Systemic Corticosteroid Management in Severe Asthma

Severe asthma represents a complex and heterogeneous condition in which airway inflammation persists despite high-dose inhaled therapies and adjunctive long-acting bronchodilators. Systemic corticosteroids remain a cornerstone for controlling exacerbations and maintaining symptom stability in patients unresponsive to standard inhaled regimens. Oral corticosteroids (OCSs) and short-course systemic bursts reduce airway hyperresponsiveness and eosinophilic infiltration, but their long-term use is tempered by well-recognised adverse effects, including osteoporosis, metabolic disturbance and increased infection risk. Recent advances in patient phenotyping have enabled more precise identification of those most likely to benefit from systemic steroids, while minimising exposure in biomarker-low individuals. Integration of objective measures such as blood eosinophil count and fractional exhaled nitric oxide (FENO) facilitates a tailored approach to dosing and tapering. Concurrent development of biologic therapies targeting interleukin-5, interleukin-4 receptor α and immunoglobulin E pathways has expanded the armamentarium, providing alternative corticosteroid-sparing options. Optimal management now emphasises multidisciplinary assessment, judicious use of OCSs guided by biomarker algorithms and early introduction of steroid-sparing biologics in eligible patients. This evolving paradigm seeks to preserve therapeutic efficacy while reducing the cumulative morbidity and healthcare burden associated with systemic steroid use on a global scale.

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Systemic Corticosteroid Management in Severe Asthma publication trend

The graph below shows the total number of articles in systemic corticosteroid management in severe asthma across all publications each year (not limited to Nature Index journals).

Technical terms

Oral corticosteroids (OCS): Systemic anti-inflammatory agents administered by mouth to control asthma exacerbations and persistent inflammation.

Type-2 (T2) inflammation: An eosinophil-driven immune response characterised by interleukin-4, interleukin-5 and interleukin-13 activity, common in allergic asthma.

Fractional exhaled nitric oxide (FENO): A noninvasive biomarker reflecting airway eosinophilic inflammation, used to guide corticosteroid dosing.

Biologic therapies: Targeted monoclonal antibodies that inhibit specific immune pathways (eg, anti-IL-5, anti-IL-4Rα, anti-IgE) to reduce steroid requirements.

Asthma exacerbation: An acute or subacute worsening of symptoms and lung function often necessitating systemic corticosteroid treatment or hospitalisation.

References

1. Composite type-2 biomarker strategy versus a symptom–risk-based algorithm to adjust corticosteroid dose in patients with severe asthma: a multicentre, single-blind, parallel group, randomised controlled trial. The Lancet Respiratory Medicine (2020).
2. Expert consensus on the use of systemic glucocorticoids for managing eosinophil-related diseases. Frontiers in Immunology (2024).
3. Application of an algorithm to analyze patterns of intermittent oral corticosteroid use in asthma. npj Primary Care Respiratory Medicine (2023).