Reducing the hidden burden of severe asthma: recognition and referrals from primary practice

Marc Humbert* (Corresponding Author), Arnaud Bourdin, Nikolaos G. Papadopoulos, Stephen T. Holgate, Nicola A. Hanania, David M.G. Halpin, Kenneth R. Chapman, Marcela Gavornikova, David B. Price, Alan Kaplan, Liam G. Heaney

*Corresponding author for this work

Research output: Contribution to journalComment/debatepeer-review

6 Citations (Scopus)


Since their introduction many decades ago, systemic corticosteroids have become a mainstay treatment for asthma. Despite being a highly effective therapy, corticosteroids can cause significant adverse effects in patients. This results in a “double hit” for some patients as they suffer the burden of disease as well as the burden of treatment-induced morbidity. This article aims to raise awareness of the potential, harmful side effects of prolonged or repeated exposure to systemic corticosteroids in asthma. It also highlights the importance of referral of the appropriate patients with asthma from primary care for specialist assessment once other considerations such as adherence, inhaler technique and co-morbidity have been evaluated. We propose a simple decision step that may help busy primary care physicians and general practitioners to identify patients who could benefit from specialist assessment. Our decision step suggests that a patient with asthma should be reviewed at least once by an asthma specialist if he/she (i) has received ≥2 courses of oral corticosteroids in the previous year; asthma remains uncontrolled despite good adherence and inhaler technique; or (ii) has attended an emergency department or was hospitalized for asthma care. Such referral could facilitate wider access to diagnostic tools, in-depth assessment of confounding comorbidities, and non-corticosteroid-based therapies as needed, which may be unavailable in primary practice.

Original languageEnglish
Pages (from-to)849-854
Number of pages6
JournalJournal of Asthma
Issue number7
Early online date13 May 2020
Publication statusPublished - 2021

Bibliographical note

Medical writing support was provided by Gillian Lavelle, PhD, and Ian Wright, PhD, of Novartis Product Lifecycle Services, Dublin, Ireland, funded by Novartis Pharma AG, Basel, Switzerland, in accordance with Good Publication Practice (GPP3) guidelines (

Disclosure statement
Arnaud Bourdin reports personal fees from Novartis, Sanofi, Genentech, and Chiesi Farma; and grants and personal fees from GlaxoSmithKline, AstraZeneca, and Boehringer Ingelheim. Kenneth Chapman reports grants and personal fees from AstraZeneca, Boehringer Ingelheim, CSL Behring, Grifols, Sanofi, Genentech, Kamada, Roche, and Novartis; grants from Baxter, GlaxoSmithKline, and Amgen; personal fees from Merck and CIHR-GSK Research Chair in Respiratory Health Care Delivery, UHN. Marcela Gavornikova was a full-time employee of Novartis Pharma AG at the time of manuscript initiation. David Halpin reports personal fees and non-financial support from Novartis, GlaxoSmithKline, and Boehringer Ingelheim; and personal fees from AstraZeneca, Chiesi, and Pfizer. Nicola Hanania reports personal fees from Novartis, Sanofi, GlaxoSmithKline, AstraZeneca, and Genentech. He also reports grants through his institution from GlaxoSmithKline and AstraZeneca outside of the submitted work. Liam Heaney reports personal fees from Novartis, Roche/Genentech Inc., Sanofi, GlaxoSmithKline, Teva, Respivert, Merck Sharp and Dohme, AstraZeneca, Nycomed, Vectura, Boehringer Ingelheim, and Aerocrine. He also reports sponsorship to attend scientific meetings from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Napp Pharmaceuticals. Vitalograph Ltd. provided INCA inhaler technology within the MRC-funded RASP-UK programme. Aerocrine AB facilitated reduced cost of Aerocrine FeNO machines within the MRC-funded RASP-UK programme. Stephen Holgate reports personal fees from Novartis and Synairgen. Marc Humbert reports personal fees from Novartis, AstraZeneca, GlaxoSmithKline, Roche, Sanofi, and Teva. Alan Kaplan reports personal fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, Pfizer, Purdue, Teva, Trudel, Mylan, Sanofi, and NovoNordisk; grants from Benton Dickinson and Trudel; and non-financial support from GlaxoSmithKline, Novartis, Pfizer, MD Briefcase, and Sea Cruises. Nikolaos Papadopoulos reports consultancy or speaker fees from Novartis, Menarini, Hal Allergy B.V., and Mylan. He also reports grants from Gerolymatos. David Price reports grants to his institution and personal fees from Aerocrine, AstraZeneca, Boehringer Ingelheim, Chiesi, Mylan, Mundipharma, Napp, Novartis, Pfizer, Regeneron Pharmaceuticals, Sanofi Genzyme, Teva, Theravance, and Zentiva (Sanofi Generics). He reports personal fees from Almirall, Amgen, Cipla, GlaxoSmithKline, Kyorin, Merck, and SkyePharma, and grants to his institution from AKL Research and Development Ltd., the British Lung Foundation, Respiratory Effectiveness Group, and the UK National Health Service. David Price has stock/stock options in AKL Research and Development Ltd., which produces phytopharmaceuticals, and owns 74% of the social enterprise Optimum Patient Care Ltd (Australia and UK) and 74% of Observational and Pragmatic Research Institute Pte Ltd (Singapore). He is peer reviewer for grant committees of the Efficacy and Mechanism Evaluation programme, and Health Technology Assessment.


  • decision step process
  • general practitioner
  • non-corticosteroid therapy
  • primary care
  • referral
  • specialist
  • Systemic corticosteroids


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