Burden of Oral Corticosteroids in Severe Asthma: Key Takeaways from a 2025 Review

For over 70 years, oral systemic corticosteroids (OCS), such as prednisolone, have been a cornerstone in severe asthma treatment, especially for flare-ups.

While effective, they are linked to serious side effects, such as gastrointestinal symptoms, osteoporosis, diabetes, cataracts, depression, and increased healthcare costs.

Despite widespread agreement that OCS use has side effects, many people with severe asthma still rely on frequent short courses or long-term treatment alongside or instead of Oral Topical Steroids (OTS) such as fluticasone/budesonide taken via inhalers. 

A 2025 review published in the Allergy (European Journal of Allergy and Clinical Immunology) highlights the health and economic burdens of OCS and explores ways to reduce reliance on OCS, especially with biologics and structured tapering.

Please note that this Severe Asthma review focused on systemic OCS, a systemic treatment via the bloodstream that affects the whole body. This is different from the oral topical steroids sometimes prescribed for Eosinophilic Oesophagitis (EoE), such as Jorveza® (budesonide tablets) or swallowed Flixotide® (fluticasone) that act locally in the oesophagus.

Why OCS Are Still Used

The review recognises several benefits of OCS:

  • Effective in controlling acute exacerbations and reducing hospitalisation risk.
  • Lower chance of worsening symptoms in the next 7–10 days after an attack, compared to those who take a placebo.
  • Inexpensive and widely available.
  • Many patients view OCS as a “safety net.”

Main Burdens of OCS Use

Adverse Effects and Mortality

Even short courses of OCS can cause side effects. Long-term use is associated with comorbid conditions, including gastrointestinal issues, weight gain, hypertension, diabetes, osteoporosis, cataracts, and mental health disorders. These conditions are often irreversible. Stopping OCS suddenly can also trigger adrenal insufficiency, a potentially life-threatening complication.

Increased Healthcare Use

Patients who rely on OCS make more GP visits and hospital or emergency department admissions than those who do not. Much of this extra healthcare use is due to steroid side effects rather than asthma itself.

Higher Costs

Healthcare costs, including pharmacy, inpatient, and outpatient care, are consistently higher for OCS users. Indirect costs are also increased, with some patients taking longer sick leave or retiring earlier due to complications.

Remission challenges

OCS dependence makes achieving clinical asthma remission (no symptoms and no systemic steroid use for 12 months) more difficult. Patients with frequent exacerbations are less likely to reach remission.

Biologics

Most patients with severe asthma have underlying type 2 inflammation, with type 2 inflammatory pathways thought to contribute to symptoms in most patients with severe asthma. This makes them eligible for biologic treatments.

Approved biologics include:

  • Omalizumab (targets IgE)
  • Mepolizumab and Reslizumab (target IL-5)
  • Benralizumab (targets IL-5 receptor α)
  • Dupilumab (blocks IL-4/IL-13)
  • Tezepelumab (targets  thymic stromal lymphopoietin, TSLP)

Studies show that biologics can lower OCS use, reduce severe asthma attacks, and potentially offset high drug costs by reducing hospitalisations.

Learn more about biologics

Barriers to Reducing OCS

Despite the risks, reducing OCS use is not always straightforward.

Healthcare system gaps: Prescriptions are often issued by different providers without a full picture of the patient’s total OCS use. Many patients are also not referred to specialist asthma services, delaying access to alternatives.

Prescriber challenges: Some clinicians may be unaware of current OCS stewardship recommendations or reluctant to adjust treatment if a patient seems stable on steroids.

Access to biologics: While biologics can reduce or replace the need for OCS, they are costly, often limited to high-income countries, and prescribing criteria vary widely across healthcare systems.

Patient complexity: OCS are sometimes prescribed for other coexisting conditions, such as chronic rhinosinusitis with nasal polyps or atopic dermatitis, making tapering decisions more difficult. Some patients are understandably reluctant to reduce or stop oral corticosteroids.

Stewardship and Tapering of OCS

Because sudden withdrawal can trigger adrenal crisis, OCS tapering must always be gradual, medically supervised, and tailored to the patient.

Key recommendations from the review:

  • Biologics can make tapering more feasible, even in long-term users, but clear guidance is lacking.
  • Stepwise tapering protocols with regular monitoring (such as cortisol testing) are essential.
  • Every patient on maintenance OCS should be assessed by a multidisciplinary team to review eligibility for biologics, comorbidities, and treatment adherence.
  • In countries with limited access to biologics, strategies such as early specialist referral, stepwise care, and patient education campaigns to raise awareness about the risks of OCS use and alternative treatments for asthma are crucial.

Conclusion

The authors stress that OCS use in severe asthma should be minimised as even short courses can cause serious side effects.

  • Biologics are highlighted as an important option to help patients reduce or stop OCS, but more guidance is needed on how best to taper steroids safely.
  • Every patient should receive an individualised care plan, taking into account their overall health, asthma type, and treatment options.
  • Ongoing communication between patients and healthcare providers is essential to manage asthma effectively while avoiding unnecessary OCS use.

Read the full publication

References:

Canonica GW, Porsbjerg C, Price DB, et al. Burden of Oral Corticosteroid Use in Severe Asthma: Challenges and Opportunities. Allergy. 2025;80(8):2113–2127. https://doi.org/10.1111/all.16569

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Author: Olena Filatova

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