CONCLUSIONS

This review highlights the variability in corticosteroid use across RCTs and its impact on evaluating new IBD therapies. Standardizing tapering protocols and defining CSF-CR are essential for accurate outcomes.

Clinical Characteristics of Difficult-To-Treat Allergic Bronchopulmonary Aspergillosis and Its Prediction Score

BACKGROUND AND OBJECTIVE

Administration of oral corticosteroids and/or azole antifungals for 4-6 months remains the standard treatment for allergic bronchopulmonary aspergillosis (ABPA). This study investigated the clinical characteristics of patients with difficult-to-treat ABPA who failed to achieve clinical remission within 6 months.

METHODS

Among the participants of a nationwide survey conducted in Japan in 2020, treatment-naïve patients with ABPA who satisfied Asano's criteria were enrolled in this study. Clinical remission was defined as stable disease without exacerbation for ≥ 6 months under minimal treatment (oral prednisolone: ≤ 5 mg/day and no antifungal medication). A risk prediction score for difficult-to-treat ABPA was developed and validated in an independent cohort comprising patients with ABPA from a prospective registration study in Japan.

RESULTS

In total, 316 treatment-naïve patients with ABPA were enrolled in the study. The median time to minimal treatment status was 4.8 months in the group receiving standard treatment. The clinical remission rate at 6 months after standard treatment was 51%. Age ≤ 50 years at onset of ABPA (p = 0.04), serum A. fumigatus-specific IgE titer of ≥ 20 UA/mL (p = 0.006), positive culture for Aspergillus spp. in the sputum/bronchial lavage fluid (p = 0.05), and presence of high attenuation mucus (HAM; p = 0.10) were associated with difficult-to-treat ABPA. The number of positive indicators indicated the risk of failure of standard treatment to yield clinical remission within 6 months in the derivation (n = 87, p < 0.001) and validation (n = 64, p = 0.009) cohorts.

CONCLUSION

Multiple components, including age at onset, allergic sensitization, airway fungal burden, and HAM, were associated with difficult-to-treat ABPA.

Burden of asthma by severity and exacerbation frequency among adult patients naive to biologic asthma therapy: A Finnish cohort study

Background

Understanding the disease burden and characteristics of asthmatic patients with frequent exacerbations is important for optimal disease management and outcomes. Asthma, and especially severe uncontrolled asthma, associates with an increased disease burden, but the comparison across asthma severity and exacerbation frequency is largely missing.

Objective

We sought to assess the association of asthma severity and exacerbation frequency with medication use, mortality, sick leaves, disability pensions, health care contacts, and comorbidities among Finnish patients with asthma.

Methods

National longitudinal retrospective data on adult patients naive to biologic asthma therapy were used to match patients on the basis of age, sex, and region across 4 subgroups (5525 patients in each) of nonsevere or severe asthma with infrequent or frequent exacerbations. The clinical characteristics, mortality rates, and morbidity across the subgroups were analyzed.

Results

Exacerbation frequency associated with an increased disease burden regardless of asthma severity. Comorbidities, health care contacts, sick leaves, and disability pensions cumulated in patients with frequent exacerbations, peaking with severe asthma. In patients with severe asthma and frequent exacerbations, the all-cause mortality rate ratio was 1.9-fold (P < .001) versus patients with nonsevere asthma and infrequent exacerbations. Patients with frequent exacerbations were also exposed to high cumulative corticosteroid doses.

Conclusions

Despite improved outcomes in asthma over the past decades, a substantial proportion of patients experience frequent exacerbations. These patients are multimorbid and at increased risk of mortality. Exacerbation frequency, rather than asthma severity, seems to be the main factor associated with an increased disease burden. Clinical awareness should be raised to improve the management and outcomes for these patients.

Recent evidence for stepping down severe asthma therapies

PURPOSE OF REVIEW

Biologics have proven safe and effective for severe asthma. Their introduction has offered hope for patients and prescribers with a growing list of novel medications and indications. While 'step-up' indications for biologic initiation are well described in guidelines, 'step-down' strategy remains poorly understood and thus guidance is limited. In this opinion article we aim to focus on recent practice changing evidence for stepping-down severe asthma management, tools for the assessment of biologic efficacy, propose a framework for the step-down of biologic and nonbiologic therapies and suggest topics of interest for future research.

RECENT FINDINGS

Clinical tools have been developed to aid in assessing biologic response. Some patients experience marked improvement and may enter a period of clinical remission or even complete remission. Following positive response, add-on therapy may safely be approached for taper or withdrawal.

SUMMARY

There is limited consensus but growing evidence for stepping-down therapies in patients who achieve clinical response and/or remission after biologic initiation. Further structured guidance would benefit clinicians who face clinical uncertainty when deciding to step-down therapy in patients with well controlled asthma.

Eosinophilic granulomatosis with polyangiitis: Patient profiles from a large US allergy practice

Background

Data on the presentation and management of patients with eosinophilic granulomatosis with polyangiitis (EGPA) in private practice are limited.

Objective

We sought to characterize the profiles and disease burden of patients with EGPA in a real-world private practice setting.

Methods

This was a retrospective, noninterventional, longitudinal study (GSK ID: 217426) of US Allergy Partners network data. For patients with a diagnosis of EGPA, confirmed by 2 or more EGPA clinical features, index was defined as their first visit with an Allergy Partners physician (January 2007-June 2021); postindex lasted until loss of follow-up or study end (December 2021). Patient characteristics at index, physician characteristics at any time, symptoms, treatment characteristics, and clinical outcomes postindex were assessed.

Results

Of 52 patients (median follow-up, 3.7 years), 75% were diagnosed with EGPA outside the Allergy Partners network. Each patient received care from a median (Q1-Q3) of 4.0 (3.0-5.0) physician specialties. Most had asthma (92%), rhinitis (75%), and sinusitis (62%) and experienced a mean ± SD of 18.1 ± 4.3 distinct self-reported symptoms. Most (85%) used oral corticosteroids, with 73% (32 of 44) on daily doses of more than 12 mg; 60% used mepolizumab. Overall, 75% of patients (39 of 52) achieved a response (improved/controlled symptoms); 46% (24 of 52) achieved controlled status after worsened, unchanged, or active symptoms, and of these 38% (9 of 24) relapsed.

Conclusions

The complex private practice presentation of EGPA, with heterogeneous patient response to standard treatments, highlights a significant disease burden and continued need for optimized treatment strategies within a multidisciplinary team approach.

Exacerbation burden in patients treated as intermittent or mild-persistent asthma using short-acting β2-agonist rescue

BACKGROUND

Most people in the United States with asthma use therapies for intermittent/mild-persistent disease; however, exacerbations and death occur in patients with infrequent symptoms or labeled as mild asthma.

OBJECTIVE

To evaluate relationships between short-acting β2-agonist (SABA) use, exacerbations, and maintenance adherence in intermittent/mild-persistent asthma.

METHODS

Retrospective cohort study using US Merative MarketScan administrative claims (January 2010 to December 2017) for patients aged 12 years or older treated as intermittent/mild-persistent asthma. Patients were indexed on a random SABA claim, with 12 months continuous enrollment pre- and post-index. Post-index SABA groups were defined as low (index fill only), medium (2-3 fills), and high (≥4 fills). Severe exacerbations were compared within the treatment, SABA fill, and adherence (medication possession ratio) groups through unadjusted comparison of proportions, χ2, and odds ratios (OR [95% CI]); P less than or equal to .05.

RESULTS

A total of 533,679 patients were included: 68.1% female; mean age (SD) 34.6 (18.3) years; 70.0% intermittent (SABA only) and 30.0% mild-persistent (8.6% low-dose inhaled corticosteroid [ICS]; 21.4% leukotriene modifier [LM]). The proportion of patients with high SABA fills differed among the treatments: SABA only (14.8%), low-dose ICS (37.0%), and LM (25.5%) (P < .001). The proportion experiencing 1 or more exacerbations was higher in SABA only (61.2%) vs low-dose ICS (40.4%) or LM (50.4%): OR (95% CI) 2.32 (2.28-2.37) and 1.55 (1.53-1.57), respectively (both P < .001). The medication possession ratio was less than 50% in 59.3% of patients with mild-persistent asthma; however, adherence was only related to exacerbations in the high SABA group.

CONCLUSION

Patients treated as intermittent/mild-persistent asthma rely on SABA and experience exacerbations. Shifting from SABA only to an anti-inflammatory rescue therapy could decrease morbidity.

Impact of Biologics Initiation on Oral Corticosteroid Use in the International Severe Asthma Registry and the Optimum Patient Care Research Database: A Pooled Analysis of Real-World Data

BACKGROUND

For severe asthma (SA) management, real-world evidence on the effects of biologic therapies in reducing the burden of oral corticosteroid (OCS) use is limited.

