Assessment of an Oral Corticosteroid Withdrawal Pathway for Severe Asthma Patients Receiving Biologic Therapies

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

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

Patients with severe asthma 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 and then 3 mg daily for 6 weeks, followed by 09.00 serum cortisol measurement. Patients with cortisol greater than 25 nmol/L followed a 20-week weaning protocol. Serum cortisol was rechecked 12 weeks after stopping mOCS.

Of 102 patients, 92 had cortisol greater than 25 nmol/L with 3 mg prednisolone and continued weaning. A total of 73 (72%) successfully discontinued mOCS with median (interquartile range) cortisol increasing from 192 (88-299) nmol/L with 3 mg prednisolone to 314 (248-437) nmol/L at 12 weeks after discontinuation (P < .0001). Twenty-nine patients (28%) paused weaning owing 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 patients are currently well and receiving a median of 3.0 (3.0-3.9) mg prednisolone. Duration of prior oral corticosteroid use was significantly shorter in the group that was successfully weaned compared with those who failed weaning (P = 0.003). No serious adverse events occurred.

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