An initiative for patients, providers, and policymakers

Initiative Overview

Corticosteroids are recommended in the treatment of many diseases, including allergies, asthma, atopic dermatitis (also called eczema), chronic obstructive pulmonary disease (COPD), eosinophilic esophagitis (EoE), and nasal polyps (often termed T2 diseases). Corticosteroids are potent anti-inflammatory drugs (you can think of inflammation as swelling).

Depending on the disease they are meant to treat, corticosteroids may be:

  • given intranasally (into the nose),
  • inhaled or breathed in,
  • swallowed,
  • Injected,
  • or can be given through the skin as ointments or creams (topical).

Oral corticosteroids (OCS), when taken by mouth, are used commonly for a short time (usually 3-7 days), treat disease flares or attacks – or for a longer time to treat severe disease that is not controlled with other treatments. People with several diseases may be using more than one type of corticosteroid (e.g., one inhaled corticosteroid and one topical).

When used properly, corticosteroids are an important and effective anti-inflammatory treatment. However, like most drugs, corticosteroids can have side effects. Some of these side effects are short term and some are long term. Corticosteroids build up in the body over time, and the more a person uses them, the greater the risk of long-term side effects.1,2

OCS, both when taken for a long time as well as taken several times in a short period, play the biggest role in these kinds of side effects. We know that taking short bursts of OCS as few as four times in your lifetime can increase your risk of many conditions like diabetes, cataracts, and osteoperosis.1 Other forms of corticosteroids, including inhaled, intranasal, and ointments, can also add to the overall buildup of corticosteroids in the body. When people are using multiple forms of corticosteroids to treat several diseases, their chances of experiencing negative side effects increases.

Taking short bursts of OCS as few as four times in your lifetime can increase the risk of stroke, heart failure, Type 2 diabetes, cataracts, osteoporosis, bone fractures, pneumonia, depression/anxiety, and kidney impairment.1

Despite the risk of future long-term side effects, OCS is often overused and given by doctors beyond what is recommended.3-5 To decrease this potentially harmful and often inappropriate use, GAAPP promotes a steroid stewardship education and empowerment initiative for patients, providers, and policy makers. The objectives of the initiative are:

  • To ensure patients are only reliant on OCS once all other treatment options have been exhausted (a last resort. 
  • To raise awareness of OCS’s short-term and long-term side effects
  • To ensure each patient gets the right treatment at the right time with the fewest barriers to achieve the best outcome
  • To ensure patients and their providers engage in shared decision-making, particularly with respect to corticosteroids
Stacey’s Story

Stacey generously shares her experience with chronic illnesses, such as allergies and asthma, as well as the difficult diagnosis of a brain tumor. She also describes the role of corticosteroids in her journey and their significant impact on her long-term functioning. 

Patient Education
  • What are corticosteroids and how are they used?

Corticosteroids (also called glucocorticoids) are anti-inflammatory drugs. These are not the same steroids used for building muscle or making athletes perform better. Corticosteroids are used on a regular basis to control symptoms and prevent flares or attacks of allergies,6 asthma,7 COPD,8 EoE,9 and to shrink nasal polyps.10

Topical corticosteroid ointments are used for short periods to treat an acute episode of eczema as well as occasionally (generally 2-3 times a week) to prevent flares.11,12 An OCS or corticosteroid injection is sometimes given to treat a flare of these diseases . Long-term OCS is only recommended as a last resort for severe disease that does not respond to standard treatment.

  • How are corticosteroids given to patients?
  • Through the nose: intranasal, used daily for allergies and nasal polyps
  • Via the mouth:
    • Swallowed topicals used daily for EoE
    • Pills or syrup used on a short-term basis for flares and as a last-resort long-term treatment for severe disease uncontrolled with other treatments
  • Breathed in: inhalers used daily or as needed (intermittently) for asthma and COPD
  • On the skin: topical ointments for eczema
  • Through the skin: injections can be used for flares of allergies, asthma, COPD, EoE, and to shrink nasal polyps
  • Intravenously (through a vein usually in the hand or arm) for hospitalized patients
  • How do corticosteroids work?

