P25 Assessment of an oral corticosteroid withdrawal pathway for severe asthma patients receiving biologic therapies

Résumé fourni par la source

Background Biologic therapies for severe asthma enable the cessation of maintenance oral corticosteroids (mOCS) for many patients. However, there is little consensus on how to wean OCS whilst avoiding adrenal insufficiency (AI). Several studies assessed the hypothalamic-pituitary-adrenal (HPA) axis once the patient reaches 5 mg daily of prednisolone, but this dose is supraphysiological for many patients, and inhaled corticosteroids further contribute to the exogenous steroid load. Thus there is inevitably HPA axis suppression in many which will not recover unless the OCS dose is reduced further. Aim We evaluated the feasibility of a protocol-driven nurse-led mOCS withdrawal pathway for severe asthma patients receiving biologics in our severe asthma service. Methods Patients with severe asthma receiving biologics and mOCS, who had good asthma control having reduced mOCS to 5mg prednisolone daily, entered the mOCS withdrawal pathway. Prednisolone dose was reduced by 1mg every 6 weeks to 3mg daily then serum cortisol was checked. Patients with cortisol <25 nmol/L were paused and referred to endocrinology. Those with serum cortisol ≥25 nmol/L followed a 20-week mOCS weaning plan. If mOCS were stopped, serum cortisol levels were re-checked 12 weeks later. All patients were given sick day rules. Results Ninety-six patients entered the pathway (age 64±13.6yr, mean FEV1=2.21±0.8L). Of these, 90 had cortisol levels >25 nmol/L on 3mg prednisolone and underwent further OCS weaning. 82% (n=74) of patients successfully stopped mOCS use with a median cortisol level of 194 (IQR 122–301) nmol/L on 3mg prednisolone, increasing to 321 (247–449) nmol/L 12 weeks after stopping prednisolone (p<0.0001). 18% (n=16) were unable to withdraw prednisolone either due to AI symptoms (56%), patient anxiety (25%), or clinician’s decision (19%). The median baseline cortisol in this group was 51.5 (25.7–136 nmol/L), and their current mOCS dose is 3 (3–4) mg prednisolone. Duration of prior OCS use at baseline was significantly lower in the successfully weaned group compared to those who failed (p=0.003). No serious adverse events such as adrenal crisis were reported. Conclusion 82% of clinically stable asthma patients receiving biologics successfully stopped their mOCS without need for dynamic testing of adrenal function.

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