The Unequal Burdens of Oral Corticosteroids

Racial and ethnic minorities have high rates of asthma and may suffer disproportionately from overtreatment with oral corticosteroids

For many of the 25 million Americans with asthma, the freedom to enjoy daily activities is often ruined by shortness of breath, coughing and other symptoms. When asthma is severe, people may also be harmed by repeated treatments with drugs known as oral corticosteroids (OCS), which are taken as pills.

Doctors prescribe
these common medicines,

including prednisone and dexamethasone, because they’re generally cheap, safe and work well when used in short cycles called “bursts.” While they are important and often necessary, longer term use of OCS can lead to side effects such as infections, weakened bones, high blood pressure and heart disease. OCS overuse can also lead to problems with mood, stress, memory and behavior. One clue to identify OCS overexposure is if two bursts of OCS are taken in a one-year period. Steroids can also be given by doctors in other forms, such as an IV injection in the emergency room or hospital. It is important to keep track of these other “bursts” too, even if they are for things other than asthma.

  • Infections
  • Weakened bones
  • High blood pressure
  • Heart disease
  • Problems with mood, stress, memory and behavior

There is another part to this problem that’s worrying to many health experts.

Evidence suggests people in socially disadvantaged communities are more likely to be overexposed to OCS. The reasons are complex—beginning with the fact that certain racial and ethnic minorities suffer from higher rates of asthma. For example, asthma prevalence among Puerto Rican and non-Hispanic Blacks is 12.8% and 10.1% respectively, versus 8.1% for non-Hispanic Whites. In children, the gap is wider: 12.6% for Blacks and 7.7% for Whites.

Genetic, environmental and socioeconomic factors all come into play, but experts think that the last two are more important than the first. In a report titled Asthma Capitals 2019, there are clear patterns between allergic asthma prevalence and environmental and economic factors such as poverty, air quality, exposure to tobacco smoke, insurance coverage and access to doctors. The analysis shows a strong link between asthma prevalence and exposure to pollutants/allergens in cities with large underserved communities.


Two regions—the Northeast Mid-Atlantic Belt and the Ohio Valley Belt—have a high concentration of cities with the concerning title of being “Asthma Capitals” in the report.

Cities on the list all score high in asthma prevalence, asthma-related emergency department (ED) visits and associated deaths. Ohio alone is home to five cities in the Top 20, and five others are scattered throughout the south.

Across the U.S.,

OCS prescriptions continue to be a routine treatment for severe asthma attacks requiring hospitalizations. Such events are far more common in people who rarely see a physician and do not manage their condition with inhaled corticosteroids, biologic drugs or other standard, non-systemic therapies. In a recent, large-scale survey by the Allergy & Asthma Network, only two in five asthma patients from low-income homes have created an asthma action plan—either on their own or working with their physician.

Sadly—but not surprisingly—families in socially disadvantaged urban communities, including neighborhoods that are predominantly Black and Hispanic, often have poor access to primary care doctors. People in these communities are among the least likely to receive prescriptions for inhaled treatments that prevent crises leading to OCS-focused care.

Asthma is just one example of the racial and ethnic disparities that persist across the healthcare continuum. What’s clear from recent studies is that early and sustained treatment with inhaled steroids and other safer options can lower reliance on medications whose side effects may outweigh their benefits in some cases.


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