Oral corticosteroids

Abstract

Refer to the publication for information on:

• history of OCS use
• the need for an OCS stewardship
• How OCS are use, why and at what dose
• How to minimise exposure
• guidelines recommendations
• current use of OCS in asthma  (evidence or overuse or over-reliance)
• Harm from OCS use (risk with short-term and long-term use, adrenal insufficiency, cumulative risk)
• perspectives from people with asthma
• Principles of prevention of overuse
• harm reduction strategies
• Core principles of OCS stewardship in asthma

Download a copy here: Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand – PMC

AIHW report where you can find time series of OCS prescriptions for respiratory conditions, by SA4 geographical areas.

Select Dashboard, PBS prescription data. Also provides comparative data at the state and national level.

In Australia and New Zealand, research has shown that more than a third of severe asthma patients used toxic cumulative doses of OCS in just one year, with further escalation within 2 years.

Data from the Australiasian Severe Asthma Registry between 2013 and 2021 shows that, amongst 924 patients with severe asthma in Australia and new Zealand:
– 23% were taking maintenance OCS at baseline
– 26% were taking biologics at baseline, benefitting from biologics
– 44% received over 500mg cumulative OCS within a year
– 32% received over 1000mg cumulative OCS within a year
– an additional 10% reached 500mg OCS within 2 years
– an additional 9% reached 1000mg OCS within 2 years
– People exceeding the OCS thresholds had poor asthma control
– 12% were identified as potentially benefitting from biologics, of whom only 23% commenced biologics within 12 months

Conclusion: toxic cumulative doses of OCS were reached in just one year in more than a third of severe asthma patients, with further escalation within 2 years.

More than 1 in 5 people with asthma using high-dose ICS/LABA regularly (filling at least 2 prescriptions within 6 months) received a dose of OCS sufficient to cover 2 exacerbations or more within those 6 months.
A recent study analysing prescription medications dispensed by about 82% of community pharmacies in Australia reported that:
– 22% of patients with difficult to treat asthma (defined as filling at least 2 prescriptions of high-dose ICS/LABA in 6 months) received sufficient OCS to cover at least 2 exacerbations within 6 months
– 10% of patients with difficult to treat asthma (defined as filling at least 2 prescriptions of high-dose ICS/LABA) received 1000mg or more OCS within 6 months
– 13% of patients with difficult to treat asthma (defined as filling at least 4 prescriptions of high-dose ICS/LABA; stringent analysis) received 1000mg or more OCS within 6 months

Geographical areas: Heat maps SA3 areas
Refer to Table 1 and Figure 3, map A for proportion of difficult to treat asthma, map B for proportion of difficult to treat asthma receiving 2 OCS scripts or more within 6 months, and map C for proportion of OCS above 1000mg within 6 months.

Difficult to treat asthma (defined as at least 2 prescriptions for high-dose ICS/LABA in 6 months):
– SA3 regions with the highest proportions of difficult to treat asthma were located more frequently in WA (22/36) followed by NT (2/9), VIC (14/66), TAS (2/15) and NSW (9/95)
– region with highest proportion (48%) was in WA, followed by a region on NSW (43%)

Uncontrolled asthma among difficult to treat asthma (prescription of enough OCS within 6 months to treat 2 exacerbations):
– SA3 regions with the highest proportions of uncontrolled asthma were located more frequently in SA (7/28) followed by TAS (3/15), VIC (9/66), QLD (5/82) and NSW (5/95)
– region with highest proportion of uncontrolled asthma (67%) was in NSW

1000mg OCS or more within 6 months among difficult to treat asthma:
– in 29 SA3 regions, 13% to 34% of patients with difficult to treat asthma were prescribed 1000mg OCS or more within 6 months. Most of them located in the Eastern half of Australia
– highest rate (34%) was in a region in NSW
– lowest rate (3%) was in a region in NT

A. Proportions of difficult to treat asthma (2 or more high-dose ICS/LABA in 6 months)

B. Proportions of uncontrolled asthma (OCS prescription sufficient for 2 or more exacerbations in 6 months) among difficult to treat asthma
C. Proportions receiving 1000mg or more OCS within 6 months among difficult to treat asthma

Powerpoint presentation to PAC on Oral Corticosteroids Stewardship, March 2022.

See presentation link: https://asthmafoundation.sharepoint.com/:p:/s/RPA/EY2QXo10ODtFoxIDMknRRpUBBMUZdoZowRz3KyOone7dGw?e=ZRBUaV

Long-term longitudinal study by David Price demonstrating increased cumulative risk at 1000mg OCS cumulative use.

Epidemiological study based on PBS data, providing useful statistics on OCS use in asthma in Australia.

About 1 in 4 people with asthma using preventer medicines receive potentially toxic cumulative doses of OCS (over 5 years). Half of those using high-dose ICS preventers and potentially toxic doses of OCS are not using their preventer regularly. (ref 1)

In Australia, amongst people with asthma aged 12 and over that were prescribed inhaled corticosteroids: (ref 1)
– 52% used OCS between 2014 and 2018
– 28% received 1000mg or more prednisoline-equivalent during the 5-year period
– 10% of those using high dose ICS/LABA preventer during 2018 received 1000mg prednisolone equivalent or more over the 12-month period, with half of them (50%) using their preventer infrequently and therefore inadequately
– 5.5% of those using ICS alone or low-moderate dose ICS/LABA preventer during 2018 received 1000mg prednisolone equivalent or more over the 12-month period, with 68% of them using their preventer infrequently and therefore inadequently
– OCS were prescribed in 2018 mostly by GPs (76%), followed by non-specialists (19%) and respiratory specialists (5.5%)

Fig from position paper (Blakey et al, ref 2)

OCS are frequently used in asthma in both acute (flare-ups) and chronic disease (severe asthma), despite the emergence of new treatments. OCS prescribing remains embedded in patient care.

Long-term or maintenance OCS is used in 20-60% of uncontrolled or severe asthma.

OCS inappropriate use frequently occurs in people with mild-moderate asthma that is poorly controlled due to poor adherence to or underuse of inhaled corticosteroid (ICS) therapy.

Download a copy here: Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand – PMC

Steroids-related side effects are associated with both short-term use and long-term use of OCS (ref 1), and affect all parts of the body:

Importantly, the risk of emergency department visit, hospitalisation and death increases with increasing exposure to OCS. (ref 1,2)

A cumulative dose of just 1000mg prednisolone (or equivalent) over a lifetime is enough to significantly increase the risk of most adverse events in adults. This lifetime exposure toxic threshold can be reach in just 4 typical courses of OCS for asthma exacerbations. (ref 1,2)

A cumulative dose as low as 500 mg prednisolone (or equivalent) has been associated with a significant increased risk of adverse outcomes. (ref 2,3)

OCS stewardship represents the careful and responsible management of OCS prescribing, aiming to:
– prevent harm, by reducing exacerbations and therefore OCS use
– minimise harm, by reducing dose and treatment duration when OCS are required