Steroid resistant asthma: what is the clinical definition?

Asthma is usually a steroid responsive disease. A few patients respond poorly to these drugs, and others need such high doses to control the disease that side-effects become a serious problem. The term steroid resistant asthma is used for both groups. In some patients, factors may be operating to make the asthma worse and, thus, to increase the requirement for steroids. In order to make a clinical diagnosis of steroid resistant asthma, it is therefore necessary to investigate the factors that could be operating to prevent a "normal" response to steroids. These factors include wrong diagnosis, insufficient steroid reaching the airway mucosa, continuing exposure to sensitizing agents, unrecognized aggravating agents, excessive use of beta-agonist aerosols, and failure to undertake regular management according to a strict management plan. Using a strict clinical definition of steroid resistant asthma leads to better investigation and treatment of individual patients, allows steroids to be stopped when they are not indicated, allows other anti-inflammatory drugs to be used with confidence, and provides a well-defined group of patients for further research relating to the mechanisms of action of steroids.