OBJECTIVE

To estimate the efficacy of biologic initiation on total OCS (TOCS) exposure in patients with SA from real-world specialist and primary care settings.

METHODS

From the International Severe Asthma Registry (ISAR, specialist care) and the Optimum Patient Care Research Database (OPCRD, primary care, United Kingdom), adult biologic initiators were identified and propensity score-matched with non-initiators (ISAR, 1:1; OPCRD, 1:2). The impact of biologic initiation on TOCS (including bursts for exacerbations) daily dose in the first- and second-year follow-up period was estimated using multivariable generalized linear models.

RESULTS

Among 5,663 patients (ISAR 48%, OPCRD 52%), the odds ratios (ORs) of biologic initiators achieving TOCS cessation in the first and second years of follow-up were 2.38 (95% CI, 1.87-3.04) and 2.11 (95% CI, 1.65-2.70), whereas the ORs of low (0- to 5-mg) TOCS intake were 1.62 (95% CI, 1.40-1.86) and 1.40 (95% CI, 1.21-1.61), respectively. Compared with non-initiators, biologic initiators had a substantially higher chance of achieving greater than 75% reduction from baseline (OR [95% CI] = 2.35 [2.06-2.68] and 1.53 [1.35-1.73] in first and second years, respectively). These findings remained persistent and robust when analyses were repeated with one country setting removed at a time.

CONCLUSIONS

Biologic initiation in patients with SA led to substantial reduction in TOCS exposure, particularly in the first year. Future analyses will explore the impact on OCS-related adverse health events.

Asthma in the Biologics Era: Should Oral Corticosteroid Therapy Be Relegated to History?

Oral corticosteroids (OCS) have been used for both maintenance and burst treatment of asthma since the 1950s owing to their beneficial effect on symptoms and exacerbations coupled with a historical lack of alternative therapies. Despite the current availability of well-tolerated and effective treatment with biologics, chronic OCS use remains high. This is of great concern because evidence suggests that a lifetime cumulative exposure even as low as 0.5 to 1.0 g prednisolone equivalent (about three to four bursts of OCS) significantly increases the risk of a wide range of acute and long-term adverse effects, some of which may not be fully reversible. Conversely, biologics have demonstrated a more favorable benefit-risk profile compared with OCS, while reducing exacerbations and improving symptom control. Here, we review the current situation, highlight the need for improved stewardship of OCS use, describe the cumulative and potentially irreversible toxicity seen with even short bursts of OCS, and discuss the role of biologics in minimizing their use. Finally, we provide our opinion on how maintenance OCS therapy in asthma can be relegated to history, with early patient risk evaluation to identify and measure biomarkers and/or clinical traits that may predict risk of future exacerbations, enabling proactive preventative intervention.

Assessment of an Oral Corticosteroid Withdrawal Pathway for Severe Asthma Patients Receiving Biologic Therapies

BACKGROUND

The optimal approach to weaning maintenance oral corticosteroids (mOCS) in patients with severe asthma receiving biologics remains unclear. Previous studies assessed hypothalamic-pituitary-adrenal function at 5 mg daily prednisolone, a supraphysiologic dose for many, necessitating further mOCS reduction for adrenal recovery.

OBJECTIVE

We evaluated a protocol-driven, nurse-led mOCS withdrawal pathway with clinical oversight for patients with severe asthma receiving biologics.

METHODS

Patients with severe asthma receiving biologics, who had reduced mOCS to 5 mg prednisolone daily and maintained good asthma control, entered the withdrawal pathway. Prednisolone was decreased to 4 mg daily for 6 weeks and then 3 mg daily for 6 weeks, followed by 09.00 serum cortisol measurement. Patients with cortisol greater than 25 nmol/L followed a 20-week weaning protocol. Serum cortisol was rechecked 12 weeks after stopping mOCS.

RESULTS

Of 102 patients, 92 had cortisol greater than 25 nmol/L with 3 mg prednisolone and continued weaning. A total of 73 (72%) successfully discontinued mOCS with median (interquartile range) cortisol increasing from 192 (88-299) nmol/L with 3 mg prednisolone to 314 (248-437) nmol/L at 12 weeks after discontinuation (P < .0001). Twenty-nine patients (28%) paused weaning owing to adrenal insufficiency symptoms (n = 22), worse asthma control (n = 1), anxiety (n = 2), and other reasons (n = 4). The baseline cortisol in this group was 53 (25-166) nmol/L, and patients are currently well and receiving a median of 3.0 (3.0-3.9) mg prednisolone. Duration of prior oral corticosteroid use was significantly shorter in the group that was successfully weaned compared with those who failed weaning (P = 0.003). No serious adverse events occurred.

CONCLUSION

Most clinically stable patients with asthma receiving biologics successfully withdrew mOCS without requiring dynamic adrenal function testing.

Health care-seeking behaviors for acute asthma: A US cross-sectional survey

BACKGROUND

Understanding patient motivations for acute care-seeking behavior for asthma attacks could guide interventions to improve outcomes and mitigate health care resource use.

OBJECTIVE

To characterize health care-seeking behaviors and motivations of patients in the United States who obtain care for an asthma attack in urgent care (UC), emergency department (ED), or hospital settings.

METHODS

A cross-sectional survey was conducted online between July and August 2023 among adults in a market research panel treated for asthma in the past 12 months and who had experienced an asthma attack that required care in an UC, ED, or hospital or an oral corticosteroid prescription.

RESULTS

Of the 504 survey participants (female = 72%; White = 79%; Hispanic = 12%), 68% self-reported asthma of moderate severity and 72% had uncontrolled asthma. Oral corticosteroids were prescribed an average of 4.2 times in the past year. During their last asthma attack, 37% of participants took medicines at home, 20% went to UC, 15% went to the ED, and 5% were hospitalized. Participants who were younger, Asian, Hispanic, or with severe asthma were the most likely to go to the ED. Using a rescue inhaler was the most common action taken when first experiencing symptoms (72%). When participants considered seeking acute care, the severity of asthma symptoms was the most common factor considered (76%), followed by fast access to help (29%) and medication access (28%).

CONCLUSION

Most patients seeking acute asthma care reported moderately severe, uncontrolled disease. Seeking acute care seems to be motivated by symptom severity and the need for fast access to care after trying rescue medications. It would be of interest in a future study to also evaluate the acute care-seeking needs of patients who are at lower risk of seeking acute care.

Physical exercise, systemic inflammation and adult-onset asthma: a 12-year follow-up study

Objective: Physical exercise in treatment of asthma is scarcely studied with no clear exercise guidelines for asthmatics. We aimed to investigate the associations between physical exercise frequency, systemic inflammation and asthma control. This has not been previously studied in adult-onset asthma.

Methods: This study is part of Seinäjoki Adult Asthma Study (SAAS), where 203 patients with adult-onset asthma were evaluated in 2012-2013. Exercise frequency was recorded with a structured lifestyle questionnaire. Study population was divided into two categories by exercise frequency: Low-frequency group exercised ≤2 times/week and high frequency group >2 times/week. Blood inflammatory markers were measured and IL-6 > 1.55 pg/ml and hs-CRP > 4.12 mg/l indicated systemic inflammation.

Results: High-exercise frequency group had lower levels of hs-CRP (p = 0.007), IL-6 (p = 0.015), suPAR (p = 0.008) and adipsin (p = 0.031) and higher levels of adiponectin (p = 0.010) than low-exercise frequency group. In logistic multivariate regression models, higher-exercise frequency lowered odds for elevated hs-CRP (OR = 0.37, 95% CI 0.15-0.94) and IL-6 levels (OR = 0.43, 95% CI 0.20-0.91), after adjusting for possible confounding factors. There was no difference in lung function tests, asthma control test or airways questionnaire 20 scores between the exercise frequency groups. However, differences were found in single symptom questions; high-exercise frequency group had less symptoms during light housework and laughing but experienced more limitation of activity in self-reports.

Conclusions: Higher-exercise frequency is associated with lower level of systemic inflammation in patients with adult-onset asthma but no clear association was found to asthma outcomes. Exercise frequency may be associated with lesser amount of some individual asthma symptoms.

