Severe asthms Case Study

Study Notes

Sara is a 30-year-old female diagnosed with systemic lupus erythematosus (SLE) for two years.
Current weight is 60 kg.
Recent urinalysis shows significant proteinuria, and a kidney biopsy confirms class IV lupus nephritis.
Initiated treatment with pulse glucocorticoid therapy followed by oral prednisone.

Transitioned to maintenance therapy after achieving remission with immunosuppressants.

Symptoms include polyarthralgia, small joint mono-oligoarthritis, and limited skin lesions.
Treatment: Prednisone (PDN) 2.5-7.5 mg/day.
Taper down over 1-2 weeks to a maintenance dose of 2.5 mg/day.
If no improvement, re-evaluate for moderate disease activity.
If improvement occurs, add hydroxychloroquine (HCQ) 200 mg/day alongside PDN 2.5 mg/day.

Symptoms include polyarthritis, moderate thrombocytopenia (20,000–50,000/mm³), hemolytic anemia with low hemolysis rate, widespread skin lesions, nonsevere pericardial effusion/pericarditis, and pleural effusion.
Treatment: Methylprednisolone (MP) at 125-250 mg/day for 3 days, followed by PDN 5-10 mg/day and an immunosuppressant.
Taper down PDN over 1-2 weeks to 2.5-5 mg/day.
If no improvement after initial treatment, repeat MP in 2-4 weeks.
If improvement is noted, prescribe HCQ 200 mg/day, PDN 2.5-5 mg/day, and continue immunosuppressant.

Symptoms may include lupus nephritis, pneumonitis, or severe thrombocytopenia.
Management for severe cases requires careful adjustment of glucocorticoids and immunosuppressants based on response to treatment.

Treatment focuses on both glucocorticoids and immunosuppressants, adjusted based on disease activity levels.
Regular monitoring and reevaluation are essential to successfully manage SLE and associated complications.

Systemic corticosteroids are essential for managing severe asthma, used for exacerbations and as chronic maintenance therapy.
Chronic use can lead to significant systemic side effects: osteoporosis, cardiovascular issues, diabetes, and obesity.
Long-term corticosteroids can inhibit adrenal gland's cortisol production, leading to adrenal insufficiency.
The risk of side effects increases with cumulative dosage over time.

New biologic treatments for severe asthma have emerged, improving clinical outcomes and reducing dependence on oral corticosteroids.
These treatments allow many patients to reduce or eliminate oral corticosteroid use altogether.
The PONENTE Study provides evidence-based guidance for tapering oral corticosteroids in patients transitioning to biologics.

Tapering guidance is aimed at patients currently on chronic oral corticosteroid therapy and have started biologic treatment.
Begins four weeks after initiating biologic therapy.

For patients on prednisone/prednisolone dosage > 20 mg/day:
- Reduce by 5 mg/day weekly until reaching 20 mg/day.
For dosage > 10 to ≤ 20 mg/day:
- Reduce by 5 mg/day every 2 weeks after reaching 20 mg/day.
For dosage > 7.5 to ≤ 10 mg/day:
- Reduce by 2.5 mg/day every 2 weeks after reaching 10 mg/day.
For dosage > 5 to ≤ 7.5 mg/day:
- Reduce by 2.5 mg/day every 4 weeks after reaching 7.5 mg/day.
Stabilize at 5 mg/day for 4 weeks before evaluating cortisol levels.

Morning cortisol levels should be assessed between 8:00 – 9:00 AM when reaching a prednisone dose of 5 mg/day.
Normal cortisol levels are > 350 nmol/L; indeterminate levels are defined, and complete adrenal insufficiency (AI) occurs at 450 nmol/L.

The tapering protocol aims to safely reduce oral corticosteroid doses in severe asthma patients starting biologics while monitoring for adrenal insufficiency.