What Is The Optimal Strategy For Titrating Inhaled Corticosteroid (ICS) Dosages In Patients With Severe Asthma Who Are Also Being Treated With Biologic Therapies, Such As Anti-IL-5 Or Anti-IgE Agents, In Order To Minimize The Risk Of Adrenal Insufficiency While Maintaining Adequate Asthma Control?

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The optimal strategy for adjusting inhaled corticosteroid (ICS) doses in patients with severe asthma on biologic therapies involves a personalized, stepwise approach to minimize adrenal insufficiency risk while maintaining asthma control. Here's a structured plan:

  1. Individualized Assessment:

    • Evaluate each patient's asthma severity, response to biologics, and history of adrenal issues.
    • Use measures like symptom scores, lung function tests (FEV1), and exacerbation frequency to assess asthma control.

  2. Response Evaluation:

    • After initiating biologic therapy, monitor for several months to assess improvement in asthma symptoms and control.

  3. Gradual ICS Reduction:

    • If significant improvement is observed, consider gradual ICS dose reduction, possibly in steps of 25-50% every 3-6 months.
    • Closely monitor for signs of reduced asthma control, such as increased symptoms or decreased lung function.

  4. Adrenal Function Monitoring:

    • Conduct tests like morning cortisol levels or ACTH stimulation tests to assess adrenal function.
    • Watch for clinical signs of adrenal insufficiency, such as fatigue or hypotension.

  5. Patient Education:

    • Inform patients about the reasons for dose adjustment, signs of adrenal issues, and the importance of adherence to treatment.

  6. Dose Adjustment Goals:

    • Aim to discontinue ICS if possible without losing asthma control.
    • If discontinuation isn't feasible, use the lowest effective ICS dose to maintain control while minimizing side effects.

  7. Consider Comorbidities and Medications:

    • Tailor the approach based on the patient's overall health, including other medications and medical history.

This strategy balances the benefits of biologic therapy with the risks of ICS, ensuring personalized care that prioritizes both safety and efficacy.