International Severe Asthma Registry (ISAR): 2017-2024 Status and Progress Update

The International Severe Asthma Registry (ISAR) was established in 2017 to advance the understanding of severe asthma and its management, thereby improving patient care worldwide. As the first global registry for adults with severe asthma, ISAR enabled individual registries to standardize and pool their data, creating a comprehensive, harmonized dataset with sufficient statistical power to address key research questions and knowledge gaps. Today, ISAR is the largest repository of real-world data on severe asthma, curating data on nearly 35,000 patients from 28 countries worldwide, and has become a leading contributor to severe asthma research. Research using ISAR data has provided valuable insights on the characteristics of severe asthma, its burdens and risk factors, real-world treatment effectiveness, and barriers to specialist care, which are collectively informing improved asthma management. Besides changing clinical thinking via research, ISAR aims to advance real-world practice through initiatives that improve registry data quality and severe asthma care. In 2024, ISAR refined essential research variables to enhance data quality and launched a web-based data acquisition and reporting system (QISAR), which integrates data collection with clinical consultations and enables longitudinal data tracking at patient, center, and population levels. Quality improvement priorities include collecting standardized data during consultations and tracking and optimizing patient journeys via QISAR and integrating primary/secondary care pathways to expedite specialist severe asthma management and facilitate clinical trial recruitment. ISAR envisions a future in which timely specialist referral and initiation of biologic therapy can obviate long-term systemic corticosteroid use and enable more patients to achieve remission.

What We Know to Date About Early Treatment With Biologics in Severe Asthma: A Scoping Review About the Use of Biologics in Severe Asthma and Possible Parallels With Early Rheumatoid Arthritis

Introduction

Theoretically, an early intervention with biologics in severe asthma (SA) patients may attenuate inflammatory processes and potentially halt disease progression and remodeling. Changing the approach to a more preventive one could alter the course of the disease, avoid its progression, and improve the likelihood of achieving clinical remission. The aims of this study were to gather scientific evidence on this topic, to draw a parallel between SA and rheumathoid arthritis (RA) and to analyze the potential benefits of establishing early treatment in SA.

Material and methods

A systematic scoping review, conducted in accordance with the methodological guidance of the Arksey and O'Malley framework and focusing on early treatment intervention with biological drugs in SA and RA is presented.

Results

Evidence supports the early intervention with biologics in RA to improve outcomes. Evidence regarding early intervention with biologics in SA is scarce. To date, the literature reviewed suggests that better clinical condition of the patient and more preserved lung function at the onset of biological treatment, together with a shorter duration of asthma, are associated with better response to biologics.

Conclusions

Data suggests that the more preventive approach may lead to improved results. The scarcity of scientific evidence highlights the importance of pursuing this line of research.

Multifunctional Boron-based 2D Nanoplatforms Ameliorate Severe Respiratory Inflammation by Targeting Multiple Inflammatory Mediators

Effective management of serious respiratory diseases, such as asthma and recalcitrant rhinitis, remains a global challenge. Here, it is shown that induced sputum supernatants (ISS) from patients with asthma contain higher levels of cell-free DNA (cfDNA) compared to that of healthy volunteers. Although cfDNA scavenging strategies have been developed for inflammation modulation in previous studies, this fall short in clinical settings due to the excessive neutrophil extracellular trap (NET) formation, reactive oxygen and nitrogen species (RONS) and bacterial infections in injured airway tissues. Based on this, a multifunctional boron-based 2D nanoplatform B-PM is designed by coating boron nanosheets (B-NS) with polyamidoamine generation 1 (PG1) dendrimer, which can simultaneously target cfDNA, NETs, RONS, and bacteria. The effects of B-PM in promoting mucosal repair, reducing airway inflammation, and mucus production have been demonstrated in model mice, and the therapeutic effect is superior to dexamethasone. Furthermore, flow cytometry with clustering analysis and transcriptome analysis with RNA-sequencing are adopted to comprehensively evaluate the in vivo anti-inflammation therapeutic effects. These findings emphasize the significance of a multi-targeting strategy to modulate dysregulated inflammation and highlight multifunctional boron-based 2D nanoplatforms for the amelioration of respiratory inflammatory diseases.

Predicting Risk of Morbidities Associated with Oral Corticosteroid Prescription for Asthma

Background

Oral corticosteroids (OCS) are commonly used to treat asthma but increase the risks for multiple morbidities; reducing OCS exposure may benefit patients. We analysed independent risk factors and longitudinal changes in OCS usage among patients with asthma to predict future risks of OCS-related adverse outcomes.

Methods

Optimum Patient Care Research Database United Kingdom primary care electronic medical records (EMR) from January 1990 to June 2021 were used to select adults (18-93 years) with asthma who had follow-up data from ≥2 years before to ≥3 years after an index visit for active symptoms; this date was defined by the largest pre-visit to post-visit change in mean annual OCS use. OCS usage during every follow-up year was categorised as none, low (mean <2 prescriptions/year), or high (mean ≥2 prescriptions/year). Pre-index to post-index changes between usage categories were calculated. Risk modelling selected cohorts without 17 morbidities (documented pre-index) reported to be associated with OCS exposure, including type 2 diabetes, osteoporosis, hypertension, and pneumonia. Cox regression analyses selected published risk factors associated with each condition and available in EMR for inclusion in proportional hazards models.

Results

The pre-index to post-index OCS usage category remained unchanged in 38.6% of patients, increased in 39.2%, and decreased in 22.2%, with 20.7% having no further OCS prescriptions. In models, the risks of all adverse outcomes increased with projected categoric OCS use; for example, hazard ratios for a one-category increment (none to low, low to high) were 1.55 (1.42-1.69) for type 2 diabetes, 1.56 (1.36-1.78) for post-menopausal osteoporosis, 1.05 (1.00-1.10) for hypertension, and 1.67 (1.52-1.83) for pneumonia (all p < 0.001).

Conclusion

OCS exposure in this primary care asthma population usually continued longitudinally. Our models predict increased risk of multiple morbidities with higher projected OCS exposure. These findings support early initiation of strategies to minimise OCS use in asthma.

Real-World Biologic Use Patterns in Severe Asthma, 2015-2021: The CLEAR Study

Background

Biologics targeting immunoglobulin E, interleukin (IL)-4/IL-13 or IL-5 signaling are effective at treating severe asthma; however, individual patients' responses may be suboptimal, leading to therapy switching or stopping. The CLEAR study aimed to assess real-world biologic use patterns and associated clinical outcomes in patients receiving care for severe asthma.

Methods

CLEAR was a multicenter, observational study that included adults (≥18 years old) from 23 countries enrolled in the International Severe Asthma Registry between December 2015 and August 2021. Patients who initiated biologic therapy were categorized as continuing the initial biologic for 6 months, switching to another biologic within 6 months or stopping biologic treatment within 6 months. Outcomes were assessed using the closest available data to 12 months after biologic initiation, using propensity score-weighted multivariable regression models.

Results

Among 1,859 patients who initiated biologic therapy, 1,116 (60.0%) continued, 474 (25.5%) switched and 269 (14.5%) stopped treatment. Patients who switched or stopped therapy had a higher annualized asthma exacerbation rate post-initiation than those who continued (adjusted incidence rate ratio [aIRR] [95% confidence interval]: switched, 1.83 [1.51, 2.22]; stopped, 1.53 [1.19, 1.95]) and were more likely to have uncontrolled asthma at last assessment (adjusted odds ratio: switched, 5.40 [3.12, 9.33]; stopped, 4.02 [2.32, 6.98]). Compared with those who continued therapy, patients who switched had a higher long-term daily oral corticosteroid dose (adjusted β: 3.77 [1.71, 4.37] mg) and higher rates of hospitalizations (aIRR: 2.58 [1.52, 4.37]) and emergency room visits (aIRR: 2.12 [1.39, 3.24]).

Conclusion

Switching or stopping biologic therapy was associated with worse clinical outcomes than continuing the initial therapy.

Relationships Between Chronic Cough and Asthma Control and Quality of Life in Patients With Severe Asthma: A 6-Month Longitudinal Analysis

BACKGROUND

The prevalence and clinical implications of chronic cough (CC) in patients with severe asthma receiving asthma treatment remain relatively unknown.

OBJECTIVE

This study aimed to evaluate the relationships between CC and asthma control and quality of life (QoL) in patients with severe asthma through longitudinal analysis.

METHODS

Baseline and 6-month follow-up data from the Korean Severe Asthma Registry were analyzed. CC was defined as a cough visual analog scale (VAS) score of ≥40 at both baseline and 6 months. Demographic parameters and clinical outcomes were compared between patients with severe asthma and CC and those without CC. Generalized estimating equation (GEE) analysis was performed to identify associations of CC with asthma control and QoL scores.

RESULTS

Of the total 286 participants with severe asthma, 116 (40.6%) were defined as having CC. Patients with CC had higher baseline cough and wheeze severity VAS scores (all P < .001), poorer asthma control (P < .001), and worse QoL (Severe Asthma Questionnaire [SAQ] and Euro-QoL 5-Dimension [EQ-5D] index, all P < .001) than those without CC. During the follow-up, patients with CC were more frequently exposed to oral corticosteroids (58.6% vs 38.6%, P = .010) and experienced more frequent asthma exacerbations (48.3% vs 28.6%, P = .009) than those without CC. GEE analysis revealed that CC was independently associated with poor asthma control, lower SAQ scores, and a lower EQ-5D index after adjusting for confounders.

