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

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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.

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