Are the side effects of oral steroids reversible?
Published online October 28, 2024
The discovery of oral steroids in 1949 revolutionized the treatment of inflammatory diseases. However, almost as soon as their treatment benefits were discovered, they were also recognized to have serious side effects: mental health problems, high blood pressure, heart attacks, diabetes, infections, bone thinning, cataracts, glaucoma, and skin changes, to name only a few. Medical research has tried to understand the immune pathways driving inflammation in individual diseases with the aim of developing targeted treatments that treat illness without causing the side effects of oral steroids.
In the last number of years, targeted treatments that successfully reduce airways inflammation in asthma (“biologics”) have been developed. These treatments diminish the need to rely upon oral steroids for the management of severe asthma (asthma that is not controlled despite high dose inhalers).
McDowell et al. have previously used a tool called the Glucocorticoid Toxicity Index (GTI) to measure the total burden of toxicities (or side effects) related to oral steroid use in individual severe asthma patients before they start biologics.
A recent study by McDowell et al. published in The Journal of Allergy and Clinical Immunology: In Practice used the GTI to measure total reduction in steroid-related toxicities after three years of biologics to see if steroid-related toxicities continued to reduce with less steroid exposure and to judge if there were any factors that predicted which patients would have better toxicity reversal. Patients were assessed before starting biologic therapies, after 1 year of biologic therapy and after 3 years of biologic therapy.
After 3 years of biological treatment, this group of severe asthma patients had improved lung function, better controlled airways inflammation, and a substantial improvement in asthma control reported by patients. Total oral steroid use in the third year of biologics was only 7% of that used in the year before biologics were started.
Half of the severe asthma patients had a decrease in steroid-related toxicities at the year one and year three toxicity assessment. However, one in three patients did not see any reduction in steroid-related toxicities over the whole three years of treatment despite very substantial reduction in oral steroid exposure. For most patients, toxicity outcome at year one (improvement or no improvement in toxicity) was predictive of toxicity outcome at year three. There were no other factors that predicted which individual patients would have reversal of steroid-related side effects and which would not.
This work shows that roughly one in three severe asthma patients exposed to oral steroids will not have reversibility of the side-effects they accumulate through oral steroid exposure. Consequently, all efforts should be made to use targeted non-steroid treatment in place of oral steroid much earlier in the course of the disease prior to the establishment of oral steroid toxicity. For patients who have toxicities associated with prior oral steroid use that have not reversed on stopping steroids, additional support may be needed to reverse steroid toxicities.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.
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