CONCLUSION

The presence of CC was associated with worse asthma control and QoL in patients with severe asthma. Further studies are warranted to better evaluate and manage CC in these patients.

Chronic Inflammation in Asthma: Looking Beyond the Th2 Cell

Asthma is a common chronic inflammatory disease of the airways. A substantial number of patients present with severe and therapy-resistant asthma, for which the underlying biological mechanisms remain poorly understood. In most asthma patients, airway inflammation is characterized by chronic activation of type 2 immunity. CD4+ T helper 2 (Th2) cells are the canonical producers of the cytokines that fuel type 2 inflammation: interleukin (IL)-4, IL-5, IL-9, and IL-13. However, more recent findings have shown that other lymphocyte subsets, in particular group 2 innate lymphoid cells (ILC2s) and type 2 CD8+ cytotoxic T (Tc2) cells, can also produce large amounts of type 2 cytokines. Importantly, a substantial number of severe therapy-resistant asthma patients present with chronic type 2 inflammation, despite the high sensitivity of Th2 cells for suppression by corticosteroids-the mainstay drugs for asthma. Emerging evidence indicates that ILC2s and Tc2 cells are more abundant in severe asthma patients and can adopt corticosteroid-resistance states. Moreover, many severe asthma patients do not present with overt type 2 airway inflammation, implicating non-type 2 immunity as a driver of disease. In this review, we will discuss asthma pathophysiology and focus on the roles played by ILC2s, Tc2 cells, and non-type 2 lymphocytes, placing special emphasis on severe disease forms.

Real-world mepolizumab treatment in eosinophilic granulomatosis with polyangiitis reduces disease burden in the United States

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, chronic inflammatory disease characterized by asthma and small/medium vessel vasculitis. Mepolizumab is approved for use in EGPA disease management alongside oral corticosteroids (OCS), but evidence of its real-world impact is limited.

OBJECTIVE

To compare real-world treatment patterns and health outcomes, particularly OCS use, EGPA-related hospitalizations/relapses, and asthma exacerbations pre- and post-mepolizumab initiation in US patients with EGPA.

METHODS

Patients with EGPA receiving more than or equal to 2 mepolizumab doses were identified using administrative claims data from Komodo Health's Comprehensive Dataset (between December 2016-March 2020). Outcomes assessed pre- and post-mepolizumab initiation included corticosteroid/other medication use, EGPA-related hospitalizations/relapses, and asthma exacerbations.

RESULTS

Overall, 114 patients were identified; of these, 60 (53%) received mepolizumab 300 mg at index. Average daily OCS dose per dispensing was significantly lower post- vs pre-mepolizumab initiation (21.2 vs 26.8 mg/d, 21% relative reduction, P < .001); mean number of OCS bursts also decreased (0.9 vs 1.8, 50% relative reduction, P < .001). Patients experienced significantly lower rates of EGPA-related hospitalization (0.86 vs 1.55 per-person year [PPY], 49% relative reduction, P = .004) and EGPA relapse (3.18 vs 3.94 PPY, 19% relative reduction, P = .004) post- vs pre-initiation. Most patients (91%) had an asthma diagnosis at baseline; among these patients, asthma exacerbation rates were significantly lower post- vs pre-initiation (1.05 vs 1.84 PPY, 42% relative reduction, P = .004).

CONCLUSION

Mepolizumab was associated with significant steroid-sparing benefits and significantly reduced rates of EGPA-related hospitalizations, EGPA relapses, and asthma exacerbations in this real-world study of US patients with EGPA, confirming the benefits of mepolizumab treatment seen in clinical trials.

Characteristics of patients with severe asthma reported to be eligible or non-eligible for biologic therapy in Poland: Results from the international observational study RECOGNISE

PURPOSE

To analyze characteristics of real-world patients with severe asthma in Poland and identify factors determining clinicians' opinion on the eligibility for biologics.

METHODS

In this retrospective, multi-national, single-visit study (NCT03629782), investigators were asked whether the patient might benefit from a referral for further clinical assessment and potentially biologic therapy. Asthma exacerbations and healthcare resource utilization (HCRU) in the last 12 months were documented by the investigators. Patient-reported outcomes included St George's Respiratory Questionnaire (SGRQ) and Asthma Control Questionnaire (ACQ-6).

RESULTS

Of 1025 patients, 146 were enrolled in Poland. Investigators considered 77.4 ​% of patients eligible for biologics and 22.6 ​% non-eligible. Patients considered eligible were diagnosed at younger age than non-eligible (median 39 vs 45 years; p ​= ​0.0113) and more frequently had a history of atopy (46 ​% vs 21.2 ​%; p ​= ​0.0106). Eligible patients had a higher frequency (93.8 ​% vs 66.7 ​%, p ​< ​0.0001) and number of exacerbations (median 2 vs 1, p ​= ​0.0003). Among eligible patients, 81.4 ​% and among non-eligible, 66.7 ​% had not well-controlled asthma; long-term oral corticosteroids were used by 46.0 ​% and 51.5 ​%, respectively. Short-term corticosteroid use was more frequent in biologics-eligible than in non-eligible patients (82.3 ​% vs 48.5 ​%, p ​< ​0.0001). Patients eligible for biologics had a higher median SGRQ total score (64.7 vs 48.4; p ​= ​0.0075) and HRCU (63.7 ​% vs 9.1 ​%; p ​< ​0.0001).

CONCLUSIONS

In Poland, 3 in 4 patients with severe asthma are recognized by clinicians as potential candidates for biologics. However, eligibility is not associated with long-term oral corticosteroid use, highlighting the need to better inform the physicians about the benefits of biologic therapy.

Predictors of revision endoscopic sinus surgery in Finnish patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Although patients with chronic rhinosinusitis with nasal polyps (CRSwNP) may benefit from endoscopic sinus surgery (ESS), some patients will experience polyp recurrence, adding to the overall disease burden of CRSwNP. We aimed to investigate predictors of revision ESS in patients with CRSwNP.

METHODS

A nationwide population-based study including all adults diagnosed with CRSwNP who had surgical procedure codes for ESS (N = 3506), followed up between January 2012 and December 2019. Logistic regression models provided adjusted odds ratios (OR) with 95% confidence intervals (CIs) for the odds of revision surgery within one and 3 years post-index surgery.

RESULTS

559 (15.9%) of the patients had at least one revision surgery during the follow-up. Median time to revision of ESS was 425 days (interquartile range: 213-898). Baseline asthma (OR = 1.58, 95% CI 1.17-2.12) and antibiotic use (OR = 1.61, 95% CI 1.27-2.04) were associated with higher odds of revision ESS, particularly within 3 years post-index surgery, whereas Increasing age was inversely associated with the odds of ESS revision (OR = 0.82, 95% CI 0.76-0.88). The highest odds of revision ESS were observed within 3 years post-index surgery in patients who had undergone extensive surgery at index (OR = 14.13, 95% CI 3.41-95.64) compared with those who had undergone limited surgery. OCS use was frequent among CRSwNP patients, with a higher cumulative dose in patients undergoing multiple ESS revisions (63%, n = 97, median daily dose 3.29 mg, IQR: 1.64-3.70) compared with patients without revisions (49%, n = 1361 and 1.64 mg, IQR: 1.64-3.29, respectively. p-value <0.001).

CONCLUSIONS

A small proportion of CRSwNP patients require revision ESS with associated high cumulative OCS doses, highlighting the need for additional therapies to achieve disease control and reduce the corticosteroid burden. A few simple baseline characteristics can predict the need for recurrent surgery among the patients with CRSwNP.

Anti-IL-4Ra therapy is superior to other biologic classes in treating allergic bronchopulmonary aspergillosis

Background

Allergic bronchopulmonary aspergillosis (ABPA) is a disease resulting from an overactive type 2 response to Aspergillus. Initial studies suggest that asthma biologics can effectively treat ABPA, but it is unclear which biologic class is superior.

Objective

We sought to compare the effectiveness of asthma biologics in the treatment of ABPA.

Methods

We performed a retrospective analysis of patients with ABPA treated with asthma biologics, and measured outcomes of respiratory exacerbations, daily oral corticosteroids, and antifungals. We assessed these variables while individuals were treated with 1 of 3 biologic classes: anti-IgE, anti-IL-5/IL-5 receptor alpha (IL-5Ra), anti-IL-4 receptor alpha (IL-4Ra).

