A perspective on systemic corticosteroid therapy in severe bronchial asthma in adults.

BACKGROUND: Systemic corticosteroids have been used in the treatment of asthma since 1950 and are still required for the treatment of acute severe asthma and corticosteroid dependent asthma.

OBJECTIVE: To provide an updated overview of clinical considerations of systemic corticosteroids use in severe adult bronchial asthma.

METHODS: PubMed searches were undertaken of studies published between 1950 and 2015.

RESULTS: In this review the following concepts are discussed. 1) The onset of action of intravenous methylprednisone is 1-2 hours with a peak at 4-6 hours and duration of 12-30 hours. 2) Each patient should serve as their own control, using their best flow rates in the previous 6 months to 2 years. 3) The individual response to corticosteroid relates to the degree of obstruction at the time of onset of steroid treatment. 4) The pattern of response is variable but tends to be consistent for an individual patient. 5) In monitoring response to steroids frequent measures of peak expiratory flow rate and forced expiratory flow in 1 second are more useful than complete spirometric and lung mechanic tests measured less often. 6) In most cases oral steroids are as effective as parenteral regimens. 7) Patients usually respond in 3 days to 40 to 100 mg of methylprednisolone equivalent. 8) In corticosteroid resistant asthma consider compliance issues, allergen sensitivity, concomitant conditions, psychiatric factors and drug interactions. 9) Corticosteroid toxicity relates to the total lifetime dosage and serious side effects are usually not observed until a total dosage of 6.8 grams of prednisone equivalent.

CONCLUSION: Until we have a better understanding of the mechanisms of action of glucocorticoids, we will continue to rely on currently available systemic corticosteroids in severe asthma. The intrapatient consistency as discussed in this review, should guide therapy.