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CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 38, No 1 March 2025
- The mechanism of action of oral corticosteroids
- Systemic and non-systemic corticosteroid therapies
- Oral corticosteroids in airways disease
- Inhaled corticosteroids in asthma management
- A laissez-faire approach to short bursts of corticosteroids may lead to overexposure in the fetus and the young child
- Co-existing hypersensitivity pneumonitis and occupational asthma
- Vaccine Allergy
- Ethical aspects of prescribing oral corticosteroids
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GUEST EDITORIAL
Author: André van Niekerk
Abstract: Many short courses (bursts) of oral corticosteroids (OCS) are commonly prescribed for indicated and non-indicated conditions. These bursts are perceived to be safe and are usually given by prescription for less than 14 days at a time. The global corticosteroid market was USD 5.7 billion in 2023, and with a projected annual growth rate of 4.6% across all regions, reflects its widespread use.2 Published data of OCS use in South Africa are difficult to find, yet parents of children attending a clinic for immune deficiencies frequently report repetitive prescriptions.
CONGRATULATIONS TO OUR NEWLY QUALIFIED ALLERGOLOGISTS!
Abstract: On behalf of the Allergy Society of South Africa (ALLSA), we would like to extend our heartfelt congratulations to Hilary Andoh and Marshé Maharaj on successfully obtaining their subspecialty qualification in Allergology! This is a commendable achievement and we are incredibly proud of their dedication and hard work. We believe that their expertise and commitment will make a significant contribution to the field of allergology. We wish them all the best in their future careers and in their efforts to advance the field and raise awareness about allergies in Africa.
Review article
THE MECHANISM OF ACTION OF ORAL CORTICOSTEROIDS IN RELATION TO SHORT- AND LONG-TERM-BURST THERAPY
Authors: Werner Cordier, Theresa Rossouw
Abstract: Corticosteroids, potent anti-inflammatory agents, are broadly used in various inflammatory and immune-dependent pathologies, which include asthma. Through non-genomic and genomic mechanisms of action, corticosteroids reduce pro-inflammatory mediators while promoting anti-inflammatory molecule expression. Furthermore, in the context of asthma treatment, they also promote the expression of β2 adrenergic receptors which increase the therapeutic potential of β2-receptor agonists to promote bronchodilation. However, corticosteroids also precipitate a variety of adverse events which reduce the quality of life of patients and predispose them to further pathological alterations. Given the ubiquitous expression of the glucocorticoid receptor, alongside the non-genomic and genomic mechanisms of corticosteroids, a myriad interconnecting physiological processes are altered upon receptor modulation. Both long- and short-course treatment has been linked to immune suppression, metabolic and cardiovascular disease, cerebrovascular accidents, osteoporosis, ophthalmic disorders, pneumonia and mood disorders. Consequently, clinical decision-making should consider the potential risks involved in short- and long-term use of corticosteroids because pathophysiological changes may be precipitated in both.
Keywords: anti-inflammatory, corticosteroids, mechanism of action, transactivation, transrepression
Review article
SYSTEMIC AND NON-SYSTEMIC CORTICOSTEROID THERAPIES: ADVERSE EFFECTS OF BOTH SHORT BURST AND CUMULATIVE LONG-TERM DOSING
Authors: Cathryn McDougall, Helen Hoenck, Jonny G Peter
Abstract: Although the adverse effects of long-term oral corticosteroid use are well-recognised, the risks associated with short courses of steroids, or steroid “bursts”, are less frequently acknowledged. With the growing availability of targeted immune therapies, the safety of short course steroid prescriptions warrants greater scrutiny. This review synthesises evidence on the adverse effects of short courses of steroids, finding that even a single burst can increase the risk of several adverse effects including sepsis, cardiovascular events, gastrointestinal bleeding and mood changes. These adverse effects appear to be transient in nature, with the highest risk occurring within 30 days and attenuating over the subsequent 90-180 days. Additionally, this review found a cumulative dose-response relationship, demonstrating that more than 1g or four short courses in a lifetime is associated with heightened risk of several long-term adverse effects. Non-systemic corticosteroids generally exhibit fewer clinically significant adverse effects, although the increased risk of respiratory infections associated with inhaled corticosteroid use should be considered in our tuberculosis-endemic setting. This review highlights the importance of considering a patient’s total and cumulative steroid exposure and prescribing steroid bursts only when clearly indicated. Clinicians are encouraged to consider non-steroidal or targeted therapies as safer alternatives wherever possible.
Keywords: systemic, inhaled, intranasal, topical, corticosteroids, adverse effects
Review article
ORAL CORTICOSTEROIDS IN AIRWAYS DISEASE: ARE WE PRESCRIBING THEM CORRECTLY?
Authors: Keketso Mopeli, Candice Mwandla, Kitso-Lesedi Mrubata, Erica Shaddock, Mervyn Mer, Charl Verwey1
Abstract: Systemic corticosteroids are effective in the management of multiple airway diseases. Owing to their ease of use and their potency, their use has become much more widespread with many of the indications having little or no data in support. It has been shown that even a single dose of systemic corticosteroids can have short- and long-term side-effects. Systemic corticosteroids should only be considered for diseases in which adequate data and guidelines are available for their use, and where other effective options for management are not available. In this review we look at the indications for and against the use of oral corticosteroids in common respiratory airway conditions, based on current available data.
