Severe asthms Case Study

Questions and Answers

What is the tapering schedule for a patient with a prednisone dosage greater than 20 mg/day?

Reduce by 5 mg/day every two weeks

Reduce by 5 mg/day every week (correct)

Reduce by 2.5 mg/day every four weeks

Reduce by 2.5 mg/day every week

What is the recommended morning cortisol evaluation timing when reaching a prednisone dose of 5 mg/day?

9:00 – 10:00 h

7:00 – 8:00 h

6:00 – 7:00 h

8:00 – 9:00 h (correct)

What should be done after a patient reaches a prednisone dosage of 7.5 mg/day?

Reduce by 2.5 mg/day every four weeks (correct)

Reduce by 5 mg/day every month

Maintain the dosage until further evaluation

Reduce by 5 mg/day every two weeks

What is considered a normal morning cortisol level when evaluating at a prednisone dosage of 5 mg/day?

350 nmol/L Signup and view all the answers

What systemic effect is least likely to result from chronic use of oral corticosteroids in asthma management?

Hyperthyroidism Signup and view all the answers

What advantage do new biologic treatments provide for patients with severe asthma on oral corticosteroids?

Reduction or elimination of oral corticosteroids Signup and view all the answers

What is the primary concern associated with the long-term use of systemic corticosteroids?

Cumulative dose-related side effects Signup and view all the answers

Which of the following statements about adrenal insufficiency is most accurate?

It can be a side effect of long-term corticosteroid use. Signup and view all the answers

What is the primary purpose of the tapering protocol in chronic OCS therapy for severe asthma?

To safely reduce the dose or eliminate oral corticosteroids. Signup and view all the answers

Study Notes

Patient Overview

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.

Treatment Strategy

Transitioned to maintenance therapy after achieving remission with immunosuppressants.

Management Plan

Mild Activity

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.

Moderate Activity

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.

Severe Activity

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.

Summary

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.

Overview of Oral Corticosteroids in Severe Asthma

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.

Advances in Treatment

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 Protocol

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

Dosage Reduction Strategy

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.

Cortisol Evaluation

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.

Conclusion

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

Description

This quiz explores a detailed case study of a 30-year-old female diagnosed with systemic lupus erythematosus and lupus nephritis. It covers her treatment regimen, including glucocorticoids and immunosuppressants, and the clinical management of her condition. Test your knowledge on SLE and nephritis therapies.