Corticosteroids are a natural hormone that control many functions in the body, including inflammation. When given as a treatment, they reduce the inflammatory cells and molecules that cause disease symptoms. If possible, doctors usually target corticosteroids to the location of inflammation, such as the lungs for asthma and COPD. OCS, on the other hand, work throughout the whole body.

  • OCS is associated with short-term side effects and can increase the risk of potentially serious long-term effects. The side effects of other corticosteroid formulations (inhaled, intranasal, swallowed, and topical) differ from OCS and have substantially fewer risks for long-term effects. Short-term side effects of OCS
  • Elevated eye pressure (glaucoma)
  • Fluid retention (causing swelling in lower legs)
  • Increased appetite
  • Insomnia/sleep disturbance
  • High blood pressure
  • Problems with mood, memory, and behavior
  • Weight gain (abdomen, face, and neck)
  • Long-term risks of OCS
    • Cataracts (clouded version)
    • High blood sugar (can trigger or worsen diabetes)
    • Infections (especially the risk of possible pneumonia in COPD patients)
    • Osteoporosis
    • Think skin, bruising, slower wound healing
    • Heart attack and stroke
    • Obesity
    • Kidney impairment
    • Bone fractures
    • Depressions/anxiety
    • Growth impairment in children

  • You can help reduce disease flares (attacks) by taking medications exactly as prescribed by your healthcare provider. OCS is primarily used to treat disease flares. Although flares may occur despite medications to control disease, taking lower doses or skipping doses can make medication less effective. Speak with your healthcare provider if you feel your disease is becoming poorly controlled; disease control can often be determined by a control test such as the ACT or AIRQ® in asthma .
  • You deserve to avoid unnecessary OCS14,15; discuss other potential treatment options with your healthcare provider. Learn more about alternatives to OCS here. You may still experience clinical events and situations for which OCS is the best option.
  • If you see multiple healthcare providers, they may not have a record of all your OCS prescriptions. It is helpful for you to communicate to all your providers how many OCS courses you have received within the past year. You and your healthcare provider can discuss medications that can treat multiple inflammatory diseases at the same time, potentially reducing flares of each disease and the need for multiple courses of OCS for your different diseases.

Resource: SAM and me, a free digital tool to help you track your steroid journey.

There are clinical situations for which OCS is the best option. However, treatment with OCS should be a last resort when no other options are available. For disease control, there are alternative medication options. Talk to your doctor and used shared decision-making to see if alternatives might be an possibility for you.

  • COPD
    • Long-acting beta-agonist (LABA)
    • LABA plus inhaled corticosteroids (ICS)
    • Long-acting anti-muscarinics (LAMA)
    • LABA/ICS/ICS/LAMA
    • Theophylline
    • Mucolytic drugs
    • Phosphodiesterase-4 enzyme inhibitors
    • Antibiotics
    • Anti IL-4/IL-13
Steroids and Me Tool

Teresa’s Story

Teresa talks candidly about living with sarcoidosis and COPD. She shares the long-term effects of overuse of prescribed cortiscosteroids. “There have to be other forms of treatment besides steroids,” she says.

Healthcare Provider Guidance

Steroid stewardship is the responsibility of the entire healthcare community. As a community, we would be wise to heed the lessons learned from antibiotic stewardship. As a clinician, you can use evidence-based best practices to minimize a patient’s exposure to OCS.

  • Re-evaluate the patient’s treatment plan if frequent OCS (more than 2 courses per year) has occurred
  • Follow recommended treatment guidelines to optimize disease control and prevent flares
  • Evaluate patient adherence to treatment and provide support to reduce barriers to adherence
  • If disease is poorly controlled, refer patient to a specialist to ensure optimal diagnosis and management
  • Prescribe effective and safe alternatives to OCS , when available
  • Determine any contraindications to OCS and screen for metabolic and endocrine conditions that may worsen with OCS use
  • Use shared decision-making to provide patients with information about the side effects and long-term risks of OCS as well as alternative treatments (i.e., medications and/or non-drug approaches such as pulmonary rehabilitation, diet, and exercise)
  • When OCS is necessary, limit the cumulative OCS dose to 1 g per year (equivalent to 4 short-term courses at the usual dose for treating an asthma exacerbation).16 Dosages for common OCS are available here.
  • Use the lowest potency formulation and lowest dose necessary for effective treatment

Good steroid stewardship can be achieved through judicious steroid prescribing (not relying solely on cost considerations), using corticosteroids with caution in patients who may be more susceptible to side effects, and communication with the patient and family. Moreover, corticosteroids should only be prescribed when absolutely necessary and for conditions in which a clinical benefit has been demonstrated.