Keywords: corticosteroids, airways disease, oral corticosteroids, systemic corticosteroids
Review article
INHALED CORTICOSTEROIDS IN ASTHMA MANAGEMENT: WHY LESS IS MORE…
Authors: Marco Zampoli, Naomi Adjetey, Jean Bangirana, Gordon Audley, Richard van Zyl-Smit
Abstract: Inhaled corticosteroids (ICS) are the cornerstone of long-term asthma treatment in children and adults. The goal of ICS – administered as either monotherapy or in combination with long-acting bronchodilators (LABA) – is to control the asthma symptoms, reduce asthma-related attacks and death, and minimise the risk of the adverse effects of corticosteroids. The last of these goals is frequently overlooked, which results in unnecessarily high doses of ICS being administered to children and adults for prolonged periods without clinical benefit. Current asthma guidelines (ie, Global Initiative for Asthma (GINA)) for children and adults recommend intermittent as-needed combination ICS–LABA as the first-step approach to treating asthma in children 12 years and older and adults. In this article, we review the rationale behind the latest GINA guidelines and discuss the different approaches to ICS treatment. We summarise the current understanding of the pharmacological aspects of diverse ICS formulations which explain the different dosages and potencies that in combination influence ICS efficacy and systemic absorption, but which could lead to adverse effects. Good asthma control is achievable in the majority of children and adults using low-to-medium-dose ICS in combination with a LABA, administered either intermittently or continuously. The failure to control asthma on low-to-medium-dose ICS should prompt a careful review of adherence, inhaler technique and appropriate referral.
Keywords: inhaled corticosteroids, long-term asthma treatment, asthma-related attacks, asthma management
Review article
A LAISSEZ-FAIRE APPROACH TO SHORT BURSTS OF CORTICOSTEROIDS MAY LEAD TO OVER-EXPOSURE IN THE FETUS AND THE YOUNG CHILD
Author: Suzanne D Delport
Abstract: Corticosteroids, in whichever form they occur, are potent drugs with serious short- and long-term side effects. Their indications for use encompass many diseases and all age groups, even extending to the fetus. In view of the potency and dangers of corticosteroids though, those who prescribe them must do so only for evidence-based indications and with informed consent. Documenting all exposures reflects corticosteroid stewardship and an awareness of a cumulative end point which determines toxicity rather than the dose and duration of therapy.
Keywords: corticosteroid short-bursts, overexposure, fetus, young child
Review article
VACCINE ALLERGY: A REVIEW
Author: Cascia Day
Abstract: Vaccination against infectious diseases is undoubtedly one of the greatest scientific advances and has saved millions of lives. Vaccines are becoming more widely used in many disciplines, and the vaccine oncology field is rapidly growing with increasing use of mRNA-based vaccines. It is important that allergists adopt a structured approach to patients who report a vaccine allergy, in addition to those who are allergic to vaccine components. This review set out both the immediate and delayed forms of vaccine allergy and also details the various allergens present in vaccines.
Keywords: vaccine allergy, vaccine hypersensitivity, vaccine anaphylaxis, vaccine components, mRNA vaccines
Ethics article
ETHICAL ASPECTS OF PRESCRIBING ORAL CORTICOSTEROIDS
Author: Sharon Kling
Abstract: Oral corticosteroids (OCS) have been integral to the treatment of acute asthma exacerbations and severe difficult-to-control asthma for the past 6 decades. As asthma is a potentially life-threatening disease, the over-prescription of OCS is common. Recent studies show that life-time exposure to OCS of > 1 000 mg prednisolone-equivalent carries serious side effects and results in adverse outcomes. There is therefore an urgent need for corticosteroid (CS) stewardship in asthma and a concomitant emphasis on other strategies to mitigate over-exposure to corticosteroids. Individuals and professional societies have an important role to play in educating healthcare professionals, patients and the general public about the dangers of OCS.
Keywords: asthma, oral corticosteroids, stewardship, prescription creep, ethical principles
ABC of Allergy
Component-resolved testing in the management of allergies
Authors: Shaunagh Emanuel, Di Hawarden
Introduction: Allergy-component testing identifies specific proteins in allergens that trigger immune reactions. Unlike traditional allergy tests that detect whole allergens, component testing pinpoints precise parts of the protein called ‘components’. This targeted testing helps distinguish between mild and life-threatening allergies, guides dietary management and, informs immunotherapy decisions.
DR SPUR’S MYSTERY CASE
The case of the chicken or is it the egg?
Authors: Sylvia van den Berg, André van Niekerk
Introduction: This patient presents a diagnostic challenge due to the potential overlap between corticosteroid-induced secondary immunodeficiency and a primary immunodeficiency disorder. Repeated short courses of oral corticosteroid treatment can have cumulative effects on the immune system, even when taken intermittently. These medications suppress the immune response by reducing inflammation and dampening the activity of immune cells, such as T-cells and macrophages. Short courses and frequent use may lead to an increased risk of infections, impaired wound healing and a potential disruption of normal immune regulation. In addition, repeated exposure to corticosteroids may suppress the hypothalamic–pituitary–adrenal (HPA) axis, which could further affect the body’s ability to mount an adequate stress or immune response when needed.
