Page 20 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

Chapter 1
to interfere with prednisolone levels [92] including some antiepileptics, antibiotics, diuretics, antihypertensives and other commonly used drugs. This interaction may cause a reduced therapeutic effect or a potentialization of the side effects of the medication.
5. Tapering of systemic glucocorticoid to the lowest effective dose
Some specialists recommend a slow but steady tapering of the dose; others advise alternate-day intake of oral steroids [75;93]. In fact, there are no evidence-based guidelines for the ideal tapering scheme. The main challenge in reducing the dose of systemic glucocorticoids is to keep the balance between the lowest dose of the drug and an acceptable level of asthma control, so that a flair-up will be avoided.
Tapering systemic glucocorticoids may also lead to withdrawal symptoms, in particular in patients with long-term use of glucocorticoids. These undesirable effects may be temporary and relatively mild (arthralgia, myalgia and malaise) but also life threatening in the event of adrenal insufficiency [94;95]. In some cases complete discontinuation of exogenous glucocorticoids is not possible and it is necessary to keep a low dose as a replacement therapy to avoid that the patient collapses [96;97].
Finally, some patients who have experienced loss of asthma control and side effects of steroid withdrawal may also show some psychological dependence on glucocorticoids. This is more likely to occur in patients who have been using glucocorticoids for a long time and adds another challenge to an effective tapering strategy.
The unresolved questions
The management of patients with glucocorticoid-dependent severe asthma remains a major problem for several reasons.
Firstly, despite the availability of new targeted therapies [85-87] with their promising steroid-sparing effects, these remain extremely expensive treatments with often limited availability, especially in less prosperous countries. For the majority of patients with severe refractory asthma, glucocorticoids are still the most effective anti-inflammatory treatment for asthma and an alternative therapy
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