  • Judicious steroid prescribing

Various steroids have different potencies. Since steroid exposure is cumulative over time, the lowest possible potency, dose, and duration to achieve an effective response should be prescribed to minimize exposure.

  • Considerations for special populations

Children

  • Topical corticosteroids should be used with caution in children because of a larger surface area to body weight ratio and poor skin barrier function.17 Consider other approaches that decrease the daily use of topical corticosteroids.
    • Corticosteroids administered by any route have been shown to suppress long-term growth in children. The clinical benefit of corticosteroids needs to be weighed against the potential for growth suppression and the availability of alternative treatments.
    • Some vaccines [live or live, attenuated (measles, mumps, and rubella)] should not be administered while a child is undergoing immunosuppressive doses of corticosteroid treatment (e.g., >20 mg/day for more than 2 weeks). Chicken pox and measles can be more serious in children on corticosteroids and exposure to these diseases should be avoided.

Elderly

  • Topical corticosteroid should be used with caution in elderly individuals because of a larger surface area to body weight ratio and fragile skin.17
    • OCS dosing should start low given the greater frequency of renal, hepatic, cardiac,  and mental health dysfunction, including depression.
  • Minimizing unnecessary steroid use

Reliance on OCS or frequent OCS are key identifying features of uncontrolled disease. Disease management plans should be discussed with patients to optimize disease control and minimize the need for OCS use.

OCS should not be prescribed for conditions (e.g., acute bronchitis, acute sinusitis) that do not have evidence to support a benefit.18 In COPD, ICS use should be minimized with the exception of specific types of patients that are known to respond well to corticosteroids (e.g., eosinophilic phenotype).

Steroid stewardship is only possible when healthcare providers are aware of the risk of corticosteroid overuse and misuse and have a clear course of action for how to avoid them. Similarly, assess the level of misinformation concerning corticosteroids patient and family may have received, in addition to communicating the importance of steroid stewardship to them..

  • Steroid stewardship education and support for healthcare teams

    Healthcare teams should have a written steroid stewardship plan. This plan should include a prescription checklist, preferred steroid names, doses and route of administration, protocols for dose titration and dose tapering, as well as instructions for follow-up.17 A lower steroid exposure for a patient reliant on OCS for disease control may be achieved with a structured tapering approach.19 Electronic alert systems that flag patients with multiple OCS prescriptions can help healthcare providers identify patients at risk of OCS overuse.
  • Tools for assessing patient needs and risks
  • Techniques for effectively communicating with patients and families

    Shared decision-making conversations – often with the use of shared decision-making aids or tools – should be used to provide patients with information about the potential benefits, side effects, and long-term risks of OCS. The importance of adherence and discussion of treatment options should also be a part of these conversations. Recommended steps for shared-decision making can be found here. A guide for patients with asthma that will help start patient-provider conversations about overreliance on OCS is available here.

A recent review has highlighted the importance of shared decision-making as a key pillar in the prevention of acute infection in patients treated with long-term steroids.

Glucocorticoids are effective at quelling inflammation and are widely used to manage inflammatory and immune-mediated diseases including inflammatory bowel disease, asthma and rheumatic diseases. The use of glucocorticoids is, however, associated with significant side-effects including osteoporosis, adrenal suppression and opportunistic infection. While these adverse effects are generally considered to be driven by dose, duration, route of administration and intensity of steroid treatment, the authors of this recent review believe that this dose-dependent model may not tell the whole story when considering opportunistic infection.  

