Page 18 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

Chapter 1
may occur in previously stable patients [69]. Sleep disturbances such insomnia and agitation are also well-recognized and unpleasant consequences of glucocorticoid consumption [70].
Chronic use of systemic steroids is the main cause of adrenal insufficiency [71;72], a very serious and often under-diagnosed condition which can eventually lead to adrenal crisis and death. A meta-analysis on risks for adrenal insufficiency described that up to 27,4% of patients with asthma can develop adrenal insufficiency when using glucocorticoids for longer than 1 year [71].
Once again, minimizing or eliminating the consumption of systemic glucocorticoid in a controlled, safe way is crucial to reduce the likelihood of adverse events and improve patients’ outcomes [65].
Management of patients with glucocorticoid-dependent asthma
Patients using chronic systemic glucocorticoids require an extensive and careful management strategy that not only addresses asthma control but also the patient’s overall health status [73-75].
The ideal strategy should include the steps summarized below. Many of these steps are already part of the management workflow of patient with severe asthma before they become dependent on systemic glucocorticoids. Nevertheless, it is always wise to recapitulate important basic concepts before considering the introduction of additional and costly therapy.
1. Refer the patient to a specialized asthma center, as recommended by international consensus and guidelines [1;14;15;19].
2. Check for differential or additional diagnoses, rule out aggravating factors, and do not overlook the potential worsening effect of occupational [76] and environmental exposures [77] on asthma symptoms.
3. Optimize the patient’s current asthma therapy
Adherence to treatment is essential to improve asthma outcomes and achieve disease control [78;79]. Nevertheless, the number of severe asthma patients with insufficient adherence is alarming [80]. Given that the causes of poor adherence
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