Safely withdrawing daily oral corticosteroids in severe asthma

Published online April 8, 2025

Before the introduction of injectable biologic therapies, patients with severe asthma often relied on daily oral corticosteroids (OCS) such as prednisolone to manage asthma symptoms. However, long-term OCS use can interfere with the body’s natural cortisol production by suppressing the hypothalamic-pituitary-adrenal (HPA) axis, making it dangerous to stop them suddenly. With the help of biologics, many patients are now able to reduce or stop daily maintenance OCS. Despite this, the best way to safely taper OCS remains unclear. Previous studies used complex dynamic tests to measure adrenal function at 5mg prednisolone daily. But recent data shows that this dose is higher than what the body needs and may still suppress HPA axis recovery. Thus, the results are often unhelpful at this stage because restoring HPA axis function requires further OCS weaning. 

In a recent issue of The Journal of Allergy and Clinical Immunology: In Practice, Aung and colleagues proposed an OCS tapering protocol for severe asthma patients receiving biologics. The approach was led by nurses with support from clinicians and focused on monitoring adrenal insufficiency symptoms and 09:00 am blood cortisol levels. Patients with well-controlled asthma who had reduced daily OCS dose to 5 mg prednisolone began the weaning process. Daily prednisolone dose was decreased to 4 mg for 6 weeks then 3 mg for 6 weeks, followed by 09:00 am blood cortisol measurement. If cortisol level was over 25 nmol/L (laboratory lower limit of normal 149 nmol/L), patients followed a further 20-week tapering plan, with repeat cortisol testing 12 weeks after stopping OCS.

Of 102 patients included, 92 had cortisol >25 nmol/L on 3 mg prednisolone and continued weaning. Seventy-three (72%) were able to stop OCS completely, with significantly improved cortisol after 12 weeks. The remaining twenty-nine patients (28%) paused weaning due to adrenal insufficiency symptoms or low (<25nmol/L) cortisol levels, worse asthma control, anxiety or other reasons. They stayed well on a low dose of daily prednisolone (median 3.0 [3.0-3.9] mg). Of a small number (n=14) seen by endocrinology specialists, their treatment was unchanged. They remained well on physiological replacement OCS doses. Only 5 patients underwent dynamic adrenal testing. No serious adverse events occurred. Slow, symptom-guided tapering of OCS, supported by cortisol monitoring, is safe and effective for most stable asthma patients on biologics without requiring dynamic adrenal function testing.

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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