Some patients with asthma may fail to respond to what appears to be an adequate dose of corticosteroids. The underlying reason for this failure can usually be found by a careful assessment of the patient.
Underlying Cause
Features
poor adherence to therapy
The patient admits to poor compliance. The patient responds to observed therapy.
deteriorated drug
The drug shows signs of deterioration or is outdated. The patient responds to a new drug supply.
failure in drug delivery or absorption
The patient responds to steroids given by a different route or a different delivery system.
pseudo-asthma
The patient responds to treatment of the condition mimicking asthma.
drug interaction increasing steroid metabolism
Discontinuation of the interfering drug corrects problem.
panic attack
Treatment of anxiety corrects the problem.
continued exposure to triggering agent, including an unrecognized triggering agent
The history may indicate the source. The patient responds to steroids once the exposure stops.
excessive exposure to beta-agonists
The patient responds once beta-agonist therapy is reduced.
cytokine-induced steroid resistance (Type I Steroid Resistance)
The patient responds to steroids once the cause of cytokine release is corrected.
hereditary resistance (Type II Steroid Resistance)
No response to steroids at any time. Family members may also be affected. Demonstration of genetic defect.
Cytokine-induced steroid resistance occurs because of increased expression of glucocorticoid receptor beta. This is a less active isoform of the receptor.
Hereditary resistance is due to decreased numbers of functional glucocorticoid receptors.
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