They set out to:

  • Understand the risk of opportunistic infections in patients taking glucocorticoids by:
  • Examining the cellular and clinical effects of steroids
  • Understanding the interaction with host biological factors such as comorbidities and concomitant medications
  • Discuss the challenges of quantifying increased risk of opportunistic infection
  • Propose strategies to prevent acute infections or reactivation of latent infections

The review incorporated studies across diverse patient cohorts (including rheumatic diseases, inflammatory bowel disease and systemic lupus erythematosus), with heterogeneous co-morbidities and concomitant medication profiles. The authors explored the quantitative and qualitative immunosuppressive effects of steroids, and the impact that long-term steroid exposure has on the risk of opportunistic infection.  

The results highlighted the complex pathways through which glucocorticoids impart their effect, altering the recruitment and activity of most types of immune cells including eosinophils, T- and B-cells. Quantifying the impact of steroids on the risk of opportunistic infections was complicated by the following factors:

  • Lack of consistency in how studies reported steroid dose, duration and administration
  • The broad range of glucocorticoids used in the different studies, with differing degrees of immunosuppression
  • The prednisone equivalent score used to normalize this variable immunosuppression, which doesn’t fully capture the heterogeneous effects of the different steroid treatments, making it difficult to accurately quantify any correlation between steroids and opportunistic infection
  • Conflicting data on the correlation between glucocorticoid dose and risk of opportunistic infections
  • Patients with diverse and complex presentations that could contribute to their risk of infection including:
  • Disease involvement, e.g., immunologic dysfunction in patients
  • Comorbidities, e.g., coexisting immunodeficiencies

Concomitant immunosuppressive medications, e.g., methotrexate, anti-TNFs and disease-modifying antirheumatic drugs that confound the risk analysis of infection from glucocorticoids

Interventions to prevent infections or disease progression caused by opportunistic pathogens in patients receiving glucocorticoid treatment are essential. However, implementation is difficult without the ability to identify which patients would benefit from such interventions. In the absence of tools to determine patients’ “net state” of immunosuppression, clinicians are forced to rely on the dose-dependent, prednisone-equivalent method to identify patients at risk of infection.

The ability to effectively determine risk of opportunistic infections in the future would benefit from more detailed information on how different steroid treatments affect the immune function. Clinical calculators that consider all aspects of steroid treatment (dose, potency, length of exposure) and incorporate patient specific elements (e.g., comorbidities, coexisting immunodeficiencies and concomitant immunosuppressive therapies) also need to be developed. New technologies that can measure cell-mediated immunity could also provide a more accurate prediction of an individual patient’s risk of opportunistic infection.

While predictive models are developed, researchers recommend a multifactorial approach that includes limiting steroid use, screening for asymptomatic infections, antimicrobial prophylaxis and immunizations.

We strongly recommend implementing shared decision-making that involves an ongoing and open discussion between patients and clinicians about disease symptoms, comorbidities, previous medications and the patient’s personal and environment risks to ensure patients can minimize their risks of developing opportunistic infections.

Patients needing long-term OCS require baseline assessment of metabolic and endocrine conditions that may worsen with OCS. In addition, a plan for monitoring and managing side effects for patients on long-term OCS.

  • Baseline and risk factor assessment
    • Weight
    • Height
    • BMI
    • Blood pressure
    • Skin tags
    • Pedal edema
    • Glucose (FPG, A1C, 2-hour OGTT)
    • Lipid profile
    • DEXA bone mineral density
    • Assessment of mood disorders
  • Monitoring patient’s undesirable response to therapy
    • Weight gain
    • Height change
    • Blood pressure changes
    • Growth changes (in children)
    • Glucose changes (FPG, A1C, 2-hour OGTT)
    • Lipid profile changes
    • Bone health
    • Spinal X-ray
    • Back pain
    • Limping
    • FRAX scoring and risk assessment for vertebral fracture risk
    • Ophthalmological assessment for cataracts and glaucoma
    • Changes in mood, including depression
    • Infections
  • Strategies for mitigating undesirable side effects

The most effective strategy to mitigate long-term effects is judicious steroid dosing and elimination of unnecessary OCS use. However, there are some measures that can mitigate short-term side effects and long-term risks.

