Alternatives to Prednisone for Asthma: Risks and Benefits
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For decades doctors have relied on oral and intravenous steroid medications to treat asthma flare-ups (exacerbations) that threaten to become emergencies, with proof of the drugs’ effectiveness going all the way back to a study published in The New England Journal of Medicine in 1986.
Although many different types of asthma medication have come along since then, the steroid prednisone, delivered orally in the form of a pill or liquid, is still the mainstay for treating exacerbations outside of a hospital setting, says Rachel Taliercio, DO, a pulmonologist at Cleveland Clinic in Ohio.
Prednisone, like other steroid drugs, mimics the effects of cortisol, a hormone that the body produces naturally to reduce inflammation. “It’s a very powerful anti-inflammatory medication that works within a couple of hours to help patients feel better,” Dr. Taliercio says. “It’s used to treat the underlying cause of an exacerbation, offering relief from asthma symptoms like breathlessness, cough, chest tightness, and wheezing.”
She adds, “Rescue inhalers and rescue nebulizer therapy are also used during an exacerbation to relieve symptoms.”
While prednisone helps rein in exacerbations, pulmonologists do not recommend it as a long-term treatment because of the risk of serious side effects, Taliercio says.
But what exactly is appropriate short-term use, why is long-term use dicey, and how do you know if you’re over-reliant? Are there prednisone alternatives?
Here’s an overview of the risks and benefits of prednisone and other drugs used to manage asthma flare-ups.
How Much Prednisone Is Generally Considered Okay?
Patients with mild or moderate asthma whose condition is well managed are still at risk for exacerbations, though the flares are usually not severe or protracted. “The duration of treatment with prednisone for these individuals is commonly five days,” says Taliercio. “For patients with more severe persistent or resistant asthma, the treatment duration for prednisone could be as long as 10 days.”
Both time periods would be categorized as short-term use, she notes.
Although short-term use of prednisone comes with less risk than long term use, it may cause side effects including weight gain, fluid retention, high blood pressure, and high blood sugar.
Still, these risks are minimal and transient, “and in almost all cases the benefits outweigh them,” Taliercio says.
When Is Prednisone Use Considered Highly Risky?
Taliercio feels that patients who have frequent flare ups — more than one or two a year — that require several bursts or courses of prednisone may run into trouble.
“Prednisone use that is longer than two weeks is concerning,” she says. Side effects associated with long-term prednisone use include growth suppression in children, diabetes, cataracts, osteoporosis, and muscle weakness, according to the Asthma and Allergy Foundation of America.
“Rarely, patients with very severe refractory asthma [asthma that is unmanageable with other medications] require a low dose of daily prednisone to maintain control — those patients are at greatest risk for long-term side effects,” Taliercio says.
“It’s the long-term overuse of prednisone over many weeks, months, years, that carries the risk of serious effects,” she adds.
Can a Person Who’s Allergic to Prednisone Use Something Else?
Allergy to prednisone is extremely rare. “But there are some people who have an intolerance — prednisone is not as effective for them,” Taliercio says.
Sometimes those patients require intravenous steroids. “There’s methylprednisolone, which is like a cousin of prednisone, and we can use that for an asthma flare,” Taliercio says.
The Best Alternative to Prednisone Is Better Day-to-Day Asthma Management
“If any patient, even a person with mild to moderate asthma, has more than one or two flares per year that require prednisone, that tells us that additional daily controller therapy is needed,” Taliercio says.
Medications to prevent exacerbations include:
Inhaled Steroids Inhaled steroids are the foundation of asthma management. There are different strengths and types of inhalers that can be used and added in a stepwise fashion when the asthma needs better control, says Jill Poole, MD, professor and division chief of allergy and asthma at Nebraska Medicine in Omaha, Nebraska, and an expert for the Allergy and Asthma Foundation of America.
Nonsteroidal Oral Medications When inhaler therapy isn’t doing enough to manage asthma, oral medications may come into play, says Dr. Poole. These can include leukotriene modifiers such as montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). Another option is theophylline (Theo-24, Elixophyllin, Theochron), a daily pill that helps keep the airways open by relaxing the muscles around the airways, according to Mayo Clinic.
These medications are considered generally safe, says the Cleveland Clinic, but you should talk with your doctor about any potential side effects.
Biologics Biologics are a relatively new treatment option for severe asthma that can help prevent the kind of flares that require prednisone. “It’s an exciting time in asthma care: In the past five years we’ve just seen this explosion of biologic therapy that’s beneficial for severe asthma,” says Poole.
As the American Academy of Allergy, Asthma, and Immunology explains, a biologic is a drug made from the cells of a living organism, such as bacteria, that’s modified to zoom in on specific molecules in humans. With asthma, the targets are antibodies, inflammatory molecules, or cell receptors. The medications work by disrupting pathways that lead to inflammation that causes asthma symptoms.
Six biologics currently are approved by the U.S. Food and Drug Administration (FDA) for moderate to severe asthma in adults and some children as young as 6, according to the Allergy and Asthma Foundation of America. These include mepolizumab (Nucala), benralizumab (Fasenra), reslizumab (Cinqair), dupilumab (Dupixent), tezepelumab-ekko (Tezspire), and omalizumab (Xolair).
There’s no one “go-to” biologic that’s the best for everyone with asthma, says Poole. “Your doctor will use a personalized approach depending on the type of asthma you have, your symptoms, and your health history,” she says.
The Bottom Line on Prednisone for Asthma
If you need prednisone more than once or twice a year to manage flare-ups, it’s time for a discussion with your doctor or asthma specialist.
Taliercio suggests asking questions such as “Am I taking my medications correctly? Have I been taught inhaler technique? Am I on the right dose of inhalers? What other medications can I use to help keep my asthma under control?”
In addition to talking with your doctor, look to see if your environment may be contributing to your flares and see if you can eliminate or reduce triggers such as dust and smoke. “If you have indoor allergies or even outdoor allergies, are there things you can change in your home or workplace?” Taliercio says.
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