Results

A total of 21 patients were included in our analysis. Anti-IL-4Ra was associated with a significantly lower number of exacerbations and oral corticosteroid use compared with anti-IgE or anti-IL-5/IL-5Ra therapies. Anti-IL-4Ra also had significantly lower antifungal use than anti-IgE, and there was a trend toward lower antifungal use when compared with anti-IL-5/IL-5Ra. In a subgroup of 10 patients treated with 2 or more biologics sequentially, we found that 8 of them achieved clinical control on anti-IL-4Ra therapy after failing anti-IgE and/or anti-IL-5/IL-5Ra therapies.

Conclusions

Dupilumab blocks the IL-4Ra, resulting in the downstream inhibition of both IL-4 and IL-13 effector pathways. Dupilumab may benefit patients with ABPA by inhibiting the generation of airway mucus (IL-13), and by reducing local B-cell differentiation into IgE antibody-secreting cells (IL-4). On the basis of our findings and with the known molecular mechanisms of dupilumab, we believe that anti-IL-4Rα-targeted therapy may be more effective than anti-IgE or anti-IL-5/IL-5Rα therapies to treat ABPA.

Adverse Impacts of Corticosteroid Treatment on Osteoporosis/Osteopenia in Adult Asthmatics: A Retrospective ICARUS Cohort Study

BACKGROUND

Inhaled corticosteroid (ICS) and oral corticosteroid (OCS) are often used in asthma management.

OBJECTIVE

To evaluate the long-term effect of ICS/OCS on osteoporosis, osteopenia, fractures, and bone metabolism in adult patients with asthma in real-world clinical practice.

METHODS

This is a retrospective study investigating deidentified electronic health records from Ajou University Medical Center (Korea). Adult patients with asthma receiving maintenance ICS with/without OCS for at least 1 year were enrolled. They were classified into the high/low-dose of ICS or OCS group. Primary outcomes (incidences of osteoporosis, osteopenia, and fractures) and secondary outcomes (drug prescription and laboratory values related to bone metabolism including albumin and alkaline phosphatase) were compared after 5 years of follow-up.

RESULTS

After propensity score matching, both high- and low-dose OCS groups included 468 patients, and high/low-dose ICS groups each comprised 1252 patients. The risk of osteoporosis/major fracture was higher (hazard ratio [95% CI], 2.00 [1.15-3.57]/3.03 [1.04-11.11]) in the high-dose OCS group (especially in females aged ≥50 years) than in the low-dose group, although the ICS groups showed no significant differences. The high-dose ICS group showed a higher risk of osteopenia (1.92 [1.05-3.70]) than the low-dose ICS group. The linear mixed model of laboratory values showed significantly decreased serum albumin and increased alkaline phosphatase in the high-dose OCS group than in the low-dose OCS group.

CONCLUSIONS

The results of this study suggest that long-term use of OCS can increase the risk of osteoporosis and osteoporosis-related fractures, whereas long-term use of ICS may increase the risk of osteopenia in adult patients with asthma.

Cumulative Dispensing of Oral Corticosteroids Over 12 Months in People with COPD

Purpose

Oral corticosteroids (OCS) are recommended for the treatment of exacerbations in people with COPD; however, high cumulative lifetime doses (≥1000mg prednisolone-equivalent) are associated with adverse health effects. This issue is well defined in asthma but is less well understood in COPD. The aim of this study was to examine cumulative OCS dispensed to people with COPD over 12 months.

Patients and Methods

This was a secondary analysis of data from two randomised controlled trials involving people with COPD followed up for 12 months following pulmonary rehabilitation. Clinical and administrative (respiratory-related hospital admissions and emergency presentations, dispensed OCS and COPD maintenance medications) data were examined to determine cumulative OCS dose relative to the 1000mg threshold and the relationship with clinical features.

Results

Of 232 participants (126 females, age mean 68 ± SD 9 years, FEV1 53 ± 22% predicted), 48% (n = 112) were dispensed OCS at least once over 12 months. Sixty-two participants (26%) were dispensed ≥1000mg. Participants with a high cumulative dose were more likely to have had a respiratory admission (OR 4.1, 95% CI 2.3 to 8.7) and greater breathlessness (modified Medical Research Council scale ≥2, OR 2.5, 95% CI 1.3 to 5.0); no relationship with disease severity or maintenance medications was demonstrated.

Conclusion

One in four people with COPD were dispensed unsafe lifetime cumulative OCS doses over a period of only 12 months. Further work is needed to determine the magnitude of this issue in COPD and strategies to address exposure to high doses of OCS.

Connections and Unmet Needs: Severe Asthma Biologics and Osteoporosis

Asthma is a chronic inflammatory disease with the main anti-inflammatory drugs for better disease control being steroids or corticosteroids. The use of steroids in asthma patients, in particular in uncontrolled asthma patients, is associated with an increased risk of osteoporosis and fragility fractures. A single oral corticosteroid course increases the risk of osteoporosis and the continual use of inhaled corticosteroids is correlated over time to an increased risk for both bone conditions. With the use of new, available biologic therapies for asthma, perhaps even anticipating the times of their use in therapeutic management, in the current guidelines and with targeted strategies of prevention it may be possible to improve asthma management, preventing some comorbidities, such as osteoporosis.

Experiences of Oral Corticosteroid Use and Adverse Effects: A National Cross-Sectional Survey of People with Asthma

Purpose

Oral corticosteroids (OCS) are an effective treatment for severe uncontrolled asthma or asthma exacerbations, but frequent bursts or long-term use carry serious and sometimes irreversible adverse effects, or complications such as adrenal insufficiency upon discontinuation. Our aim was to survey people with asthma on their experiences of, and attitudes towards, using OCS.

Patients and Methods

This study was a national descriptive cross-sectional survey of people with asthma in Australia. An anonymous survey was hosted online with invitations to participate distributed by national consumer peak bodies. Survey free-text responses were coded to the Theoretical Domains Framework (TDF) to elicit determinants of OCS use.

Results

1808 people with asthma participated between 3 and 16 May 2022. Most common reasons for using OCS were severe asthma symptoms (40%), doctor prescription (38%) or asthma action plan recommendations (20%). Approximately 55% of people had experienced adverse effects from OCS use. Commonly reported adverse effects were trouble sleeping (69%), weight gain (56%) and mood problems (41%). Of people who had OCS at home or an OCS script, 44% did not have an action plan that described when and how they should take them. People (33%) did not feel well informed about OCS adverse effects from their healthcare team. People had varied awareness (3-65%) of current available strategies to reduce OCS use. 'Knowledge', 'Environmental context and resources' and 'Social influences' were the most coded TDF domains influencing OCS use.

Conclusion

Adverse effects of OCS use are common. People with asthma are not adequately informed about optimal OCS use or strategies to reduce overuse. These findings can help guide the implementation of OCS stewardship initiatives.

Patient-centred outcomes in severe asthma: fatigue, sleep, physical activity and work

Severe asthma places a significant burden on patients, with recent research revealing overlooked patient needs extending beyond physical symptoms. To optimise the patient-centred approach to managing severe asthma, it is crucial to deepen our understanding of these needs. This review examines the prevalence and impact of four prioritised patient needs in severe asthma, namely fatigue, sleep disturbances, physical inactivity and reduced presence and productivity at work. It explores how these factors relate to classic asthma outcomes and quality of life, and the potential impact of interventions. Fatigue affects up to 90% of patients, while sleep difficulties impact 70-75% of severe cases, contributing to impaired daily function and quality of life. Although both are linked to asthma control, the cause-and-effect relationship remains unclear, making it clinically intriguing to investigate whether interventions targeting fatigue or sleep problems affect asthma control. In asthma patients, physical inactivity occurs both as consequence and contributing factor to uncontrolled disease. Interventions promoting physical activity improve asthma control and quality of life, suggesting a potential role in severe asthma management. Finally, work productivity loss, notably present in severe asthma cases, strongly correlates with asthma control and exacerbations. While biologic therapies show potential to reverse this loss, their effects on physical activity, fatigue and sleep disturbances warrant further investigation. Nonpharmacological interventions targeting these needs, such as pulmonary rehabilitation and behavioural therapies, may provide opportunities to enhance patients' well-being. Overall, this review highlights significant gaps in understanding patient-centred aspects of severe asthma, urging for research on comprehensive interventions to improve patients' lives.

The role of biologics in inducing remission in asthma

Asthma remissions have been identified as a new treatment outcome and as based on experience with biologics. Remissions are defined as no symptoms, no exacerbations, no use of systemic corticosteroids, and stabilization (optimization) of lung functions; all these criteria need to be sustained for at least 1 year. This study discussed the evolution of remissions, the evolving criteria, and experiences in achieving remission after treatment with biologics. In severe, uncontrolled asthma, treatment with biologics has led to remissions in 20% to 35% of the subjects treated. It is proposed that remissions will become a new and important treatment outcome for asthma.

