Not everyone benefits equally, and with 3X risk of pneumonia from one course, it’s important to prescribe wisely…

For most doctors, “stewardship” evokes instant thoughts about antibiotics and multi-resistant organisms, with its use in the context of oral corticosteroids (OCS) being a new concept for many.

Professor David Price from the Department of Primary Care Respiratory Medicine at the University of Aberdeen says OCS stewardship is being recognised now in the context of asthma, but is just as important for chronic obstructive pulmonary disease (COPD).

Professor Price says there has been a significant increase in OCS prescriptions for both asthma and COPD since the 1990s. He doesn’t think that the severity of disease has worsened, so much as “our threshold to provide is lower; we provide rescue packs, which on the surface seems great, but in reality people end up using a lot more steroids.”

“But does it matter?” To Professor Price, the answer is resoundingly yes. “Steroids are poisonous. Yes, they may save lives, but they are poisonous. And the more we give, the more poisonous they are.”

Even a single course of OCS in COPD is associated with increased risk of many adverse outcomes, he says. These include osteoporosis, sleep disorders, anxiety and depression, diabetes, heart disease, glaucoma, and cataracts. Professor Price is most astonished by the pneumonia risk.

“Everyone thinks about COPD as a risk factor for pneumonia, everyone thinks about inhaled steroids,” he says, “yet a single course of OCS in a COPD patient increases their pneumonia risk three times.” He goes on to explain that a cumulative dose of one gram of OCS (roughly four courses, depending on dosage regimen) increases all-cause mortality by 50%.

The benefits of a short course of OCS in a COPD exacerbation include shorter recovery time, improved lung function and oxygenation, and decreased length of hospitalisation. However Professor Price says there are caveats: “interestingly, that only seems to be in patients with higher eosinophil counts. Those with lower eosinophil counts seem to get less benefit, and they seem to be at risk of pneumonia, sepsis and death, as well as long term consequences.”

With regards to asthma specifically, Professor Price is concerned about both OCS and salbutamol use. He notes that salbutamol is available over the counter without a prescription, and that even most prescriptions would offer two inhalers with five repeats. Yet the evidence shows that needing three inhalers across a year is associated with two to four times the risk of exacerbations. He says this is because patients using just as-needed ventolin are not benefiting from adequate anti-inflammatory medication.

Professor Price says this is the reasoning for global and Australian guidelines moving to suggest combination therapy (with an inhaled corticosteroid and long-acting beta agonist) as the reliever of choice. This anti-inflammatory option decreases exacerbations, and subsequently decreases OCS requirement, he says.

Professor Price feels that GPs are well placed to minimise harms from excessive OCS use, not just through judicious prescribing (and hopefully not issuing “just in case” scripts and excess repeats).

Any exacerbation requiring OCS should be an opportunity to revisit the underlying management. “How could this be prevented next time?” he asks. And when a patient says it’s “just a script” for their asthma meds, this is the perfect time to assess dosage, technique and symptoms – both with a view to deprescribing unnecessary medication (or down-titrating dose) and to up-titrating preventers to avoid an exacerbation.

Professor Price has studied PBS data on asthma prescribing in Australia, finding that many people with asthma are on very high dose inhaled corticosteroids, frequent courses of OCS, and that a proportion of patients are even on long term OCS for their asthma. “We’re seeing very, very high steroid use, and I would argue that we are actually poisoning many, many patients. Are we seeing side effects? The answer is yes.”

Some patients will continue to experience exacerbations despite maximal preventer triple therapy (with the addition of a long-acting muscarinic antagonist) and combination reliever. If the patient needs multiple courses of OCS, and we are sure the diagnosis is correct and the adherence is adequate, what should we do then?

“Refer them,” Professor Price says. “Because we have a really exciting arena now of biologics targeting a whole load of different mechanisms, all of which are very safe, all of which are proven to dramatically reduce exacerbations and the need for oral steroids, as well as improving other parameters of asthma.”

Professor Price is certainly not suggesting OCS are not used for asthma or COPD exacerbations. “They are appropriate and they are useful, but we need short courses of up to five days, and we need to keep the dose down,” he says. “Prevention is way, way better than treating an exacerbation.”