              Long-term risk mitigation

  • Taper dosing when stopping long-term treatment to avoid suppression of the hypothalamic-pituitary adrenal axis
  • Lifestyle modifications (e.g., smoking cessation, limit alcohol, participation in daily exercise) to reduce risk of osteoporosis
  • Calcium and vitamin D supplementation and a weight-bearing exercise program may help with bone health
  • Restriction of dietary salt and potassium supplementation may help with water retention and hypertension
  • Take with food or milk to reduce gastric irritation
  • For large dose OCS, antacids or proton pump inhibitors (PPDs) may help prevent peptic ulcers
  • Alternate day dosing at twice the usual daily dose to minimize adrenal suppression and withdrawal symptoms

Short-term side effect mitigation

  • Restriction of dietary salt may help with water retention
  • Take with food or milk to reduce gastric irritation

Short-term doses do not need to be tapered

Resource: SAM and me is a free digital tool that can help your patients track their steroid journey.  

Asthma and OCS Stewardship
Payer and Policy Maker Resources

The true costs of OCS use still has not been well defined. From cataracts to cardiovascular complications, the adverse events associated with long-term use of glucocorticoids are wide-ranging, taking a heavy toll on patients and healthcare systems.

Quantifying the economic impact of glucocorticoid-use is a key undertaking to enable value-based care for the millions of patients who suffer from inflammatory conditions like asthma, COPD & eczema.

Since their discovery, steroids have become a keystone treatment for autoimmune and inflammatory diseases, as their ability to swiftly and effectively bring symptoms under control often makes them indispensable. However, the persistence of these conditions frequently necessitates long-term use, increasing the risk of steroid-toxicities.

The first side effects of steroids were recognized shortly after their clinical introduction. Patients treated with glucocorticoids in the 1950s exhibited significant adverse events, including cushingoid appearance and psychosis. Over time, other serious steroid-toxicities have been well documented, including osteoporosis, cardiovascular complications and infection risks. Despite these risks, formal guidelines to manage these effects only emerged decades later, reflecting a historical underestimation of their severity.

The authors cite a recent study2 that surveyed Canadian neuromuscular neurologists to assess their practices in managing chronic glucocorticoid therapy. Findings revealed substantial variability in screening, monitoring and prophylaxis against steroid-toxicity. While most clinicians discussed risks like osteoporosis and hyperglycemia with their patients, there was inconsistency in vaccination recommendations and other preventive measures.

Addressing the adverse events of glucocorticoids requires coordinated efforts across specialties. Clear delineation of responsibilities among prescribing clinicians, primary care providers and specialists is crucial. Utilizing electronic health records with automatic reminders and clinical decision-support tools can enhance the monitoring and management of steroid-toxicities. The authors also suggest adopting validated tools like the Steritas Glucocorticoid Toxicity Index (GTI) to track and mitigate effects in the clinic.

According to the authors, the extensive adverse events caused by glucocorticoids make it debatable whether they would pass modern regulatory scrutiny. Current clinical trials would bring into question whether the risk-benefit ratio of these powerful drugs would make their development viable. If a more recent medication were to cause such significant adverse events, would it be withdrawn from the market?

While glucocorticoids remain a cornerstone in treating autoimmune and inflammatory diseases, their use today necessitates a careful, informed approach. Incorporating guidelines from related specialties, employing advanced monitoring tools, and fostering interdisciplinary collaboration are essential steps in optimizing glucocorticoid therapy.

The authors stress that, given the hazards associated with glucocorticoids, their use should be approached with caution. Thorough patient education and rigorous monitoring should be ensured to balance their benefits against the harms.

  1. Habib AA, Narayanaswami P. Would glucocorticoids be approved for clinical use if discovered today? Muscle Nerve. 2024 Jul;70(1):9-11. https://doi.org/10.1002/mus.28111 Epub 2024 May 8. PMID: 38720486.
  2. Stepanian L, Laughlin R, Bacher C, et al. Chronic glucocorticoid management in neuromuscular disease: a survey of neuromuscular neurologists. Muscle Nerve. 2024;70(1):52-59. https://doi.org/10.1002/mus.28069

Resources

Haughney J, Winders T, Holmes S, Chanez P, Menzies-Gow A, Kocks J, Mansur AH, McPherson C, Canonica GW. A Charter to Fundamentally Change the Role of Oral Corticosteroids in the Management of Asthma. Adv Ther. 2023 Jun;40(6):2577-2594. doi: 10.1007/s12325-023-02479-0. Epub 2023 Apr 7. PMID: 37027115; PMCID: PMC10080509.