Glucocorticoid therapy in classic congenital adrenal hyperplasia: traditional and new treatment paradigms

INTRODUCTION

Classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) is a rare genetic condition characterized by cortisol deficiency and excess adrenal androgens. CAH treatment is a lifelong balancing act between the need to reduce excess androgens, typically with supraphysiologic glucocorticoid (GC) doses, and concerns about potentially serious GC-related adverse events. Tradeoffs between the consequences of excess androgens versus GCs must be constantly reassessed throughout each patient's lifetime, based on current clinical needs and treatment goals. Adding to this burden are limited treatment options and the need for new CAH medications.

AREAS COVERED

This narrative review describes the current challenges of CAH treatment, the potential of new non-GC therapies to reduce excess androgens and thereby allow for lower GC doses, and the potential implications of decreasing GC doses to a more physiologic range (i.e. sufficient to replace missing cortisol, but without the need to reduce androgens).

EXPERT OPINION

Even with non-GC therapies, patients' needs will continue to shift throughout their lifetimes. Treatment will therefore always require joint decision-making between physicians and patients. However, over the lifetimes of patients with CAH, any reduction in GC daily dose may have a large cumulative impact in decreasing the GC-related burden of this disease.

Introducing the concept of loss of corticosteroid credit in asthma

The widespread use of systemic corticosteroids (SCS) in asthma is associated with significant comorbidities and mortality. A dose-response relationship for cumulative SCS exposure with most adverse outcomes began at cumulative exposures of 1.0-<2.5 g, equivalent to four lifetime SCS courses. The purpose of creating the SCS credit concept was to increase awareness of the risks of SCS exposure and to promote better therapeutic alternatives. Consuming the lifetime SCS credit of 1.5 g/yr significantly increased morbidity and mortality.

Oral Corticosteroid-Related Healthcare Resource Utilization and Associated Costs in Patients with COPD

INTRODUCTION

Oral corticosteroids (OCS) are used to manage chronic obstructive pulmonary disease (COPD) exacerbations but are associated with adverse outcomes that may increase healthcare resource utilization and costs. We compared attendance/costs associated with OCS-related adverse outcomes in patients who ever used OCS versus those who never used OCS and examined associations between cumulative OCS exposure and attendance/costs.

METHODS

This direct matched observational cohort study used the UK Clinical Practice Research Datalink GOLD database (data range 1987-2019). Patients with a COPD diagnosis on/after April 1, 2003, and Hospital Episode Statistics linkage were included. Emergency room, specialist or primary care outpatient, and inpatient attendance were analyzed. Costs, estimated using Health and Social Care 2019 and National Health Service Reference Costs 2019-2020 reports, were adjusted for sex, age, exacerbation number, and inhaler type used in the 12 months before index date.

RESULTS

The OCS cohort had higher annualized disease-specific (excluding respiratory) total attendance/costs versus the non-OCS cohort (adjusted incidence rate ratio [aIRR] with 95% confidence intervals [CIs]) ranging from 37% (1.37 [1.31, 1.43]) for emergency room attendances to 149% (2.49 [2.36, 2.63]) for specialist consultations. Disease-specific (excluding respiratory) attendance/costs increased in a positive dose-response relationship for most attendance categories versus the < 0.5 g reference dose. For the 0.5 to < 1.0 g cumulative dose category, the greatest increases in disease-specific (excluding respiratory) attendance/costs occurred for primary care consultations (aIRR [95% CI] 1.38 [1.32, 1.44]). For the ≥ 10 g cumulative dose category, the greatest increases were observed for primary care consultations (aIRR [95% CI] 2.83 [2.66, 3.00]), non-elective long stays (≥ 2 days; 2.54 [2.15, 2.99]), and non-elective short stays (≤ 1 day; 2.51 [2.12, 2.98]). Similar findings were observed for all-cause attendance/costs.

CONCLUSION

Among patients with COPD, OCS-related adverse outcomes were associated with higher attendance and costs, with a positive dose-response relationship. A graphical abstract is available with this article.

Identifying super-responders: A review of the road to asthma remission

Asthma is a chronic respiratory disease marked by heterogeneity and variable clinical outcomes. Recent therapeutic advances have highlighted patients achieving optimal outcomes, termed "remission" or "super-response." This review evaluates the various definitions of these terms and explores how disease burden impedes the attainment of remission. We assessed multiple studies, including a recent systematic review and meta-analysis, on biologic treatments for asthma remission. Our review highlights that type 2 inflammation may be the strongest predictor of biologic response. Key comorbidities (eg, obesity and mood disorders) and behavioral factors (eg, poor adherence, improper inhalation technique, and smoking) were identified as dominant traits limiting remission. In addition, asthma burden and longer disease duration significantly restrict the potential for remission in patients with severe asthma under the current treatment paradigm. We review the potential for a "predict-and-prevent" approach, which focuses on early identification of high-risk patients with type 2 inflammation and aggressive treatment to improve long-term asthma outcomes. In conclusion, this scoping review highlights the following unmet needs in asthma remission: (1) a harmonized global definition, with better defined lung function parameters; (2) integration of nonbiologic therapies into remission strategies; and (3) a clinical trial of early biologic intervention in patients with remission-prone, very type 2-high, moderately severe asthma with clinical remission as a predefined primary end point.

Complications of Oral Corticosteroid Use in Otolaryngology

OBJECTIVE

Oral corticosteroids (OCS) are frequently prescribed by otolaryngologists. However, there are limited quantitative data on OCS-related adverse events (AEs) in otolaryngology. We sought to quantify OCS-related AEs in otolaryngology.

METHODS

All outpatient otolaryngology encounters in our healthcare system (2018-2023) at which an OCS was prescribed were identified via the electronic medical record. The diagnoses indicating OCS were categorized as sinonasal, otologic, pharyngo-laryngeal, and other. The medical record was subsequently examined to assess for OCS AEs during the 21-day period following the prescription. OCS AEs were grouped into (1) gastrointestinal, (2) metabolic, (3) bone/muscle, (4) ophthalmologic, and/or (5) psychiatric complications. The frequency and types of OCS related AEs were determined.

RESULTS

A total of 20 746 otolaryngology encounters with OCS prescribed were examined. Seventy OCS courses had 1 or more AEs, implying a number needed to harm of 296.4 (240.2-386.8). There were 83 total OCS-related AEs, yielding an AE incidence rate of 4.0:1000 (95% CI, 3.0-5.0:1000) OCS prescriptions. The mean age of subjects with AEs (61.5 years) was significantly higher than those without (50.3 years; P < .001). Forty-seven (56.6%) of the complications were metabolic, with hyperglycemia and hypokalemia the most common, followed by gastrointestinal (26.5%), ophthalmologic (3.6%), psychiatric (2.4%), and musculoskeletal (2.4%).

CONCLUSION

AEs related to OCS prescribed by otolaryngologists occur at a rate of once per 296 courses of treatment and older populations may be at increased risk for AEs. Otolaryngologists should balance AE rates against anticipated benefits of steroid therapy.

LEVEL OF EVIDENCE

3.

Treating eosinophilic exacerbations of asthma and COPD with benralizumab (ABRA): a double-blind, double-dummy, active placebo-controlled randomised trial

BACKGROUND

Exacerbations of asthma and chronic obstructive pulmonary disease (COPD) are important events and are associated with critical illness. Eosinophilic inflammation is a treatable trait commonly found during acute exacerbations of asthma and COPD. We hypothesised that for patients with eosinophilic exacerbations, a single injection of benralizumab, a humanised monoclonal antibody against interleukin-5 receptor-α, alone or in combination with prednisolone, will improve clinical outcomes compared with prednisolone, the standard of care.

METHODS

The Acute exacerbations treated with BenRAlizumab trial (ABRA) was a multicentre, phase 2, double-blind, double-dummy, active placebo-controlled randomised trial completed in the UK at Oxford University Hospitals NHS Foundation Trust and Guy's and St Thomas' NHS Foundation Trust. Patients were recruited from urgent care clinics and emergency departments of these two hospitals. At the time of an acute exacerbation of asthma or COPD, adults with blood eosinophil counts of equal to or more than 300 cells per μL were randomly assigned in a 1:1:1 ratio to receive acute treatment with: prednisolone 30 mg once daily for 5 days and 100 mg benralizumab subcutaneous injection once (BENRA plus PRED group); placebo tablets once daily for 5 days and 100 mg benralizumab subcutaneous injection once (BENRA group); or prednisolone 30 mg once daily for 5 days and placebo subcutaneous injection once (PRED group). Randomisation was performed with a centralised interactive computer randomisation service. All patients and study research staff involved in data collection were masked to study blood results and treatment allocation. The co-primary outcomes were proportion of treatment failures over 90 days and total visual analogue scale (VAS) symptoms at day 28 in the pooled benralizumab groups compared with the prednisolone alone group and analysed in the intention-to-treat population. The trial was registered on Clinicaltrials.govNCT04098718.

