For people with severe asthma, oral corticosteroids (OCS) have long been the go-to rescue when breathing gets bad. They work fast. They stop flare-ups. But for many, that relief comes at a steep price-weight gain, bone loss, diabetes, mood swings, and even a higher risk of early death. And it’s not just the patient who pays. The healthcare system shoulders billions in hidden costs from complications that show up months or years later. The truth? OCS aren’t a long-term solution. They’re a stopgap. And today, there are better ways.
Why Oral Corticosteroids Are a Problem
Oral corticosteroids like prednisone or prednisolone reduce inflammation in the airways. That’s why they’re effective during an asthma attack. But using them regularly-even just a few short courses a year-starts to wear on the body. A 2025 study in Frontiers in Allergy found that 93% of people with severe asthma who rely on OCS develop at least one serious side effect. Some of these show up in as little as two weeks: blood sugar spikes, fluid retention, insomnia, or elevated blood pressure. Long-term use? That’s when the real damage sets in: osteoporosis that leads to fractures, cataracts, adrenal suppression, and increased risk of heart disease and infections.
It’s not just health. It’s money. In Italy, the annual cost of managing OCS-related complications in asthma patients hit €1,960 per person-almost double what non-asthma patients pay for similar side effects. And OCS themselves? Cheap. A 30-day supply might cost under $10. But the real cost is in the hospital visits, the bone density scans, the diabetes meds, the mental health care. These are the shadow costs no one talks about until it’s too late.
When OCS Use Becomes Dependence
Dependence isn’t addiction. It’s when your body can’t manage asthma without steroids. Clinically, it’s defined as using OCS for six months or longer. Many patients don’t even realize they’re dependent until they try to stop. They get short of breath. Their peak flow drops. They panic and reach for the pills again. That cycle-flare, steroid, feel better, taper, flare again-is exhausting. Patients call it a "necessary evil." They know it’s harming them, but they feel trapped. No OCS? No breathing. It’s a cruel trade-off.
Guidelines from GINA (Global Initiative for Asthma) say OCS should only be used as a last resort-Step 5 treatment-after all other options have failed. But in practice, many doctors keep prescribing them because they’re familiar, accessible, and fast-acting. The problem? That’s not what the evidence says anymore. We have better tools now.
Biologics: The Game-Changing Alternative
Biologics are the most powerful shift in asthma treatment in decades. These are injectable or infusion therapies that target specific parts of the immune system driving inflammation. They don’t suppress the whole body like steroids. They hit the exact culprits-like IL-5, IgE, or IL-4/13-that cause airway swelling in type 2 asthma.
There are six FDA-approved biologics for asthma: omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab. They’re not for everyone. About half to two-thirds of severe asthma cases are driven by type 2 inflammation, which these drugs target. Blood tests for eosinophils or FeNO (fractional exhaled nitric oxide) help identify who will benefit.
One study of 106 Italian adults with uncontrolled asthma showed what happens when you switch from OCS to mepolizumab:
- 79% were OCS-dependent before treatment. After 12 months? Only 31% still needed them.
- Those who still needed steroids cut their daily dose by nearly 5 mg on average.
- Exacerbations dropped from 4.1 per year to 0.8.
- Hospitalizations fell from 0.4 to 0.06 per year.
Dupilumab had similar results in multiple trials. People didn’t just have fewer attacks-they slept better, could exercise more, and reported less anxiety. One patient in Sydney told her doctor, "I haven’t felt this normal in 12 years."
Cost Isn’t the Barrier You Think It Is
Yes, biologics cost more upfront. A single dose can run $10,000 to $30,000 a year. OCS? A few dollars. But here’s the math that matters: if you avoid one hospitalization, you save $15,000. If you prevent a hip fracture from osteoporosis? That’s $50,000. If you avoid diabetes meds, dialysis, or cardiac surgery? The savings multiply.
Studies show that over three to five years, switching to biologics actually reduces total healthcare spending-even after factoring in drug costs. The Italian study confirmed it: fewer ER visits, fewer admissions, fewer specialist appointments. The economic case isn’t just strong-it’s undeniable.
Some patients worry about access. Insurance coverage varies. But in Australia, PBS subsidies now cover several biologics for eligible severe asthma patients. In the U.S., a June 2024 move capped inhaler costs at $35/month for many-but that doesn’t help those on public insurance. Biologics are still a challenge to get, but the tide is turning. More clinics now have dedicated asthma transition programs. Pharmacies offer co-pay assistance. Manufacturers provide patient support networks.
Other Alternatives-What Works and What Doesn’t
Biologics aren’t the only option, but most others have limited proof.