Suehs CM, Menzies-Gow A, Price D, Bleecker ER, Canonica GW, Gurnell M, Bourdin A; Oral Corticosteroids Tapering Delphi Expert Panel. Expert Consensus on the Tapering of Oral Corticosteroids for the Treatment of Asthma. A Delphi Study. Am J Respir Crit Care Med. 2021 Apr 1;203(7):871-881. doi: 10.1164/rccm.202007-2721OC. PMID: 33112646.

Menzies-Gow A, Jackson DJ, Al-Ahmad M, Bleecker ER, Cosio Piqueras FBG, Brunton S, Canonica GW, Chan CKN, Haughney J, Holmes S, Kocks J, Winders T. A Renewed Charter: Key Principles to Improve Patient Care in Severe Asthma. Adv Ther. 2022 Dec;39(12):5307-5326. doi: 10.1007/s12325-022-02340-w. Epub 2022 Oct 17. PMID: 36251167; PMCID: PMC9573814.

Bleecker ER, Al-Ahmad M, Bjermer L, Caminati M, Canonica GW, Kaplan A, Papadopoulos NG, Roche N, Ryan D, Tohda Y, Yáñez A, Price D. Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group. World Allergy Organ J. 2022 Dec 10;15(12):100726. doi: 10.1016/j.waojou.2022.100726. PMID: 36582404; PMCID: PMC9761384.

Monica Fletcher, Tonya Winders, John Oppenheimer, Peter Howarth, Zeina Eid Antoun, Thys Van Der Molen, Mike Thomas
European Respiratory Journal 2021 58: PA3555; DOI: 10.1183/13993003.congress-2021.PA3555

Blakey J, Chung LP, McDonald VM, Ruane L, Gornall J, Barton C, Bosnic-Anticevich S, Harrington J, Hew M, Holland AE, Hopkins T, Jayaram L, Reddel H, Upham JW, Gibson PG, Bardin P. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology. 2021 Dec;26(12):1112-1130. doi: 10.1111/resp.14147. Epub 2021 Sep 29. PMID: 34587348; PMCID: PMC9291960.

Dominguez-Ortega J, Muñoz-Gall X, Delgado-Romero J, Casas-Maldonado F, Blanco-Aparicio M. Challenges in the Implementation of the Spanish Consensus on the Reduction of Oral Corticosteroids: Insights From the Medical Community. Open Respir Arch. 2024 May 8;6(3):100331. doi: 10.1016/j.opresp.2024.100331. PMID: 38883425; PMCID: PMC11176918.

Haughney J, Winders TA, Holmes S, Chanez P, Saul H, Menzies-Gow A; PRECISION Improve Access to Better Care Task Force. Global Quality Standard for Identification and Management of Severe Asthma. Adv Ther. 2020 Sep;37(9):3645-3659. doi: 10.1007/s12325-020-01450-7. Epub 2020 Jul 28. PMID: 32725419; PMCID: PMC7444397.

Winders T, Maspero J, Callan L, Al-Ahmad M. Perspectives on decisions for treatment and care in severe asthma. World Allergy Organ J. 2021 Jan 16;14(1):100500. doi: 10.1016/j.waojou.2020.100500. PMID: 33537114; PMCID: PMC7817505.

Kalra S, Kumar A, Sahay R. Steroid Stewardship. Indian J Endocrinol Metab. 2022;26(1):13-16.

Politis J, Chung LP, Igwe E, Bardin P, Gibson PG. Oral corticosteroid stewardship: key insights from the Australasian Severe Asthma Registry. Intern Med J. 2024;54(7):1136-1145.

Dvorin EL, Ebell MH. Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care. Am Fam Physician. 2020;101(2):89-94.

Chung LP, Upham JW, Bardin PG, Hew M. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology. 2020;25(2):161-172.

Acknowledgements

Thank you to Erin Scott, PhD and Dr. Don Bukstein for their contributions to this project.

