The Scope of the Problem
Asthma affects more than 300 million people around the world. It is a chronic condition in which the airways become inflamed and narrowed, making breathing difficult. For many people, symptoms are mild and manageable with an inhaler. But for others — especially those with moderate to severe asthma — control is harder to achieve, and treatment escalates.
Corticosteroids (commonly called steroids) are among the most effective tools doctors have to control asthma. Inhaled versions, used daily, have an excellent safety record. But systemic steroids — taken as pills or injections — are a different story. They flood the entire body with anti-inflammatory signals, not just the lungs.
A Love-Hate Relationship With a Powerful Drug
The title of the original review — "odi et amo," Latin for "I hate and I love" — captures the paradox of steroid use in asthma perfectly.
Steroids work. They reduce inflammation fast. For someone in an acute asthma attack, a short course of oral steroids can be life-saving. But when used repeatedly over months and years, they carry serious consequences: weight gain, high blood pressure, diabetes, weakened bones, cataracts, adrenal suppression (where the body's own hormone system shuts down), and increased infection risk.
But here is the twist: despite the availability of newer biologic therapies — targeted drugs that address the root immune drivers of severe asthma — systemic steroids are still being used far too often in real-world clinical practice.
Why Steroids Get Overused
Think of steroids like the loudest switch on a circuit board — one flip and everything dims. They are fast, cheap, and familiar. Biologics, by contrast, are more like surgical instruments: precise, expensive, and requiring specialist oversight to prescribe.
In many healthcare settings, when asthma flares, the path of least resistance is another steroid course. The immediate effect looks like success. The long-term cost builds quietly.
Many patients do not know they are accumulating harm. Some doctors underestimate cumulative exposure because individual prescriptions seem short or reasonable in isolation. And in some health systems, biologics simply are not accessible or covered by insurance.
This systematic review, published in Frontiers in Medicine, analyzed published research on corticosteroid use in asthma, with a focus on the prevalence of steroid overuse, the types of adverse effects it causes, and strategies to reduce it. Researchers looked at both epidemiological data on real-world steroid use and clinical evidence on alternatives.
The data confirmed what many clinicians suspect but rarely say plainly: systemic steroid overuse in asthma is widespread. Even as biologic therapies have become available and proven effective for severe asthma, prescription rates for oral steroids have not decreased in proportion.
The review highlighted that patients receiving four or more courses of oral steroids per year face significantly elevated risk of multiple systemic side effects. Even fewer courses per year carry compounding risk that builds over time.
Researchers identified specific risk factors that should trigger a closer review of a patient's steroid burden: frequent oral steroid prescriptions, high inhaled steroid doses, poor symptom control despite treatment, and comorbidities like obesity or osteoporosis.
Recognizing at-risk patients earlier is the most actionable step clinicians can take right now.
The review also outlined two complementary strategies: first, identifying and screening patients who are accumulating harmful steroid exposure; and second, actively transitioning appropriate patients to biologic therapies that eliminate or dramatically reduce steroid need.
Where the Field Is Moving
The development of biologic drugs — such as those targeting specific immune proteins involved in asthma inflammation — has changed what is possible for people with difficult-to-control asthma. Several are already approved and have strong evidence behind them. For the right patients, they can achieve steroid-free asthma control.
The challenge is getting those treatments to the patients who need them. That requires better identification tools, more specialist involvement, and health system support.
If you take oral steroid pills (like prednisone) more than a few times a year for asthma, or if you have been on them for extended periods, talk to your doctor about your cumulative steroid exposure. Ask whether your asthma has been formally evaluated for biologic eligibility. You may qualify for a treatment that reduces your steroid burden significantly.
This is not about stopping your medication on your own. Never do that. It is about asking the right questions and advocating for a full review of your treatment plan.
This was a review of existing evidence, not a new clinical trial. The research included in the review varied in quality and design. Real-world prescribing data does not always capture the full picture of why steroids were used, making it difficult to determine in every case whether alternatives were truly available or appropriate.
The research community is now focused on two parallel goals: reducing the unnecessary use of systemic steroids in asthma and improving access to biologic alternatives for those with severe disease. Better tools to identify steroid overuse early — possibly including electronic health record alerts or standardized screening questions — are being developed and tested. As evidence mounts and guidelines become more explicit, the hope is that fewer asthma patients will carry the long-term burden of preventable steroid harm.