Page 117 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

Internet-based tapering of OCS in severe asthma
Introduction
Despite the regular use of high doses of inhaled corticosteroids and long- acting bronchodilators patients with severe asthma may require frequent bursts or even depend on daily oral corticosteroids. [1;2]. In the majority of these patients the use of systemic corticosteroids leads to serious adverse effects, including osteoporosis, bone fractures [3], diabetes, hypertension, cataract and muscle weakness [4]. These adverse effects may seriously affect patients’ quality of life and have considerable public health implications [5]. Since adverse effects are dose and time dependent, systemic corticosteroids should be used in the lowest possible dose [3;4;6].
Tapering oral corticosteroids in patients with severe asthma remains a challenge [7]. These patients although relatively few, generally require considerable time and resources because their disease is often complicated by co-morbidities [8], steroid-resistance [9] and fixed airflow limitation [10]. Moreover, patients with suppressed HPA axis or psychological dependencies may have unpredictable or unsuspected responses to tapering [11]. This is why patients are often prescribed higher doses of oral corticosteroids than strictly indicated which leads to unnecessarily high cumulative doses of oral corticosteroids [12].
Currently, there are no guidelines on how to safely taper oral corticosteroids in severe asthma [6]. Generally, clinicians make occasional attempts to reduce the dose of oral corticosteroids based on symptoms, physical signs and lung function. Ideally, tapering should be a continuous, dynamic and personalized process based on frequent evaluations, objective parameters of disease severity and constant monitoring of risks. In conventional settings it can be quite complicated to achieve this ideal situation, both for patients and physicians. Therefore, internet-based management strategies have been developed to enhance feasibility and effectiveness of intensive monitoring. Many examples of internet-based applications can be found in the management of chronic diseases and severe patients, including HIV [12], diabetes [13], hypertension [14,] asthma [15;16] and lung transplantation [17]. The recent development of hand-held devices to measure lung function and exhaled biomarkers at home, also provide new opportunities for more frequent and accurate adjustments of asthma therapy [18].
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