Oral Corticosteroid Burden in Severe Asthma: Proven Alternatives

For decades, oral corticosteroids (OCS) have been the go-to rescue for severe asthma flare-ups. They work fast. They save lives. But for many patients, that relief comes with a heavy price tag-on their body, their wallet, and their long-term health. If you or someone you know is on daily or frequent OCS for asthma, you’re not alone. But you also don’t have to stay stuck there. There are real, science-backed alternatives that can cut or even eliminate the need for these pills-without putting breathing at risk.

Why Oral Corticosteroids Are a Double-Edged Sword

Oral corticosteroids like prednisone and prednisolone are powerful anti-inflammatories. In an acute asthma attack, they can stop a hospital visit in its tracks. GINA guidelines recommend short courses of 3-5 days for kids and 5-7 days for adults during flare-ups. That’s fine. The problem isn’t occasional use. It’s dependence.

When someone needs OCS for six months or longer, that’s not management-it’s a sign the asthma isn’t under control. And it’s far more common than many realize. One 2025 study found 93% of people with severe asthma suffered side effects directly tied to OCS use, even if they weren’t on it every day. These aren’t minor complaints. They include weight gain, type 2 diabetes, bone thinning (osteoporosis), eye pressure leading to glaucoma, mood disorders like anxiety and depression, heart problems, and even adrenal insufficiency-where the body stops making its own cortisol because it’s been flooded with synthetic versions for too long.

And the damage doesn’t stop at symptoms. A 2025 study in Italy calculated that each asthma patient on long-term OCS adds nearly €1,960 a year in extra healthcare costs just from treating the side effects. That’s almost double what non-asthma patients pay for similar complications. Meanwhile, the pills themselves cost pennies. The real cost is hidden in ER visits, fractures, insulin prescriptions, and mental health care.

Biologics: The Game-Changing Alternative

The biggest shift in severe asthma care over the last decade isn’t a new inhaler. It’s biologics. These are targeted, injectable or infused drugs that silence specific parts of the immune system driving inflammation in asthma. Unlike OCS, which blanket the whole body, biologics hit only the troublemakers.

Six are approved for asthma right now: omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab. They’re not for everyone. They work best in people with type 2 inflammation-a subtype found in about half to two-thirds of severe asthma cases. That’s measured through blood tests (eosinophils) or FeNO (fractional exhaled nitric oxide), both now standard in specialist clinics.

The results speak for themselves. In a 2023 study of 106 Italian adults with uncontrolled asthma, mepolizumab slashed OCS dependence from 79% to just 31% in under a year. Daily steroid doses dropped by nearly 5 mg on average. Exacerbations fell from 4.1 per year to 0.8. Hospitalizations dropped from 4 in 10 patients to just 6%. Dupilumab showed similar results in multiple trials, cutting both flare-ups and OCS use by more than half.

These aren’t just numbers. Patients report feeling like they’ve gotten their life back. Fewer missed workdays. Less fear of the next attack. No more bloating, insomnia, or mood swings from steroids. One woman in Nottingham, on biologics for 18 months, told her pulmonologist: “I didn’t realize how tired I was until I wasn’t taking prednisone every other month.”

Why Aren’t More People on Biologics?

If they’re this effective, why aren’t they first-line treatment? Two big reasons: access and cost.

Biologics cost thousands per year. OCS cost less than £10 for a month’s supply. On paper, OCS win. But that ignores the hidden costs-the hospital stays, the bone scans, the diabetes meds, the mental health support. When you add it all up, studies show biologics actually save money over time. The Italian data proved it: fewer hospital visits meant lower overall spending, even with the drug price tag.

The bigger barrier? Getting tested and referred. Not every GP knows how to identify type 2 asthma. Not every clinic has the lab access or the specialist slots. And insurance coverage varies wildly. In the UK, NHS access to biologics has improved but still depends on local commissioning and strict criteria. Patients often need to fail multiple controller therapies first.

GINA guidelines now say: if you’re on maintenance OCS (even just 7.5 mg/day or less), you should be offered a biologic before staying on steroids long-term. That’s a major shift. But in practice, many patients are still being kept on OCS because the system hasn’t caught up.

Other Options-What Works, What Doesn’t

Beyond biologics, there are other paths, but they’re either narrow or unproven.

Bronchial thermoplasty is a procedure where a catheter delivers heat to the airway muscles, reducing their ability to tighten during an attack. It’s done in three sessions under sedation. Studies show it can reduce exacerbations and improve quality of life-but only for a small group: severe asthma patients who’ve tried everything else. And in the six weeks after treatment, symptoms often get worse before they get better. It’s not a first choice. It’s a last resort.

What about vitamins? Many patients try vitamin D, hoping it’ll help. But multiple trials, including a 2021 review by the American Academy of Family Physicians, found no benefit. High-dose vitamin D3 didn’t reduce flare-ups, didn’t improve lung function, and didn’t cut steroid use in adults with asthma-even those who were deficient.

Lifestyle changes matter. Quitting smoking, losing weight if overweight, managing stress-all help. But they don’t replace the need for targeted medical therapy in severe cases. They’re support, not substitutes.

How to Start the Transition

If you’re on long-term OCS and want out, here’s how to begin:

1. Get tested for type 2 inflammation. Ask for a blood eosinophil count and FeNO test. These are simple, non-invasive, and covered by most insurers.
2. Review your asthma control. Are you on the right inhaled corticosteroid dose? Are you using a spacer? Are you taking your meds correctly? Poor technique can make asthma seem worse than it is.
3. Talk to your respiratory specialist about biologics. Don’t wait for them to bring it up. Bring the data: “I’ve been on prednisone for 8 months. What are my options to get off it?”
4. Ask about a steroid taper plan. You can’t stop OCS cold turkey. Your body needs time to restart its own cortisol production. A slow, monitored reduction-over weeks or months-is essential.
5. Track your symptoms. Use a peak flow meter and asthma diary. Note how you feel before, during, and after starting a biologic. This helps your team adjust safely.

The Bigger Picture: Changing the Rules

The medical world is finally waking up to the fact that OCS are not a long-term solution. They’re a Band-Aid on a broken system. The goal isn’t to manage side effects-it’s to fix the asthma so you don’t need them at all.

The 2023 Advances in Therapy ‘Charter’ called for a fundamental reset: move biologics earlier in the treatment ladder, not at the very end. That’s happening slowly. In some UK centers, patients now get biologic referrals after just one hospital admission for asthma, not after years of OCS.

The economic case is clear. The clinical case is clear. The patient experience is clear. The only thing holding us back is inertia-and access.

If you’re on daily or frequent oral steroids for asthma, you’re not failing. The system is. But change is here. And you have more power than you think to ask for it.