Acute asthma exacerbations remain a major driver of morbidity and hospitalisation, accounting for substantial healthcare utilisation worldwide. Systemic oral corticosteroids (OCS) are the first-line treatment for acute asthma exacerbations and continue to be widely given in fixed durations.1 2 Their intended use is clear; to reduce airway inflammation, improve lung function and prevent relapse. However, OCS has well-documented harms.3 Clinicians treating acute asthma and chronic obstructive pulmonary disease (COPD) prescribe the most steroids in health systems, and unlike other specialties, little progress has been made to curtail their widespread use in acute care.4 5

Do systemic steroids work for asthma attacks? The landmark placebo-controlled trials supporting this were conducted before the inhaled steroid era.3 6 Moreover, these trials were small, with the largest randomising less than 100 patients and the benefits were marginal. In adults, the evidence…