Breaking the Cycle: Reducing OCS Overuse in Under-Resourced Communities
Certain groups of people face higher rates of asthma, allergies and skin diseases. These groups include people with low income and people with skin of color. They may also be more affected by over-treatment with pills called oral corticosteroids (OCS, also referred to as oral steroids).
Oral corticosteroids treat flare-ups for respiratory, allergic and skin conditions. These include asthma, COPD, allergies, nasal polyps, sinusitis, eczema, hives and psoriasis. OCS are also prescribed for arthritis and lupus.
More than 28.2 million people in the U.S. have asthma. About 1 in 3 adults and 1 in 4 children live with allergies. Almost 6% of adults and more than 10% of children have eczema. These health problems can make it hard to do everyday tasks and activities.
When symptoms get worse, doctors may prescribe patients oral corticosteroids. The pills can help quickly, but even a short time on them can cause serious side effects.t from anabolic steroids. These are related to the male hormone testosterone and sometimes used for muscle building.
Oral corticosteroid use in communities that are underserved
OCS prescriptions are intended to treat flare-ups of symptoms, such as asthma attacks. They are not intended for asthma management or daily eczema treatment. That’s why they are prescribed in a short course or “burst” for 3-5 days. Anyone who takes OCS frequently or long-term is at risk of experiencing adverse effects, or side effects.
Research shows people in under-resourced communities are more often prescribed OCS. Why is this? The reasons are complex.
| Asthma Prevalence | Adults | Children |
|---|---|---|
| Non-Hispanic Black | 11.6% | 11.1% |
| Non-Hispanic White | 9.2% | 5.6% |
| Hispanic | 7% | 5.9% |
| ER Treatment for Asthma 2020 | Adults | Children |
|---|---|---|
| Non-Hispanic Black | 80.6% | 89.5% |
| Non-Hispanic White | 13.7% | 14.4% |
| Hispanic | 16.5% | 16.5% |
| Hospital Admissions for Asthma 2020 | Adults | Children |
|---|---|---|
| Non-Hispanic Black | 54.3% | 79.4% |
| Non-Hispanic White | 15.4% | 16.6% |
| Hispanic | 14.9% | 24.6% |
First, certain racial and ethnic minority groups tend to have higher rates of disease. This includes Black and Hispanic/Latino children and adults with an asthma diagnosis. Research shows they are at higher risk for severe persistent asthma or asthma exacerbations that need emergency department treatment or hospitalization. OCS is often part of asthma treatment for acute exacerbations seen in ERs and hospital stays.
This means that people in under-resourced communities are at greater risk for side effects due to OCS use or overuse.
Side effects from short-term use include:
- weight gain
- eye problems
- high blood pressure
- muscle weakness
- high blood sugar levels
- sleep problems
Adverse outcomes from long-term use include:
- immune system suppression
- osteoporosis
- diabetes onset
- slow growth in children
OCS and Social Determinants of Health
Genetic, environmental and socioeconomic factors play a significant role in disparities of care. The latter two factors are part of what is called “social determinants of health.” The term describes “the conditions in the environments where people are born, live, learn, work, play, worship, and age. It affects a wide range of health and quality-of-life outcomes and risks.”
Research shows a link between asthma prevalence and certain environmental and socioeconomic factors. These factors increase disease risk and create barriers to accessing care. Your risk level might depend on your income, education, employment, and where you live. For example, air quality (both outside and indoors) and regular exposure to tobacco smoke might cause asthma symptoms.
Access to medical care including health insurance coverage is critical. Patients and families in urban areas may struggle to see a physician due to inability to get to the doctor’s office. People in rural areas may have fewer options or need to travel a far distance to see a doctor. They are less likely to get prescriptions for inhaled treatments that prevent flare-ups. This results in more frequent exacerbations requiring OCS-focused care.
Flare-ups requiring OCS can occur unpredictably. Rather than go to a primary care doctor or a specialist to manage symptoms, patients may go to the emergency department or hospital when there’s a flare-up. Since OCS is often used to treat flare-ups in ERs and hospitals, patients may start to rely on these pills. Also, they are very affordable medications.
Oral corticosteroids are effective in treating severe flare-ups, such as severe asthma symptoms. Over-reliance signals gaps in preventive care or long-term disease management.
Uncontrolled asthma is more common in people who rarely see a physician or whose asthma is poorly managed. For asthma patients, effective management may involve inhaled corticosteroids, biologic drugs or other therapies.
This issue extends beyond respiratory diseases. Conditions like eczema, arthritis, and lupus also require consistent care to prevent exacerbations. Proper treatment and management, including the use of safer and long-term therapies, can reduce the need for OCS.
A recent large-scale survey by Allergy & Asthma Network revealed only 2 in 5 low-income patients with chronic respiratory conditions had a management plan with their physician. Such plans are critical for reducing the frequency and severity of flare-ups. This reduces the need for OCS. An Asthma Action Plan is one type of management plan. For people with severe or uncontrolled asthma, it can help reinforce daily asthma control.
Addressing disparities in care that lead to OCS overuse
How to avoid adverse outcomes from over-reliance on OCS? One solution is to address disparities in care. This may involve systemic changes, such as:
- improving access to preventive treatments;
- enhancing patient education;
- developing management plans, such as an Asthma Action Plan
- promoting management of symptoms.
By reducing reliance on OCS treatment, healthcare providers can reduce adverse effects due to long-term OCS use. This can improve health outcomes for all patients.
Reviewed by:
William E. Berger, MD, FACAAI, is a board-certified allergist and immunologist who serves as Medical Director with Allergy & Asthma Network. He is a Distinguished Fellow and Past President (2002-03) of the American College of Allergy, Asthma & Immunology (ACAAI).
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