Internet-based tapering of oral corticosteroids in severe asthma: a pragmatic randomised controlled trial

Abstract

BackgroundIn patients with prednisone-dependent asthma the dose of oral corticosteroids should be adjusted to the lowest possible level to reduce long-term adverse effects. However, the optimal strategy for tapering oral corticosteroids is unknown. Objective To investigate whether an internet-based management tool including home monitoring of symptoms, lung function and fraction of exhaled nitric oxide (FE NO ) facilitates tapering of oral corticosteroids and leads to reduction of corticosteroid consumption without worsening asthma control or asthma-related quality of life. Methods In a 6-month pragmatic randomised prospective multicentre study, 95 adults with prednisone-dependent asthma from six pulmonary outpatient clinics were allocated to two tapering strategies: according to conventional treatment (n¼43) or guided by a novel internet-based monitoring system (internet strategy) (n¼52). Primary outcomes were cumulative sparing of prednisone, asthma control and asthma-related quality of life. Secondary outcomes were forced expiratory volume in 1 s (FEV 1 ), exacerbations, hospitalisations and patient's satisfaction with the tapering strategy. Results Median cumulative sparing of prednisone was 205 (25e75th percentile À221 to 777) mg in the internet strategy group compared with 0 (À497 to 282) mg in the conventional treatment group (p¼0.02). Changes in prednisone dose (mixed effect regression model) from baseline were À4.79 mg/day and +1.59 mg/day, respectively (p<0.001). Asthma control, asthma-related quality of life, FEV 1 , exacerbations, hospitalisations and satisfaction with the strategy were not different between groups. Conclusions An internet-based management tool including home monitoring of symptoms, lung function and FE NO in severe asthma is superior to conventional treatment in reducing total corticosteroid consumption without compromising asthma control or asthma-related quality of life. Clinical trial registration number Clinical trial registered with http://www.trialregister.nl (Netherlands Trial Register number 1146).

Oral Glucocorticoid-Sparing Effect of Mepolizumab in Eosinophilic Asthma

“…First, we assumed a relationship between a worsening of symptoms and an increase in eosinophilic airway inflammation, which may not be valid for all patients. 21 It is possible that if we had mandated evidence of eosinophilic inflammation in the optimization phase, a different drug effect would have been seen. Second, as with other studies of oral glucocorticoid withdrawal, our study was relatively short in duration and used a cautious strategy for oral glucocorticoid reduction.…”

The Clinical Utility of Fractional Exhaled Nitric Oxide (FeNO) in Asthma Management

“…Thus, FeNO had good utility to exclude exerciseinduced bronchoconstriction in atopic children. 104 In another study in which 33 percent of the asthmatic children age 4-7 had atopic dermatitis, FeNO values correlated with asthma severity, atopic dermatitis and steroids use; and marginally with allergic rhinitis (p=0.06). 105 And in a third study in patients aged 8-16 years with atopic asthma not receiving daily controller therapy and monitored bi-monthly over 2 years, loss of asthma control was predicted by the highest FeNO value of serial measurements and the percentage of sampling time points when FeNO > 21 ppb.…”

Severe refractory asthma: an update

“…Unfortunately, chronic systemic glucocorticosteroid use has serious dose-and time-dependent side-effects, such as osteoporosis, diabetes, hypertension, cataract formation and myopathy [69,70]. Therefore, tapering oral glucocorticosteroids to the lowest effective dose is of high priority [69]. Classical steroid sparing treatments including oral gold [71], methotrexate [72] and ciclosporin [73] have not gained acceptance because of limited effects and significant side-effects.…”

“…Still, many patients with the persistent eosinophilic phenotype need low dose systemic glucocorticosteroids to maintain acceptable asthma control [67,68]. Unfortunately, chronic systemic glucocorticosteroid use has serious dose-and time-dependent side-effects, such as osteoporosis, diabetes, hypertension, cataract formation and myopathy [69,70]. Therefore, tapering oral glucocorticosteroids to the lowest effective dose is of high priority [69].…”