FINDINGS

Between May 13, 2021, and Feb 5, 2024, 287 patients were screened for study inclusion. 129 were excluded due to not having an exacerbation captured or not meeting the eosinophil exclusion criteria. 158 patients were randomly assigned at acute eosinophilic exacerbation of asthma or COPD where 86 (54%) patients were female and 72 (46%) were male with a mean age of 57 years (range, 18-84). 53 patients were randomly assigned to the PRED group, 53 were randomly assigned to the BENRA group, and 52 were assigned to the BENRA plus PRED treatment group. At 90 days, treatment failures occurred in 39 (74%) of 53 in the PRED group, and 47 (45%) of 105 in the pooled-BENRA group (OR 0·26 [95% CI 0·13-0·56]; p=0·0005). The 28-day total VAS mean difference was 49 mm (95% CI 14-84; p=0·0065), favouring the pooled-BENRA group. There were no fatal adverse events and benralizumab was well tolerated. Notably, hyperglycaemia and sinusitis or sinus infection adverse events were related to the prednisolone study drug only.

INTERPRETATION

Benralizumab can be used as a treatment of acute eosinophilic exacerbations and achieves better outcomes than the current standard of care with prednisolone alone. These results offer a new way of treating eosinophilic endotypes of asthma and COPD exacerbations.

FUNDING

AstraZeneca.

Systemic corticosteroid dose-response effects in asthma: an observational cohort study

This study is among the first in a large patient database over an extended period to identify a link between SCS use/overuse and mortality in asthma in a positive dose-response relationship with average daily exposure and cumulative dose categories https://bit.ly/3zzl2QN.

Long-Term Eosinophil Depletion: A Real-World Perspective on the Safety and Durability of Benralizumab Treatment in Severe Eosinophilic Asthma

Background/Objectives: Benralizumab is an anti-IL-5 receptor alpha monoclonal antibody that induces the near-complete depletion of eosinophils. This study aimed to evaluate the long-term safety and effectiveness of benralizumab in patients with severe eosinophilic asthma (SEA) over an extended 48-month follow-up period, offering one of the longest real-world perspectives available. Methods: This was a single-arm, retrospective, observational, multicenter study involving 123 SEA patients treated with benralizumab at a dosage of 30 mg every 4 weeks for the first 3 doses and then every 8 weeks. The safety endpoints focused on the frequency and nature of adverse events and the likelihood that they were induced by benralizumab. The efficacy endpoints focused on lung function, asthma exacerbations and control, and oral corticosteroid use. Results: Benralizumab, consistent with its mechanism of action, led to the rapid and nearly complete depletion of eosinophils. In total, 26 adverse events (21.1%) were observed, with 1.6% related to the treatment and 0.8% categorized as serious (vagal hypotension). Bronchitis was the most common unrelated adverse event (15.4%), occurring between months 36 and 38. Importantly, benralizumab effectiveness and safety were maintained consistently across the 48-month duration, resulting in significant improvements in lung function and reductions in oral corticosteroid use and exacerbation frequency. Conclusions: Benralizumab demonstrated a favorable safety profile, comparable to previously published studies, with perdurable effectiveness in controlling SEA and reducing oral corticosteroid use. Finally, this study provides evidence that near-complete eosinophil depletion does not increase long-term safety risks and supports benralizumab as a reliable treatment option for SEA patients.

The economic burden of asthma in Italy: evaluating the potential impact of different treatments in adult patients with severe eosinophilic asthma

INTRODUCTION

Asthma is a prevalent chronic respiratory condition that significantly impacts public health, with severe asthma subtypes, such as severe eosinophilic asthma, imposing substantial socioeconomic burdens.

METHODS

Real-world data from the Italian Health Information System were analyzed to evaluate the economic consequences of asthma in Italy. An in-depth comparative analysis was conducted to investigate the economic implications of various asthma subtypes, focusing on severe eosinophilic asthma. Additionally, the study projected the potential cost-effectiveness of novel treatments aimed at reducing hospitalization rates, specialist visits, and oral corticosteroid use for patients with severe eosinophilic asthma in Italy.

RESULTS

The analysis revealed that severe asthma, and notably severe eosinophilic asthma, places a substantial economic burden on the Italian National Health System. Estimates demonstrated that implementing innovative treatments to mitigate the risks of hospitalization and specialist visits, as well as reducing oral corticosteroid usage in severe eosinophilic asthma patients, could lead to significant cost savings. The cost-consequence analysis indicated potential yearly reductions of €50.0 million (27%) for the treatment of severe asthma and €31.7 million (26%) for severe eosinophilic asthma.

CONCLUSIONS

This study presents a comprehensive evaluation of the economic repercussions of severe asthma in Italy. The findings emphasize the necessity of identifying and developing effective therapeutic strategies to improve the management of severe asthma while simultaneously reducing the economic burden on the healthcare system. These results offer valuable insights for healthcare policymakers and practitioners, facilitating evidence-based decisions in asthma management and healthcare policy in Italy.

Terpenoids, a Rising Star in Bioactive Constituents for Alleviating Food Allergy: A Review about the Potential Mechanism, Preparation, and Application

Food allergies affect approximately 2.5% of the global population, with a notable increase in prevalence observed each year. Terpenoids, a class of natural bioactive constituents, have been widely utilized in the management of immune- and inflammation-related disorders, and their potential in alleviating food allergies is increasingly being recognized. This article summarizes various terpenoids derived from plant, fungal, and marine sources. Among them, triterpenoids, such as oleanolic acid, ursolic acid, and lupeol, possess the highest proportion and bioactivity in alleviating food allergy. Additionally, the mechanisms by which terpenoids may mitigate allergic diseases were categorically outlined, focusing on their roles in epithelial mucosal barrier function, immunomodulatory effects during the sensitization phase, inhibition of effector cells, oxidative stress, and regulation of microbial homeostasis. Finally, the advantages and limitations of natural extraction and artificial synthesis methods were compared, and the application of terpenoids in the food industry were also discussed. This article serves as a useful reference for the development of methods or functional foods based on terpenoids, which could represent a promising avenue for alleviating food allergy.

Severe Fatigue in Uncontrolled Asthma: Contributing Factors and Impact of Rehabilitation

BACKGROUND

Fatigue is a major concern for patients with severe asthma.

OBJECTIVE

This observational study aims to assess fatigue severity and associated factors, to explore the effect of pulmonary rehabilitation on fatigue, and to investigate which factors predict persistent severe fatigue.

METHODS

Patients with severe, uncontrolled asthma referred for alpine altitude climate treatment (AACT) between 2007 and 2018 were systematically assessed before and after rehabilitation regarding clinical, inflammatory, functional, and psychological characteristics. Fatigue severity was assessed by Checklist Individual Strength (CIS-Fatigue). Multivariable regression analyses were used to identify factors associated with fatigue severity and persistence.

RESULTS

A total of 420 patients were assessed, of whom 91% reported severe fatigue (CIS-Fatigue ≥36). Stepwise multiple regression explained 35% of variance in initial fatigue severity. Significant contributing factors were higher Asthma Control Questionnaire (ACQ) (36%), sleeping problems (21%), female sex (19%), reflux (12%), and lower fractional exhaled nitric oxide (12%). AACT led to significant improvements in CIS-Fatigue (median [IQR] 50 [11] to 27 [21]) (P < .001), ACQ (3.0 [1.3] to 1.2 [1.3]) (P < .001), and other asthma outcomes. However, 27% of patients reported persistent severe fatigue, correlating with less improvement in asthma outcomes. Daily oral corticosteroid use (odds ratio [OR] [95% confidence interval (CI)]: 2.4 [1.4-4.1]), sleeping problems (OR [95% CI]: 2.7 [1.6-4.5]), initial very severe fatigue (OR [95% CI]: 3.1 [1.6-6.3]), and older age (OR [95% CI]: 1.02 [1.0-1.04]) were independent predictors of persistent severe fatigue.

CONCLUSIONS

Severe fatigue is highly prevalent in patients with severe, uncontrolled asthma. AACT results in recovered fatigue and improved asthma control in most patients. Predicting factors of persistent fatigue suggest exploring the effect of targeted treatment strategies beyond the asthma domain.

