Examining the Oral Steroid Burden in Asthma and COPD

Patients with asthma and chronic obstructive pulmonary disease (COPD) often receive systemic corticosteroids from multiple specialties, and that cumulative exposure is rarely tracked in 1 place. At the same time, the options for reducing reliance on oral steroids have grown, with approvals of dupilumab and mepolizumab for eosinophilic COPD and of depemokimab, a twice-yearly anti-interleukin (IL)-5 agent, for severe asthma.

1-4 Clinicians outside pulmonology increasingly manage these patients when specialty access is limited. On October 6, 2026, Mollie Chartoff, FNP-BC, a nurse practitioner on the advanced COPD team at Vanderbilt Lung Institute in Nashville, Tennessee, moderated a virtual clinical forum for advanced practice providers on asthma and COPD.

Participants included nurse practitioners and physician assistants in pulmonology, allergy and asthma, dermatology, oncology, and interventional pain practices in Tennessee, Texas, Missouri, and North Carolina. The discussion covered biomarkers, oral corticosteroid (OCS) exposure, biologic selection, and access barriers.

Cumulative Oral Steroid Exposure Across Specialties Participants described patients who consider 1 or 2 steroid courses per year normal and who prefer intermittent oral steroids to daily inhaled therapy. Chartoff noted that cumulative exposure of 500 to 1000 mg of prednisone has been associated with increased risk of diabetes, osteoporosis, cataracts, and other adverse effects.

Participants from dermatology, oncology, and pain medicine described steroids prescribed for skin disease, chemotherapy regimens, and orthopedic conditions, and 1 participant described avascular necrosis in patients in their 30s to early 50s with lung disease. Several participants said they now ask patients about any steroid use since the last visit rather than only steroids for breathing.

Participants noted that few health systems flag outside prescriptions automatically, and some suggested pharmacists could alert patients and prescribers to repeated courses. For patients already on oral steroids from another prescriber, Chartoff and others described switching to nebulized inhaled corticosteroid therapy during exacerbations, though 1 rural participant said cost limits that option.

Biomarkers and Biologic Selection in Asthma Participants described trending eosinophil counts over time, accounting for steroid use, time of day, and season, and several pair them with IgE, allergen panels, and inflammatory markers. In polling, 46% of participants cited comorbid conditions as the main driver of biologic choice, reflecting the group's mix of specialties.

Participants from dermatology described coordinating with pulmonology to select a single agent that addresses both asthma and atopic dermatitis. Participants reported generally good tolerability with dupilumab, with injection site pain the most common complaint and the reason several pediatric patients stopped therapy.

Suggested mitigations included bringing the syringe to room temperature, icing the skin, and using the prefilled syringe instead of the pen. For depemokimab, participants described using twice-yearly dosing for a patient who struggled with injection adherence and for a rural Medicare patient who lived more than an hour from any site that could administer biologics.

Tezepelumab was described as a common next step after inadequate response to other biologics, though Chartoff said she receives the most payer pushback on it. Eosinophilic COPD and Access to Care Participants said they now draw eosinophil counts earlier in COPD. In BOREAS and NOTUS, dupilumab reduced exacerbations in patients with chronic bronchitis and eosinophil counts of 300 cells/μL or higher on triple therapy, and in MATINEE, mepolizumab reduced moderate or severe exacerbations by 21% in a broader population.

2-4 Chartoff said she considers biologics for any patient hospitalized for COPD or with 2 moderate exacerbations, and that she favors dupilumab for patients with chronic bronchitis and mucus hypersecretion, while noting that mepolizumab offers an option when eosinophil counts fall between 150 and 300 cells/μL.

Participants outside pulmonology said agent choice often reflects familiarity and supervising physician preference. Access dominated the discussion of unmet needs, with participants in Chattanooga and Dallas-Fort Worth describing shortages of outpatient pulmonologists, and others describing difficulty affording any maintenance inhaler before a biologic can be considered.

Participants also described specialty pharmacy teams and electronic prior authorization services as reducing administrative burden. In closing, participants emphasized educating primary care and urgent care clinicians about repeated steroid courses and referring earlier. Chartoff described how she frames inhaled therapy for patients.

"I describe it to patients all the time that taking an inhaler is like putting a cream on your skin," Chartoff said. References Jackson DJ, Wechsler ME, Jackson DJ, et al. Twice-yearly depemokimab in severe asthma with an eosinophilic phenotype.

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N Engl J Med . 2023;389(3):205-214. doi:10.1056/NEJMoa2303951 Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with blood eosinophil evidence of type 2 inflammation.

N Engl J Med . 2024;390(24):2274-2283. doi:10.1056/NEJMoa2401304 Sciurba FC, Criner GJ, Christenson SA, et al. Mepolizumab to prevent exacerbations of COPD with an eosinophilic phenotype.

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