Page 13 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

Glucocorticoid-dependent severe asthma: balance between disease control and serious side effects.
Case vignette:
Mr B., a 40-year-old never-smoking man with a six-year history of oral glucocorticoid-dependent asthma visits the pulmonologist for advice regarding his chronic use of glucocorticoids. After a second episode of pulmonary embolism, he is worried that the side effects of this medication are more life threatening than his asthma.
Despite an optimal medication regimen and apparently good adherence, Mr. B. has persistent asthma symptoms that require the daily use of short- acting β-agonists, with impairment of activities of daily life and an average of three asthma exacerbations per year for which he receives bursts of oral glucocorticoids.
In addition to recurrent pulmonary embolisms, he exhibits several components of an exogenous Cushing’s syndrome including osteoporosis, myopathy and diabetes. Previous attempts to taper down the prednisolone failed due to worsening of his asthma control.
The pulmonologist refers Mr. B. to a specialized asthma center to adjust his medication regimen, including a reevaluation of the indication for oral glucocorticoids, possible alternative treatment and titration of the glucocorticoids to the lowest possible dose.
The clinical problem: glucocorticoid-dependent severe asthma
Asthma is a heterogeneous chronic disease of airways in which inflammation plays a key role [1]. The implementation of international guidelines [1-3] emphasizing the use of preventive anti-inflammatory medication [4] was a milestone in the management of patients with persistent asthma. The regular use of inhaled glucocorticoids not only reduces the number and severity of exacerbations [4-6] but also restrains the decline in lung function [7], thereby improving the course of the disease in the majority of the patients with asthma [8-11].
Nevertheless, in approximately 5% of patients with asthma the use of inhaled corticosteroids does not lead to the desired effect [12;13]. Despite all the diagnostic and management steps recommended by the guidelines [1;2], these patients remain very symptomatic with restricted quality of life,
General introduction and aims of the thesis
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