Beyond oral corticosteroids: uncovering the risks of high-dose inhaled corticosteroids in asthma
Published online January 31, 2025
It is well established that oral corticosteroid use in asthma is associated with increased risk of serious adverse events (AEs), including osteoporosis, cardiovascular disease, and type 2 dia-betes (T2DM). Inhaled corticosteroids (ICS) remain the cornerstone of asthma management, effectively reducing both morbidity and mortality in asthma patients. However, patients with severe asthma, comprising approximately up to 3-8 percent of the asthma population, are, by definition, exposed to high dose-ICS. These elevated doses raise concerns about systemic corticosteroid-related side effects, though the full extent of these risks remains uncertain.
A recent study published in The Journal of Allergy and Clinical Immunology: In Practice by von Bülow et al. investigated whether high-dose ICS use is associated with corticosteroid-related adverse events (AEs) in asthma patients. Utilizing the Swedish nationwide NORD-STAR dataset, the authors conducted a large observational cohort study including more than 529,000 adult asthma patients between 2009 and 2019. ICS exposure was assessed based on both current use and average daily dose (budesonide equivalents), and associations with cor-ticosteroid-related AEs were analyzed using Cox proportional hazards models adjusting for age, sex, and OCS use.
The study found that approximately five percent of total person-time was spent on high or very-high doses of ICS (≥800 µg and ≥ 1600 µg budesonide/day, respectively). These higher ICS doses were significantly associated with increased risk of several corticosteroid-related AEs, including osteoporosis, T2DM, pneumonia, and cardiovascular disease. The study found that high-dose ICS was associated with a risk of AEs that was comparable to the use of low-dose maintenance OCS. Notably, the findings were consistent whether exposure was meas-ured according to the current ICS dose or longer-term average ICS use —underscoring ro-bustness of the results. Importantly, the increased risk persisted even after excluding patients who had used OCS during follow-up, further strengthening the link between high-dose ICS usage and adverse outcomes. In contrast, low to moderate ICS doses were generally not asso-ciated with increased risk, except for cataract.
Overall, this study reveals that corticosteroid-related AEs are not limited to oral steroids—high-dose ICS also pose a considerable risk. The findings underscore the need for greater awareness of these risks in clinical practice and support a shift toward earlier use of cortico-steroid-sparing therapies, such as biologics, in patients who require high-dose ICS.
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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