Bronchial thermoplasty uses heat delivered through a bronchoscope to reduce excess smooth muscle in the airways. It can improve quality of life and reduce flare-ups-but only in carefully selected patients who’ve tried everything else. The procedure requires three sessions and can make asthma worse for up to six weeks afterward. It’s not a first-line fix.
Vitamin D was once thought to help. Multiple studies, including one reviewed by the American Academy of Family Physicians in 2021, found that giving high-dose vitamin D3 to adults with asthma-even those who were deficient-didn’t prevent exacerbations or reduce steroid use. It’s not the magic bullet some hoped for.
Improved inhaler technique and trigger avoidance are always important. But if someone is still needing OCS monthly despite perfect inhaler use, they’re not getting the right underlying treatment. That’s where biologics come in.
How to Start the Transition
Stopping OCS isn’t a switch you flip. It’s a process. Too fast? You risk a life-threatening flare. Too slow? You keep accumulating damage.
Here’s how it works in practice:
- Confirm you have type 2 inflammation. Get an eosinophil blood test and FeNO test.
- Discuss biologic eligibility with your asthma specialist. Not all are approved for every patient.
- Start the biologic. Wait 3-6 months for full effect. Don’t rush the steroid taper.
- Work with your doctor to reduce OCS by 25% every 4-8 weeks. Monitor symptoms and lung function closely.
- Keep rescue inhalers handy. You may still need them during illness or flare-ups.
- Track your progress: peak flow, symptom logs, exacerbation count.
Some patients need help from an asthma nurse or transition clinic. These programs exist in major cities like Sydney, Melbourne, and Brisbane. They’re not everywhere yet-but they’re growing.
The Future Is OCS-Free Asthma
The goal isn’t just to reduce OCS. It’s to eliminate dependence. And it’s working. In clinics that prioritize biologics early, up to 60% of patients stop OCS completely within two years. Their lungs improve. Their lives improve. They stop fearing the next attack.
The old model-"steroids until we find something better"-is over. The new model is: "Use biologics to get off steroids before they break you."
It’s not about avoiding OCS forever. It’s about not letting them become your only option. If you’re on monthly or quarterly oral steroids for asthma, you deserve better. You have better options now. The question isn’t whether they’re available. It’s whether you’re ready to ask for them.
Can I stop oral corticosteroids on my own if I start a biologic?
No. Stopping oral corticosteroids too quickly can cause adrenal insufficiency, which is dangerous. Even if you feel better on a biologic, you must taper steroids slowly under medical supervision. Your doctor will monitor your cortisol levels and symptoms to adjust the dose safely over weeks or months.
Are biologics covered by Medicare or PBS in Australia?
Yes, several biologics for severe asthma are listed on the Pharmaceutical Benefits Scheme (PBS) in Australia. Eligibility depends on your asthma severity, history of exacerbations, and confirmed type 2 inflammation. You’ll need a specialist referral and specific test results. The out-of-pocket cost is typically under $30 per script with a concession card.
How do I know if I have type 2 inflammation?
Two simple tests can tell you: a blood test for eosinophils (a type of white blood cell) and a FeNO test (fractional exhaled nitric oxide), which measures airway inflammation. If your eosinophil count is above 300 cells/μL or your FeNO is above 25 ppb, you’re likely a candidate for biologics. Your asthma specialist will order these.
Do biologics work for everyone with severe asthma?
No. Biologics target type 2 inflammation, which affects about 50-70% of severe asthma cases. If your asthma is driven by non-type 2 pathways-like obesity-related or neutrophilic inflammation-biologics won’t help. That’s why testing is critical. New biologics targeting non-type 2 pathways are in development, but none are approved yet.
What if I can’t afford biologics?
If you’re in Australia and eligible for PBS, your cost is low. In the U.S., many manufacturers offer co-pay cards that reduce monthly costs to under $5. Nonprofit organizations like the Asthma and Allergy Foundation of America also help with financial aid. Talk to your clinic’s patient navigator-they specialize in finding solutions. Never skip treatment because of cost. There are always options.
How long before I see results from a biologic?
Most people notice fewer symptoms and less reliance on rescue inhalers within 3-4 months. Full benefits-like reduced steroid use and fewer hospitalizations-usually take 6-12 months. Patience is key. Biologics don’t work like steroids. They’re a long-term repair tool, not a quick fix.
What Comes Next
If you’re on oral steroids for asthma, don’t wait until you have a fracture, diabetes, or a hospital stay to act. Talk to your asthma specialist today. Ask for the eosinophil and FeNO tests. Ask if a biologic is right for you. You don’t have to live with the trade-offs anymore. The tools are here. The evidence is clear. The path forward is safe, effective, and within reach.