Trends in oral corticosteroids use in severe asthma: a 14-year population-based study

Abstract

Background Oral corticosteroids are important components of pharmacotherapy in severe asthma. Our objective was to describe the extent, trends, and factors associated with exposure to oral corticosteroids (OCS) in a severe asthma cohort. Methods We used administrative health databases of British Columbia, Canada (2000–2014) and validated algorithms to retrospectively create a cohort of severe asthma patients. Exposure to OCS within each year of follow-up was measured in two ways: maintenance use as receiving on average ≥ 2.5 mg/day (prednisone-equivalent) OCS, and episodic use as the number of distinct episodes of OCS exposure for up to 14 days. Trends and factors associated with exposure on three time axes (calendar year, age, and time since diagnosis) were evaluated using Poisson regression. Results 21,144 patients (55.4% female; mean entry age 28.7) contributed 40,803 follow-up years, in 8.2% of which OCS was used as maintenance therapy. Maintenance OCS use declined by 3.8%/calendar year (p < 0.001). The average number of episodes of OCS use was 0.89/year, which increased by 1.1%/calendar year (p < 0.001). Trends remained significant for both exposure types in adjusted analyses. Both maintenance and episodic use increased by age and time since diagnosis. Conclusions This population-based study documented a secular downward trend in maintenance OCS use in a period before widespread use of biologics. This might have been responsible for a higher rate of exacerbations that required episodic OCS therapy. Such trends in OCS use might be due to changes in the epidemiology of severe asthma, or changes in patient and provider preferences over time.

Characteristics of Oral Corticosteroid Users Among Persons with Asthma on GINA Step 3 Therapy and Above: A Cross-Sectional Study in Portuguese Community Pharmacies

“…OCS users were then classified into low-dose users (<2.5mg prednisolone/day/year) and high-dose users (≥2.5mg prednisolone/day/year). 21,22 For subgroup analysis (OCS users vs non-OCS users), the Chi-square test for independence or Fisher exact test were used for categorical variables, as appropriate, and non-parametric test such as Mann-Whitney Wilcoxon test was used for continuous variables (after rejecting the normality and homoscedasticity assumption for parametric tests). OCS use was defined as having used OCS at least once in the previous 12 months.…”

“…OCS users were then classified into low-dose users (<2.5mg prednisolone/day/year) and high-dose users (≥2.5mg prednisolone/day/year). 21 , 22 …”

Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group

“… 16 Furthermore, recent population-based studies demonstrate that many people receiving SCS are exposed to relatively high doses over a prolonged period of time, increasing their risk of AEs. 17 , 18 , 19 During a study in the European Union from July 2011 to February 2018 (N = 702,685), 14–44% of the patients with asthma were receiving OCS and 6–9% were "high-OCS users" with an average dose of 5.5–7.5 mg/day for ≥2 years. 18 Similarly, a study from January 2012 to December 2017 in the United States (N = 435,675) reported that 65% of patients with asthma were receiving OCS over the 2-year follow up, and 19% were classed as "high-OCS users" with an average dose of 5.1–7.1 mg/day over 3 years.…”

“… 20 Variation in the prevalence of SCS use globally and regionally may be attributed to multiple factors, including patient age, sex, disease severity, socioeconomic status, level of ICS use, and access to and reimbursement of alternative therapies. 3 , 16 , 17 , 21 Additional challenges are faced by children with asthma receiving SCS, who are at an increased risk of AEs compared with children with asthma not receiving SCS, yet the prevalence of SCS use in children with asthma remains high. 22 …”

Oral corticosteroid-sparing effects of mepolizumab in severe eosinophilic asthma: evidence from randomized controlled trials and real-world studies

“…Indeed, even short-term OCS use is associated with sleep disturbance and an increased risk of infections, bone fractures, and thromboembolism, 12 and OCS bursts (OCS use for ⩽14 days) are associated with increased risk of gastrointestinal bleeding, sepsis, and heart failure within a month after treatment initiation. 29 Notably, the benefit of reducing long-term OCS may often be countered by an increased need for short-term OCS, 30 as any reduction in OCS use must be balanced with the risk of asthma exacerbations requiring rescue therapy. Overall, OCS use is a major contributor to the substantial risk among patients with severe asthma, worsening prognosis and potentially reducing life expectancy.…”