Assessment of an oral corticosteroid withdrawal pathway for severe asthma patients receiving biologic therapies

Background

The optimal approach for weaning maintenance oral corticosteroids (mOCS) in severe asthma patients receiving biologics remains unclear. Previous studies assessed hypothalamic-pituitary-adrenal function at 5 mg daily prednisolone, a supraphysiological dose for many, necessitating further mOCS reduction for adrenal recovery.

Objective

We evaluated a protocol-driven nurse-led mOCS withdrawal pathway with clinical oversight for severe asthma patients receiving biologics.

Methods

Severe asthma patients receiving biologics who had reduced mOCS to 5 mg prednisolone daily and maintained good asthma control, entered the withdrawal pathway. Prednisolone was decreased to 4 mg daily for 6 weeks then 3 mg daily for 6 weeks, followed by 09.00 serum cortisol measurement. Patients with cortisol >25 nmol/L followed a 20-week weaning protocol. Serum cortisol was re-checked 12 weeks after stopping mOCS.

Results

Of 102 patients, 92 had cortisol >25 nmol/L on 3 mg prednisolone and continued weaning. Seventy-three (72%) successfully discontinued mOCS with median [IQR] cortisol increasing from 192 [88-299] nmol/L on 3 mg prednisolone to 314 [248-437] nmol/L 12 weeks after discontinuation (p<0.0001). Twenty-nine patients (28%) paused weaning due to adrenal insufficiency symptoms (n=22), worse asthma control (n=1), anxiety (n=2) and other reasons (n=4). The baseline cortisol in this group was 53 [25-166] nmol/L, and they are currently well receiving median 3.0 [3.0-3.9] mg prednisolone. Duration of prior OCS use was significantly shorter in the successfully weaned group compared to those who failed (p=0.003). No serious adverse events occurred.

Conclusion

Most clinically stable asthma patients receiving biologics successfully withdrew mOCS without requiring dynamic adrenal function testing.