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This work was supported by a grant from the Program of Strategic Technologies of the National Plan for Science and Technology and Innovation, Saudi Arabia. Source of Support: This work was supported by a grant from the Program of Strategic Technologies of the National Plan for Science and Technology and Innovation, Saudi Arabia. Conflict of Interest: None declared. Oral steroids in asthma: a double-edged sword. Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Eleftherios Zervas. There is poor evidence on the benefits of long-term systemic steroid use in asthma while the risks of morbidity and mortality are high. Systemic steroids should be a last resort and should be withdrawn in non-responders. Since the introduction of inhaled steroids, the management of asthma has been revolutionised and the lives of millions of patients have improved. Nevertheless, systemic corticosteroids (SCS), usually prescribed as oral treatment, but which can also be prescribed for intravenous and intramuscular administration, are still quite extensively used, both for the management of severe asthma exacerbations and, in many cases, for the long-term management of difficult to treat and severe asthma. Is the use of systemic steroids justified? And what are the short- and long-term risks associated with their use? Musculoskeletal, gastrointestinal, cardiovascular, endocrine, psychiatric, ocular, dermatological and immunological side-effects are all possible, and there is undisputable evidence linking long-term SCS use with infection, osteoporosis and bone fractures, cataracts, adrenal failure, diabetes, and hypertension, to name some of these side-effects [1]. Increased use of healthcare services has also been reported, and this can be associated to both the severity of the underlying disease as well as SCS side-effects. Moreover, there is evidence linking SCS use with mortality in various diseases: in a prospective study that followed of 5600 rheumatoid arthritis patients for a median of 4. In a much smaller study following 52 moderate’severe asthma patients for 20 years, the authors also report increased risk of mortality associated with systemic steroid use in asthma [3], buy cheque drops 250 mcg oral steroids $57.00 cheque drops. In this issue of the European Respiratory Journal , L ee et al. They also report that there is a significant dose’response relationship; that is, the higher the dose of steroids, the higher the risk. L ee et al. The importance of the study comes with the enormous database, a total of 466 941 patients with asthma, of whom 8334 were SCS-dependent. Considering that severe asthma comprises 2’10% of all asthma and that 20’60% of severe asthma patients receive SCS, the numbers appear correct [5’7]. It is of course difficult to retrospectively identify asthma patients and, moreover, severe asthma patients, using pre-existing electronic records. This may be considered a problem in the study but defining asthma for an epidemiological study is always a problem, even in large prospective trials such as the European Community Respiratory Health Survey [8]. Epidemiological definitions are based on symptoms indicative of asthma, medication prescriptions and a doctor diagnosis of asthma, and should exclude COPD or other diseases with similar symptoms. The definition of asthma that the authors used in order to identify asthmatic patients in the electronic records included the asthma patients with two or more visits and asthma-related medication under ICD-10 codes J45’J46 and, furthermore, to identify severe SCS-dependent asthma, the definition included those with at least 6 months of SCS use during a period of 12 months at baseline (prior to entry to the study). The authors compared the severe group to a 1:1 matched non-severe subgroup of the cohort.
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