Integrating hot topics and implementation of treatable traits in asthma

People with asthma experience many different problems related to their illness. The number and type of problems differ between patients. This results in asthma being a complex and heterogeneous disorder which mandates a personalised approach to management. These features pose very significant challenges for the effective implementation of evidence-based management. "Treatable traits" is a model of care that has been specifically designed to address these issues. Traits are identified in the pulmonary, extrapulmonary (comorbidity) and behavioural/risk factor domains. Traits are clinically relevant, recognisable with validated trait identification markers and treatable using evidence-based therapies. The clinician and patient agree on a personalised management plan that addresses the relevant traits, and trials show superiority of this approach with significant improvements in asthma control and quality of life. A number of tools have now been developed to assist the clinician in the implementation of this approach. The success of the treatable traits model of care is now being realised in other disease areas.

Best practice advice for asthma exacerbation prevention and management in primary care: an international expert consensus

Primary care clinicians play a key role in asthma and asthma exacerbation management worldwide because most patients with asthma are treated in primary care settings. The high burden of asthma exacerbations persists and important practice gaps remain, despite continual advances in asthma care. Lack of primary care-specific guidance, uncontrolled asthma, incomplete assessment of exacerbation and asthma control history, and reliance on systemic corticosteroids or short-acting beta2-agonist-only therapy are challenges clinicians face today with asthma care. Evidence supports the use of inhaled corticosteroids (ICS) + fast-acting bronchodilator treatments when used as needed in response to symptoms to improve asthma control and reduce rates of exacerbations, and the symptoms that occur leading up to an asthma exacerbation provide a window of opportunity to intervene with ICS. Incorporating patient perspectives and preferences when designing asthma regimens will help patients be more engaged in their therapy and may contribute to improved adherence and outcomes. This expert consensus contains 10 Best Practice Advice Points from a panel of primary care clinicians and a patient representative, formed in collaboration with the International Primary Care Respiratory Group (IPCRG), a clinically led charitable organization that works locally and globally in primary care to improve respiratory health. The panel met virtually and developed a series of best practice statements, which were drafted and subsequently voted on to obtain consensus. Primary care clinicians globally are encouraged to review and adapt these best practice advice points on preventing and managing asthma exacerbations to their local practice patterns to enhance asthma care within their practice.

Real-World Effectiveness of Mepolizumab in Severe Asthma: Results from the Multi-country, Self-controlled Nucala Effectiveness Study (NEST)

INTRODUCTION

The Nucala Effectiveness Study (NEST) assessed the effectiveness of mepolizumab in patients with severe asthma (SA) in countries previously underrepresented in real-world studies.

METHODS

A multi-country, bi-directional, self-controlled, observational cohort study conducted in Colombia, Chile, India, Türkiye, Saudi Arabia, United Arab Emirates, Kuwait, Oman, and Qatar. Historical and/or prospective data from patients with SA were assessed 12 months pre- and post-mepolizumab initiation.

PRIMARY ENDPOINT

incident rate ratio (IRR) of clinically significant exacerbations (CSEs). Key secondary endpoints: healthcare resource utilisation (HCRU), oral corticosteroid (OCS) use, lung function and symptom control (Asthma Control Test [ACT] scores).

RESULTS

Overall, 525 patients with SA burden pre-initiation (geometric mean blood eosinophil count [BEC] 490.7 cells/µl; 31.4% prior biologic use; 37.3% obese) received at least one dose of mepolizumab 100 mg subcutaneously. Post-initiation, a significant reduction in CSEs was observed (76% [p < 0.001]; IRR [95% confidence interval] 0.24 [0.19-0.30]); 72.0% of patients had no CSEs. Mepolizumab treatment led to a reduction in OCS use (52.8% pre-initiation vs. 16.6% post-initiation) and a mean (standard deviation [SD]) change in OCS dose of - 18.1 (20.7) mg post-initiation; 36.1% of patients became OCS-free. Fewer patients were hospitalised post-initiation (22.5% pre-initiation vs. 6.9% post-initiation). Improvements in mean (SD) forced expiratory volume in 1 s (62.8 [20.2]% pre-initiation vs. 73.0 [22.7]% post-initiation) and ACT scores (15.0% pre-initiation vs. 64.5% of patients post-initiation with well-controlled asthma) were observed. Proportion of patients with BEC ≥ 500 cells/µl decreased from 84.4% pre-initiation to 18.1% post-initiation.

CONCLUSION

Mepolizumab was effective in reducing the burden of SA by significantly reducing CSEs, reducing OCS use and HCRU, and improving lung function and asthma control, which could translate to improvements in health-related quality of life in patients with SA and high OCS dependency in the countries studied. A graphical abstract is available with this article.

Consultation for Chronic Rhinosinusitis With Nasal Polyps and Asthma: Clinical Presentation, Diagnostic Workup, and Treatment Options

Chronic rhinosinusitis (CRS) is characterized by chronic inflammation of the sinonasal mucosa, affects over 12% of the US population, and costs over $20 billion annually. CRS can be divided into 2 major phenotypes based on whether nasal polyps are present (chronic rhinosinusitis with nasal polyps [CRSwNP]) or absent (chronic rhinosinusitis without nasal polyps). This grand rounds review will discuss the clinical approach to patients with CRSwNP, including typical presentations, workup, and currently available treatment options. Tools that physicians can use to assess subjective sinonasal symptoms, as well as objective measures of disease, will be reviewed. Additional focus will be on recognizing clinical comorbidities commonly associated with CRSwNP, including asthma, bronchiectasis, allergic rhinitis, and nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. Clinical outcomes can be improved by providing a comprehensive approach to evaluating (and managing) patients with CRSwNP.

[Efficacy and toxicity of short-course corticosteroid therapy in chronic bronchial diseases]

Chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) are characterized by airway inflammation. While corticosteroids (CS) are frequently prescribed during exacerbations of these conditions, their repeated use is associated with numerous side effects. The aim of this review is to synthesize the recent literature on the indications, benefits, and risks of short-term CS therapy for these two diseases. French guidelines recommend short-term CS as a first-line treatment during asthma exacerbation (0,5 to 1mg/kg/day, not exceeding 60mg/day, for at least 5 to 7 days) or as a second-line treatment for COPD exacerbation (5 days, 30 to 40mg/day). However, these recommendations are not without limitations; they are primarily based on studies conducted in hospital settings, raising questions about the generalizability of their results to primary care, and as they employ a "one size fits all" strategy, they do not take into account the phenotypic heterogeneity of different patients. Moreover, repeated short-term CS courses generate side effects that even at low doses can appear early in young asthma patients, and they can exacerbate pre-existing comorbidities in COPD patients. The concept of a threshold dose should be employed in routine practice in view of accurately assessing the risk of side effects. In the near future, it will be important to consider recently published data supporting the use of predictive biomarkers for responses to CS, particularly in COPD cases.

Maintenance OCS Were Used More Frequently Than Biologics in Patients with Uncontrolled GINA 4/5 Asthma in Germany in 2019

Purpose

Asthma is affecting 4-5% of all adults (10% of children) in Germany, ≥ half are inadequately controlled. In 2019 up to 54 thousand patients suffered from severe uncontrolled asthma, 52% were treated/co-treated by pneumonologists. 45% of them had continuous oral corticosteroid (OCS)- and short-acting β2-agonist (SABA) overuse for ≥2 years. The aim of the current study was to analyze the main treatments, escalation schemes and the adherence to the GINA recommendations.

Patients and Methods

Retrospective analysis in 2021 based on data from January to December 2019 in Germany, using the IQVIA™ LRx prescription database and the IQVIA™ Disease Analyzer database containing anonymized electronic medical records as the main data sources.

Results

In 2019 25,200 patients with severe, uncontrolled asthma treated in a pneumonologist´s practice in Germany received GINA 3 (0,4%), GINA 4 (76%) or GINA 5 therapy (24%) during the study year compared to 59% GINA 5 therapy in the 5-10% (1,500-3,000) co-treated in a specialized outpatient department. In Pneumonologists` practices the most frequent choice in GINA 5 was OCS in 69% of patients (biologicals 37%, long-acting muscarinic antagonist (LAMA) 20%) compared to 66% biologicals, 55% OCS, and 25% LAMA in the outpatient department. 54,958 of 613,000 GINA 4/5 patients were treated with OCS, 9,725 even with doses above the so called "Cushing threshold" for prednisolone of 2700 mg/year. After introduction of a biological treatment, patients reduced their SABA prescriptions by 28%, OCS by 55%, and OCS overall exposure by 40%, one-third did not need OCS anymore.

Conclusion

In 75% of patients with uncontrolled asthma for ≥2 years therapy was not escalated beyond GINA 4 or low dose OCS was used as the most frequent add-on treatment in GINA 5 contradictory to treatment recommendations. Use of biologics reduced on demand rescue medication and OCS use.