Can oral corticosteroids (CS) be given to all bronchial asthma patients as a first-line treatment?

Oral Corticosteroids Should NOT Be Given to All Bronchial Asthma Patients

Oral corticosteroids are not appropriate as first-line treatment for all asthma patients and should be reserved for specific clinical scenarios: acute exacerbations, patients with frequent sleep interruptions or severe activity limitations despite optimal inhaled therapy, and those with very poorly controlled asthma. 1

First-Line Treatment for Asthma

Inhaled corticosteroids (ICS), not oral corticosteroids, are the most effective first-line controller medications and should be prescribed to all patients with persistent asthma. 1, 2 The stepwise approach prioritizes inhaled therapy because it delivers medication directly to the airways with significantly lower systemic absorption and toxicity compared to oral formulations. 3

Appropriate Use of Oral Corticosteroids in Asthma

Oral corticosteroids have three legitimate roles in asthma management:

1. Acute Exacerbations (Short Bursts)

• Short courses of oral corticosteroids (typically prednisolone 40-60 mg daily or 1-2 mg/kg/day for children, maximum 60 mg/day) for 3-10 days are effective for establishing control during acute exacerbations. 1
• These short bursts do not require tapering when used for less than two weeks. 1
• The maximal benefit occurs when administered in the morning (prior to 9 am) to align with natural cortisol rhythms. 4

2. Gaining Rapid Control in Chronic Asthma

• A short course may be considered for patients whose asthma frequently interrupts sleep or normal daily activities, or who are experiencing an exacerbation at assessment. 1
• This is a bridge to adequate inhaled corticosteroid therapy, not a maintenance strategy. 1

3. Severe, Refractory Asthma (Last Resort)

• Long-term oral corticosteroids should only be used when high-dose ICS plus long-acting beta-agonists fail to control symptoms. 1, 2
• When unavoidable, alternate-day therapy is preferable to minimize hypothalamic-pituitary-adrenal (HPA) axis suppression and other adverse effects. 4, 5

Why Oral Corticosteroids Are NOT First-Line

The risk-benefit profile strongly favors inhaled over oral corticosteroids for chronic asthma management:

• Systemic side effects: Long-term oral corticosteroid use causes glucose metabolism abnormalities, increased appetite, fluid retention, weight gain, hypertension, peptic ulcers, osteoporosis, growth suppression in children, and HPA axis suppression. 1, 4, 5
• HPA axis suppression risk: Any patient treated with corticosteroids for longer than 4 weeks requires evaluation for adrenal suppression, which can be life-threatening during stress or illness. 5
• Superior safety of inhaled therapy: ICS achieve therapeutic effects with minimal systemic absorption due to rapid inactivation after absorption from the respiratory tract. 3

Stepwise Treatment Algorithm for Asthma

Follow this evidence-based sequence 1, 2:

1. Mild intermittent asthma: As-needed low-dose ICS-formoterol 2
2. Mild persistent asthma: Low-dose ICS daily 1, 2
3. Moderate persistent asthma: Low-dose ICS plus long-acting beta-agonist (LABA) 2
4. Severe persistent asthma: High-dose ICS plus LABA 2
5. Very severe/refractory asthma: Consider adding oral corticosteroids only after maximizing inhaled therapy 1

Common Pitfalls to Avoid

• Never start oral corticosteroids without first ensuring therapeutic levels of bronchodilators and adequate doses of inhaled corticosteroids have been achieved. 5
• Do not discontinue ICS when adding LABA in patients already on combination therapy, as this increases exacerbation risk. 2
• Avoid prescribing long-term daily oral corticosteroids when alternate-day therapy or higher-dose ICS could achieve control. 4, 5
• Do not abruptly withdraw oral corticosteroids after prolonged use (>4 weeks); taper gradually to allow HPA axis recovery. 4, 5

Special Populations

Pregnancy: The major risk to the fetus is hypoxia from uncontrolled bronchospasm, not corticosteroid therapy itself. However, use the lowest possible dose of systemic corticosteroids needed to control symptoms, preferably with concurrent ICS. 5

Surgery: All asthmatics who have needed systemic or aerosolized corticosteroids within 6 months prior to surgery should receive perioperative corticosteroid coverage to prevent adrenal crisis. 5