Page 129 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

Internet-based tapering of OCS in severe asthma
satisfaction with both tapering strategies showed to be similar and even tended to be in favour of the conventional asthma treatment, this seems highly unlikely. Therefore, the success of the internet based strategy does not seem to be biased by enthusiasm for the new intervention.
The design of the tapering algorithm was such that stable symptoms (increase in ACQ <0.5) would always lead to a reduction in corticosteroid dose, and increased symptoms (increase in ACQ ≥0.5) only to a step-up in dose if there was a concomitant increase in FeNO. This was to avoid overtreatment in patients with corticosteroid withdrawal symptoms or discordance between symptom expression and inflammation [33]. Post-hoc analysis showed that weekly ACQ (with FEV1 included) was the major driver of the algorithm decision, suggesting that corticosteroid sparing could have occurred without daily measures of FeNO. Whether daily FeNO measurements have additional value in predicting exacerbations in these patients is as yet unknown.
The major advantage of the internet-based management tool in the present study is twofold. First, it uses frequent objective measures of asthma control, and second, it provides the possibility of daily communication and feedback with an asthma nurse. Together, this allows rapid and safe adjustment of the corticosteroid dose under continuous supervision, which is not practicable in a conventional treatment setting. A sparing of 205 mg prednisone in 6 months is a significant clinical benefit, given that a difference of 55 mg in 6 months is associated with an adjusted odds ratio’s of 9.2 for vertebral fracture 3.1 for cataracts, and 3.3 for muscle weakness [3].
The use of internet-based therapies combined with novel technologies to assess disease severity will become more and more common in future health care [12-16]. Such technologies may allow centralized continuous long- distance support of patients, improve the quality of care, and reduce the time and efforts required for intensive monitoring processes such as tapering of oral corticosteroids. Therefore, the implementation of internet-based management tools in real life would increase the safety of the patient and improve the communication between patients and care givers.
In conclusion, we have shown that in patients with severe, prednisone- dependent asthma, oral corticosteroids can successfully be titrated by the use
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