Tapering Oral Corticosteroids in Asthma: Expert Consensus Statements

Expert consensus statements regarding the use and tapering of oral corticosteroids (OCS) may be used to help inform treatment in clinical practice and to optimize the management of patients with severe asthma. an international panel of experts participated in a 4-round Delphi study (ClinicalTrials.gov Identifier: NCT03934801) to begin the process of creating an OCS tapering algorithm, as well as a minimum OCS adverse event (AE) screening list. Results of the Delphi study were published in the American Journal of Respiratory and Critical Care Medicine.

Recognizing the need exists to minimize OCS use in patients with asthma to prevent the costly, burdensome AEs of the therapy, investigators sought to develop expert consensus statements on OCS tapering. They used a modified Delphi technique to create expert consensus statements associated with OCS use, tapering, AEs, adrenal insufficiency, and patient-physician shared decision making. All initial statements proposed by the experts were categorized, filtered for repetition, and then presented back to the experts during 3 ranking rounds to obtain consensus (≥70% agreement).

Of a total of 363 experts who were invited to take part in the Delphi study, 169 were enrolled in the expert panel and 131 completed at least 1 of the 4 survey rounds. Overall, 296 statements were ranked. Attrition rates among the participants during the ranking process were low, with 96 of the 108 experts who had participated in the first ranking round ultimately completing all 3 rounds of ranking. Of the specialties represented among the experts, 73% were pulmonologists and 18% were allergists, although a broad range of other specialties were included as well.

The initial brainstorming occurred between April and May 2019, and 3 rounds of ranking surveys (rounds 2 to 4) were completed between August 31 and September 26, 2019. Overall, 91 experts provided at least 1 brainstorming statement, with a total of 1447 statements generated. Round 1 involved expert demographics and brainstorming, during which time the participants completed an electronically administered questionnaire to provide such demographic information as sex, age, qualifications, specialty, practice environment, years since completion of training, time spent caring for patient treated with OCS, and the number of patients seen each year.

In rounds 2, 3, and 4, the final list of statements was presented to the expert panel for ranking via use of a predefined Likert scale that ranged from “strongly disagree”

(-2 points) to “strongly agree” (+2 points). Experts were also requested to choose specific responses regarding treatment duration, threshold values, and assessment frequencies. 

Numerous recommendations with respect to appropriate OCS use were determined. The experts agreed that OCS tapering should be attempted in all individuals with asthma receiving maintenance OCS treatment, with personalization of tapering speed. The significance of recognizing individual AEs was also established. No unified approach to the evaluation of adrenal insufficiency was attained. However, the experts agreed that adrenal insufficiency should be assessed in patients taking regular, long-term OCS therapy, particularly in those whose doses exceed more than 2 g per year or 4 repeated OCS short courses per year. In addition, the experts considered shared decision making to be an important goal to achieve during the OCS tapering process.

The investigators concluded that the results of this study highlight the need for additional research to inform clinical practice and to drive the development of future evidence-based guidelines. Additional research is warranted in the specific domain of managing adrenal insufficiency since no unified consensus was reached.

Disclosure: This clinical trial was supported by AstraZeneca. Please see the original reference for a full list of authors’ disclosures.

Reference

Suehs CM, Menzies-Gow A, Price D, et al. on behalf of the Oral Corticosteroids Tapering Delphi Expert Panel. Expert consensus on the tapering of oral corticosteroids for the treatment of asthma: a Delphi study. Am J Respir Crit Care Med. Published online October 28, 2020. doi:10.1164/rccm.202007-2721OC