A36-12 The Asthma Treatment Paradox: High Steroids, Low Controllers, and Fewer Biologics

Abstract Introduction Asthma is a heterogeneous airway disorder characterized by variable and reversible obstruction. Despite robust evidence and updated Global Initiative for Asthma (GINA)guidance emphasizing single maintenance and reliever therapy (SMART) and biologic agents for severe uncontrolled asthma (SUA), real-world adherence to guideline-based therapy remains suboptimal. Barriers include provider hesitation, patient nonadherence, and insurance-related constraints. This study evaluated inhaler and biologic therapy utilization patterns among patients with frequent asthma exacerbations within a large integrated healthcare network. Methods We performed a retrospective quality-improvement analysis of adults treated for SUA across the Allegheny Health Network between 2023-2024. Inclusion criteria were ≥1 asthma-related hospitalization or ≥ 2 outpatient exacerbations requiring systemic corticosteroids within 12months. Outcomes assessed included inhaler prescribing patterns, biologic therapy utilization(stratified by absolute eosinophil count), mean cumulative oral corticosteroid (OCS)exposure, and pulmonology follow-up rates. Inhaler use was categorized as: (1) no inhaler therapy, (2) short-acting β-agonist (SABA) only, or (3) combination controller therapy incorporating inhaled corticosteroids (ICS) with long-acting bronchodilator(s). Results A total of 740 patients met inclusion criteria (mean age 55.6 ± 17.6 years; 72.3% female;76.6% White, 19.6% Black, 3.8% other). The mean BMI was 33.1 ± 9.6 kg/m². Inhaler prescribing patterns revealed significant variation: 69.7% received ICS-based combination therapy, 22.4% used SABA-only regimens, and 7.9% were not prescribed any inhalers. The median cumulative annual OCS dose was 300 mg (IQR 49-668 mg) and did not differ by sex or race. Biologic therapy utilization remained low (11.3%), without significant difference across eosinophil strata. Despite frequent exacerbations and high systemic steroid exposure, pulmonology follow-up and biologic initiation were underutilized relative to disease severity. Discussion Inhaler and biologic prescribing patterns among SUA patients demonstrated persistent gaps in adherence to GINA and ERS/ATS guideline recommendations. Nearly one-third of patients lacked ICS-based controller therapy—an essential component of asthma management—while chronic OCS exposure remained high. Low biologic uptake, even among patients with elevated eosinophil counts, mirrors national trends and highlights barriers in referral, payer approval, and care coordination. Conclusion Suboptimal inhaler prescribing and limited biologic use represent major opportunities for system-level improvement. Interventions such as clinician education, EMR-based prescribing prompts, post-exacerbation referrals, and multidisciplinary asthma care pathways are essential to align real-world management with evidence-based guidelines and reduce preventable steroid exposure. This abstract is funded by: none