Oral corticosteroids (OCS) are commonly used to manage acute exacerbations and as maintenance in some people with severe asthma. Although the need for maintenance OCS has been significantly reduced by the introduction of biologics and add-on therapies in severe asthma. Nevertheless, despite the availability of these alternative treatments, OCS continue to be overused and prescribed in asthma management. This overuse is linked to a wide range of adverse effects that can impact nearly every organ system. Short term effects such as dyspepsia, insomnia, thromboembolism, infection, fluid retention and mood changes, and long term effects such as weight gain, osteoporosis/fracture, cataracts, hypertension and metabolic disorders (Thomas & McDonald, 2025). Difficult to treat asthma can often lead to use of recurrent bursts of OCS use. The table below indicates prevalence of use and highlights the patient experience of the side effects of OCS usage. Evidence indicates that cumulative lifetime doses exceeding 1000mg of OCS significantly increases the risk of serious side effects and long-term organ damage, occurring in more than 25% of patients (Blakey et al. 2021). Further complicating the issue, is some patients are prescribed OCS in type 2-low asthma, which is less responsive to corticosteroids, akin to using antibiotics on a viral illness.
A position paper for written for the Thoracic Society of Australia and New Zealand (TSANZ) calls for OCS stewardship to manage their use in the treatment of asthma, reduce the detrimental side effects they can have on patients and move towards alternative treatments options. The Centre of Excellence will support the OCS stewardship programme focusing on optimising a balance between OCS efficacy and safety, and continued promotion of alternative agents. Monoclonal therapies (mepolizumab, benralizumab and dupilumab) have been proven to reduce the use of OCS in severe eosinophilic asthma by up to 75% (Blakey et al., 2021). Macrolide antibiotics (azithromycin) are also useful in mitigating the use of OCS. Shifting the focus to addressing modifiable and treatable traits in severe asthma such as improved medication adherence and technique, lifestyle factors such as smoking cessation, education and specialist input can prevent the worsening of symptoms and overall need for OCS.
In summary the core principles of OCS Stewardship should include:
- A focus on improving inhaler technique, adherence and optimising treatment to reduce the need for OCS
- Timely specialist assessments
- Consider biologic agents in patients with uncontrolled asthma as a priority
- Identify and manage comorbidities and risk factors including smoking cessation
- Placing restrictions on the way OCS are prescribed in both acute and primary care settings
- Understanding the perspectives of people with asthma is key to informing the implementation and translation of any OCS stewardship initiatives (Jones et al, 2025)
