A third of patients with severe asthma are taking harmful doses of oral steroids, according to a study of several thousand people in the Netherlands, presented this week at the European Respiratory Society International Congress.

The majority of these patients could avoid taking oral steroids by improving their adherence to their other asthma medication and their inhaler technique, Katrien Eger, MD, told the congress. However, there remains a proportion who might be eligible for treatment with new biologic asthma drugs, yet only half are receiving them.

“Asthma patients using high doses of oral steroids are at risk of serious adverse effects such as diabetes, osteoporosis and adrenal insufficiency, in which the adrenal glands do not produce adequate amounts of steroid hormones,” says Eger, a PhD student and pulmonologist in training at Amsterdam University Medical Centre in the Netherlands. “Our findings show that many patients with severe asthma are taking harmfully high doses of oral steroids. Every prescription for oral steroids should alert doctors to assess adherence to inhaled therapies and inhalation techniques in these patients. Furthermore, now that there is an increasing number of biologic asthma drugs available that avoid the need for oral steroids, doctors should initiate biologic treatment in suitable patients to reduce exposure to harmful oral steroids.”

Eger and her colleagues analyzed information from a pharmacy database of 500,500 Dutch inhabitants to identify patients who were using high doses of inhaled corticosteroids (500 micrograms or more a day) plus long-acting beta agonists, and who were identified as having severe asthma according to the Global Initiative for Asthma (GINA). The database also contained information on oral steroid use (cortisone). The researchers sent questionnaires to 5002 of these patients and then analyzed the 2312 that were returned. Information from the pharmacy database enabled them to collect information on oral steroid use and adherence to medication. Pharmacists assessed inhaler technique in a sample of the patients.

The questionnaire asked about medical history, including any other medical conditions, asthma diagnosis and control, and smoking history. If prescriptions were completed 80% or more of the time, the patients were considered to be adherent to their medication.

“We found that 29% of asthma patients who were using high doses of inhaled steroids were also taking harmfully high doses of oral steroids of 420 milligrams a year or more,” says Eger. Of these patients, 78% had poor adherence to inhaled medication or incorrect inhalation technique. So these problems should be tackled first in these patients before considering biologic treatment. The remaining 22% are candidates for biologic drugs.

“If we extrapolate our results from the database to the general Dutch population, this would mean that there are about 6000 patients with severe asthma who are candidates for biologic treatment – 1.5% of the whole asthma patient population. But less than half – 46% – are currently receiving it. This shows that there is potential to substantially reduce oral steroid overuse.”