We thank AstraZeneca, Novartis, and Sanofi for their support of GAAPP’s Steroid Stewardship Educational Initiative.

References

1. Price DB, Trudo F, Voorham J, Xu X, Kerkhof M, Ling Zhi Jie J, et al. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy. 2018;11(193-204.

2. Voorham J, Xu X, Price DB, Golam S, Davis J, Zhi Jie Ling J, et al. Healthcare resource utilization and costs associated with incremental systemic corticosteroid exposure in asthma. Allergy. 2019;74(2):273-283.

3. Menzies-Gow AN, Tran TN, Stanley B, Carter VA, Smolen JS, Bourdin A, et al. Trends in Systemic Glucocorticoid Utilization in the United Kingdom from 1990 to 2019: A Population-Based, Serial Cross-Sectional Analysis. Pragmat Obs Res. 2024;15(53-64)

4. Jones YO, Hubbell BB, Thomson J, O’Toole JK. Things We Do for No Reason: Systemic Corticosteroids for Wheezing in Preschool-Aged Children. J Hosp Med. 2019;14(12):774-776.

5. van der Meer AN, de Jong K, Ferns M, Widrich C, Ten Brinke A. Overuse of Oral Corticosteroids in Asthma Is Often Underdiagnosed and Inadequately Addressed. J Allergy Clin Immunol Pract. 2022;10(8):2093-2098.

6. Wise SK, Damask C, Roland LT, Ebert C, Levy JM, Lin S, et al. International consensus statement on allergy and rhinology: Allergic rhinitis – 2023. Int Forum Allergy Rhinol. 2023;13(4):293-859.

7. Global Initiative for Asthma (GINA) 2024 Report: Global Strategy for Asthma Management and Prevention. Available at: https://ginasthma.org/2024-report/. Accessed August 3, 2024.

8. Global Initiative for Chronic Obstructive Lung Disease. Available at: https://goldcopd.org/2024-gold-report/, 2024.

9. Hirano I, Chan ES, Rank MA, Sharaf RN, Stollman NH, Stukus DR, et al. AGA institute and the joint task force on allergy-immunology practice parameters clinical guidelines for the management of eosinophilic esophagitis. Ann Allergy Asthma Immunol. 2020;124(5):416-423.

10. Rank MA, Chu DK, Bognanni A, Oykhman P, Bernstein JA, Ellis AK, et al. The Joint Task Force on Practice Parameters GRADE guidelines for the medical management of chronic rhinosinusitis with nasal polyposis. J Allergy Clin Immunol. 2023;151(2):386-398.

11. Chu DK, Schneider L, Asiniwasis RN, Boguniewicz M, De Benedetto A, Ellison K, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol. 2024;132(3):274-312.

12. Sidbury R, Alikhan A, Bercovitch L, Cohen DE, Darr JM, Drucker AM, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. Journal of the American Academy of Dermatology. 2023;89(1):e1-e20.

13. Oral Corticosteroid Stewardship Statement. Available at: https://allergyasthmanetwork.org/images/Misc/oral-corticosteroid-stewardship-statement.pdf. Accessed August 12, 2024.

14. Maurer M, Albuquerque M, Boursiquot JN, Dery E, Gimenez-Arnau A, Godse K, et al. A Patient Charter for Chronic Urticaria. Adv Ther. 2024;41(1):14-33.

15. Menzies-Gow A, Jackson DJ, Al-Ahmad M, Bleecker ER, Cosio Piqueras FBG, Brunton S, et al. A Renewed Charter: Key Principles to Improve Patient Care in Severe Asthma. Adv Ther. 2022;39(12):5307-5326.

16. Price D, Castro M, Bourdin A, Fucile S, Altman P. Short-course systemic corticosteroids in asthma: striking the balance between efficacy and safety. Eur Respir Rev. 2020;29(155).

17. Kalra S, Kumar A, Sahay R. Steroid Stewardship. Indian J Endocrinol Metab. 2022;26(1):13-16.

18. Dvorin EL, Ebell MH. Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care. Am Fam Physician. 2020;101(2):89-94.

19. Chung LP, Upham JW, Bardin PG, Hew M. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology. 2020;25(2):161-172.