CF and cortisone

Question

Dear expert team,
as a CF patient with severe allergic asthma (trees, grasses, fungus spores) I face the problem to be forced to reduce the cortinsone (prednisone 10 mg daily / symbicort 200® (budesonide and formoterol) 3puffs 3 times daily) that I take for 10 years, due to recurrent infections.
The infections are due to the chronic colonization with Pseudomonas and recently, I started to inhale with Cayston® (aztreonam, one year on/off) now for 2 months alternating with colistin and I take futhermore all drugs belonging to the standard therapy against Pseudomonoas.
In Switzerland, there are only studies about the unfavourable effect of topic steroids. Do you have further studies on the effect of oral cortisone and is it rather more advisable to reduce at first the oral or the inhalative cortisone (which cortisone boosts more the infections, the oral or the inhalative)?
Many thanks for your help and best regards from Switzerland,
S.

Answer

Dear S.,
in case of allergic bronchial asthma, a step-by-step therapy is recommended, independent of the illness of CF but dependent on the severity grade of the asthma, including i.a. cortisone. In the foreground and at first place it deals hereby with inhalative cortisone. In addition, also inhalative drugs are used that widen the bronchi with a short-term and/or long-term effect (in your case Symbicort®). Systemical cortisone, thus as tablets (like prednisone) are at a quite advanced step in the treatment of bronchial asthma, can however be necessary in case of severe asthma. The therapy and the dosage of drugs has to be adjusted individually. The aim is to control the illness of bronchial asthma in the long runs without systemic cortisone. Therefore, the answer to your question: generally it is more advisable to reduce the oral cortisone. Thereby the inhalative cortisone can and should (in case of severe asthma) be continued as a long term therapy.
Your antibiotic inhalative therapy against Pseudomonas aeruginosa with Cayston® (aztreonam) and colistin alternating every 28 days, has a therapeutical justification in case of chronic colonization with Pseudomonas aerugionsa (this is true for you). In case of CF patients with a bronchial asthma, a possible obstruction (narrowing of the bronchi) after inhalation with an antibiotic drug (or also other inhalative drugs e.g. from the group of mucolytics) should be excluded.
The decision about the concrete therapeutical regimen has however to be taken by your physician, who knows you and your results well. We cannot give a recommendation about this via the internet.

Yours sincerely,
Dr. med. Christina Scmaczny

08.07.2014