Page 39 - Škrgat, Sabina, ed. 2022. Severe Asthma - Basic and Clinical Views. Koper: University of Primorska Press. Severe Asthma Forum, 1
P. 39
wareness is therefore needed, if we consid- - dose or duration of systemic GC
er the evidence that a lifetime cumulative sys- treatment is cause for concern,
temic GC load of 0.5-1 g was associated with
diabetes, while most other adverse effects - asthma control is achieved (especial-
emerged at 1 to less than 2.5 g5. ly with biologics),
Therefore, a routine screening using a - there is a reasonable likelihood of
minimal checklist for adverse effects and co- HPA axis recovery.
morbidities is recommended in all patients
with asthma on systemic GC treatment (Ta- Table 2. Consensus information on systemic GC
ble 1). tapering and suggested tapering speeds according
to current systemic GC (methylprednisolone) dose21
Table 1. Minimal checklist for glucocorticoid
adverse effects screening21 Daily dose ≥ 16 mg Daily dose 8-16 mg Daily dose 4-8 mg 39
Glycemic control Faster pace Medium pace Slower pace
Bone mineral density
Reduce by 8 mg/ Reduce 2-4 mg Reduce by 1-2 mg
Blood pressure week or 30-50 % every 1-2 weeks every 1-2 weeks
Cataracts and glaucoma every 2-4-weeks
Weight change During systemic GC tapering patients challenges of systemic glucocorticoids taper in the treatment of severe asthma
Fracture risk assessment (e.g., FRAX) should be continuously evaluated for adrenal
insufficiency (AI), comorbidities, and asthma
Definition of abbreviation: FRAX=Fracture Risk symptoms. If GC taper is intolerable, tapering
Assessment Tool. attempts should be stopped and postponed to
a later date. Return to previous efficacious
According to the expert consensus sys- dose is also recommended. When symptoms
temic GC tapering should be initiated only are mild, current GC dose should be main-
when it is considered appropriate for the clini- tained and tapering speed should be reduced.
cal situation and asthma phenotype.
Proceeding toward GC cessation is sug-
Three common baseline clinical scenari- gested when:
os were provided21:
- daily systemic GC dose is ≤ 4 mg of
1. Do not attempt tapering in EGPA (eosin- methylprednisolone,
ophilic granulomatosis with polyangii-
tis) and ABPA (allergic bronchopulmo- - a sparing strategy has been initiated,
nary aspergillosis) that relapses during - the patient has agreed to cessation,
tapering and no other changes can be - there is no evidence of EGPA/ABPA,
proposed. - there is no evidence of adrenal insuffi-
2. Tapering with caution in cases with: ciency.
- history of life-threatening attacks,
- systemic GC dependence for extend- AI is very common among users of sys-
temic GC after tapering22 and experts21 agreed
ed period (e.g., more than 6 months), that this condition is insufficiently assessed or
- in patients with comorbidities that underrecognized. Risk factors for develop-
ment of GC-induced AI include the duration
respond to systemic GC. of GC therapy, mode of administration (e.g.,
3. Tapering should be done if: oral vs. inhaled), GC dose and potency, con-
- systemic GC result in no asthma im- comitant drugs that interfere with GC me-
tabolism, and individual susceptibility. Im-
provement and/or side effects, portantly, the risk of developing GC-induced
AI is difficult to predict on an individual b asis
er the evidence that a lifetime cumulative sys- treatment is cause for concern,
temic GC load of 0.5-1 g was associated with
diabetes, while most other adverse effects - asthma control is achieved (especial-
emerged at 1 to less than 2.5 g5. ly with biologics),
Therefore, a routine screening using a - there is a reasonable likelihood of
minimal checklist for adverse effects and co- HPA axis recovery.
morbidities is recommended in all patients
with asthma on systemic GC treatment (Ta- Table 2. Consensus information on systemic GC
ble 1). tapering and suggested tapering speeds according
to current systemic GC (methylprednisolone) dose21
Table 1. Minimal checklist for glucocorticoid
adverse effects screening21 Daily dose ≥ 16 mg Daily dose 8-16 mg Daily dose 4-8 mg 39
Glycemic control Faster pace Medium pace Slower pace
Bone mineral density
Reduce by 8 mg/ Reduce 2-4 mg Reduce by 1-2 mg
Blood pressure week or 30-50 % every 1-2 weeks every 1-2 weeks
Cataracts and glaucoma every 2-4-weeks
Weight change During systemic GC tapering patients challenges of systemic glucocorticoids taper in the treatment of severe asthma
Fracture risk assessment (e.g., FRAX) should be continuously evaluated for adrenal
insufficiency (AI), comorbidities, and asthma
Definition of abbreviation: FRAX=Fracture Risk symptoms. If GC taper is intolerable, tapering
Assessment Tool. attempts should be stopped and postponed to
a later date. Return to previous efficacious
According to the expert consensus sys- dose is also recommended. When symptoms
temic GC tapering should be initiated only are mild, current GC dose should be main-
when it is considered appropriate for the clini- tained and tapering speed should be reduced.
cal situation and asthma phenotype.
Proceeding toward GC cessation is sug-
Three common baseline clinical scenari- gested when:
os were provided21:
- daily systemic GC dose is ≤ 4 mg of
1. Do not attempt tapering in EGPA (eosin- methylprednisolone,
ophilic granulomatosis with polyangii-
tis) and ABPA (allergic bronchopulmo- - a sparing strategy has been initiated,
nary aspergillosis) that relapses during - the patient has agreed to cessation,
tapering and no other changes can be - there is no evidence of EGPA/ABPA,
proposed. - there is no evidence of adrenal insuffi-
2. Tapering with caution in cases with: ciency.
- history of life-threatening attacks,
- systemic GC dependence for extend- AI is very common among users of sys-
temic GC after tapering22 and experts21 agreed
ed period (e.g., more than 6 months), that this condition is insufficiently assessed or
- in patients with comorbidities that underrecognized. Risk factors for develop-
ment of GC-induced AI include the duration
respond to systemic GC. of GC therapy, mode of administration (e.g.,
3. Tapering should be done if: oral vs. inhaled), GC dose and potency, con-
- systemic GC result in no asthma im- comitant drugs that interfere with GC me-
tabolism, and individual susceptibility. Im-
provement and/or side effects, portantly, the risk of developing GC-induced
AI is difficult to predict on an individual b asis
