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Review
. 2025 Aug;80(8):2113-2127.
doi: 10.1111/all.16569. Epub 2025 Jun 23.

Burden of Oral Corticosteroid Use in Severe Asthma: Challenges and Opportunities

G Walter Canonica  1   2 , Celeste Porsbjerg  3 , David B Price  4   5 , Michael E Wechsler  6 , Liam G Heaney  7 , Nicola A Hanania  8 , Rebecca Gall  9 , Nami Pandit-Abid  10 , Juby A Jacob-Nara  10 , Harry J Sacks  9
Affiliations
Review

Burden of Oral Corticosteroid Use in Severe Asthma: Challenges and Opportunities

G Walter Canonica et al. Allergy. 2025 Aug.

Abstract

Over the past 70 years, oral corticosteroids (OCS) have played an important role in the management of acute and chronic asthma; however, their use is associated with an increased incidence of adverse events, chronic diseases such as osteoporosis and diabetes, and mortality, as well as increased healthcare resource utilization and costs. Despite a consensus that the use of OCS should be minimized in asthma treatment strategies, many patients still routinely receive long-term or frequent short courses of OCS. Add-on biologics can help to improve asthma control in patients with severe asthma and evidence of type 2 inflammation; in clinical trials and real-world studies, both short- and long-term OCS-sparing effects have been demonstrated. In this review, we discuss the benefits and burdens of OCS in patients with severe asthma from the perspective of both patients and healthcare providers and outline potential methods for reducing reliance on OCS. Given the risk of adrenal insufficiency or crisis upon cessation of OCS, we discuss the need for clear guidance and algorithms for the tapering of OCS together with the requirement for multidisciplinary patient-provider interactions as part of an effective OCS stewardship scheme.

Keywords: OCS stewardship; biologics; dose sparing; oral corticosteroid; severe asthma.

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Conflict of interest statement

G. Walter Canonica has received research grants, lecture fees, and/or advisory board fees from A Menarini, Allergy Therapeutics, AstraZeneca, Chiesi Farmaceutici, Genentech, GSK, Guidotti‐Malesci, HAL Allergy, INNOVACAREMD, Novartis, OM Pharma, Red MAPLE, Regeneron Pharmaceuticals Inc., Sanofi, Stallergenes Greer, and Uriach Pharma. Celeste Porsbjerg has received research grants and consultancy and/or speaker fees from ALK, AstraZeneca, Chiesi, GSK, Novartis, Sanofi, and Teva; and advisory board fees from ALK, AstraZeneca, Novartis, Sanofi, and Teva. David B. Price has or had advisory board membership with AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Viatris, and Teva Pharmaceuticals; consultancy agreements with AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Viatris, and Teva Pharmaceuticals; grants and unrestricted funding for investigator‐initiated studies (conducted through Observational and Pragmatic Research Institute Pte Ltd) from AstraZeneca, Chiesi, Novartis, Regeneron Pharmaceuticals Inc., Sanofi Genzyme, UK National Health Service, and Viatris; payment for lectures/speaking engagements from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Inside Practice, GlaxoSmithKline, Medscape, Novartis, Regeneron Pharmaceuticals Inc., Sanofi Genzyme, Teva Pharmaceuticals, and Viatris; payment for travel/accommodation/meeting expenses from AstraZeneca, Boehringer Ingelheim, Novartis, Medscape, and Teva Pharmaceuticals; owns 74% of the social enterprise Optimum Patient Care Ltd. (Australia and UK) and 92.61% of Observational and Pragmatic Research Institute Pte Ltd. (Singapore); is peer reviewer for grant committees of the UK Efficacy and Mechanism Evaluation Programme and Health Technology Assessment; and he was an expert witness for GlaxoSmithKline. Michael E. Wechsler has received consulting and/or advisory honoraria from Allakos, Areteia Therapeutics, Arrowhead Pharmaceutical, Avalo Therapeutics, Belenos Bio, Celldex, Connect Biopharma, Eli Lilly, Equillium, Incyte, Jasper Therapeutics, Kinaset, Kymera, Merck, MyBiometry, Pharming, Phylaxis, Pulmatrix, Rapt Therapeutics, recludix Pharma, Roche/Genentech, Sentien, Sound Biologics, Tetherex Pharmaceuticals, Uniquity Bio, Verona Pharma, and Zurabio; consulting/advising/speaking honoraria from AstraZeneca, Amgen, GlaxoSmith Kline, Regeneron Pharmaceuticals Inc., and Sanofi/Genzyme and is doing research sponsored by them; has received consulting honoraria and stock options and is doing research sponsored by Upstream Bio. Liam G. Heaney has received grant funding, participated in advisory boards, and given lectures at meetings supported by Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, Circassia, Evelo Biosciences, GSK, Hoffman‐La Roche, Novartis, Sanofi, Teva, and Theravance Biopharma; grants from Aerocrine, Amgen, AstraZeneca, Genentech/Hoffman‐La Roche, GSK, MedImmune, Novartis, Roche‐Genentech, and Vitalograph; sponsorship to attend international scientific meetings from AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, and Napp Pharmaceuticals; and institutional remuneration for participation in asthma clinical trials sponsored by AstraZeneca, Boehringer Ingelheim, GSK, and Hoffman‐La Roche; and is academic lead for the Medical Research Council Stratified Medicine UK Consortium in Severe Asthma, which involves industrial partnerships with a number of pharmaceutical companies, including Amgen, AstraZeneca, Boehringer Ingelheim, GSK, Hoffman‐La Roche, and Janssen. Nicola A. Hanania has received consultancy or advisor honoraria from Amgen, AstraZeneca, Boehringer Ingelheim, GSK, Novartis, Sanofi, and Teva; and grant support to the institution from AstraZeneca, Boehringer Ingelheim, Genentech, GSK, Novartis, and Sanofi. Rebecca Gall is an employee of and shareholder in Regeneron Pharmaceuticals Inc. Nami Pandit‐Abid is an employee of Sanofi and may hold stock and/or stock options in the company. Juby A. Jacob‐Nara is a former employee of Sanofi and may hold stock and/or stock options in the company. Harry J. Sacks is an employee of Regeneron Pharmaceuticals Inc. and may hold stock and/or stock options in the company. He has also been a shareholder of Optinose Inc.

Figures

FIGURE 1
FIGURE 1
Barriers to reducing OCS use in patients with severe asthma. Developed from Chung 2020 [17]. OCS, oral corticosteroids.
FIGURE 2
FIGURE 2
Schematic of consensus protocol for OCS tapering and down‐titration. aAdrenal insufficiency (AI) should be assessed routinely in the morning with fasting cortisol. If intermediate results are obtained, a (short) tetracosactide/cosyntropin assessment should follow. Management of AI should be cross‐disciplinary and include an endocrinologist. bComorbidities to be screened for should include (but not be limited to): blood pressure, bone density, cataracts and glaucoma, fracture risk score, glycemic control, weight change, and growth in pediatric populations. Recommendations regarding the frequency of comorbidity screening vary. ABPA = allergic bronchopulmonary aspergillosis; ACQ = asthma‐control questionnaire; ACTH = adrenocorticotropic hormone; EGPA = eosinophilic granulomatosis with polyangiitis; HPA = hypothalamic–pituitary–adrenal axis; OCS = oral corticosteroid. Adapted with permission from Suehs et al. [122, 123].
See this image and copyright information in PMC

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