Inhaled Corticosteroid

Aka: Inhaled Corticosteroid, Inhaled Steroid, Inhaled Steroid Therapy, Respiratory Corticosteroid, Inhaled Triamcinolone, Azmacort, Inhaled Flunisolide, Aerobid

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II. Indications

  1. Inhaled Corticosteroids are the most important agent in Asthma Management
  2. Indicated as daily maintenance agents in all persistent Asthma
    1. Mild Persistent Asthma
    2. Moderate Persistent Asthma
    3. Severe Persistent Asthma

III. Medications: Active in U.S.

  1. All steroid Inhalers are approved for children 6 to 11, and age >12 years to adult
    1. Mometasone DPI (Asmanex Twisthaler) is approved down to age 4 years old
  2. Inhaled Beclomethasone Dipropionate HFA MDI (QVAR Redihaler)
  3. Inhaled Budesonide DPI or Neb (Pulmicort, Nebulized Budesonide)
  4. Inhaled Ciclesonide HFA MDI (Alvesco)
  5. Inhaled Fluticasone Propionate DPI or HFA (Flovent, ArmonAir)
  6. Inhaled Fluticasone Furoate DPI (Arnuity Ellipta)
  7. Inhaled Mometasone DPI or HFA (Asmanex)

IV. Medications: Discontinued

  1. Listed for historical purposes only (discontinued in U.S. in 2016 at time of CFC Inhaler ban)
  2. Flunisolide (Aerobid)
  3. Triamcinolone (Azmacort)

V. Efficacy

  1. Inhaled Corticosteroids reduce Asthma related death
    1. Mortality risk decreases with steroid Inhalers/year
    2. Suissa (2000) N Engl J Med 343:332-6 [PubMed]
  2. Benefits in COPD and Asthma persist for >5 years
    1. Douma (2002) Chest 121:151-7 [PubMed]
  3. Costs
    1. HFA Inhalers are non-generic and costly
    2. Older CFC Inhalers are no longer available

VI. Adverse Effects

  1. Dysphonia
  2. Oral and Esophageal Candidiasis
    1. Rinse mouth after inhalation
    2. Use a spacer device
  3. Glaucoma Risk of high dosed Inhaled Corticosteroids
    1. Study: n=9783, age > 66 years
      1. 1600 ug Beclomethasone
      2. 1500 ug Flunisolide
      3. Glaucoma increased 44% over non steroid users
      4. Not associated with nasal steroids
    2. Reference
      1. Garbe (1997) JAMA 277:722-7 [PubMed]
  4. Cataract Risk
    1. Study: n=3,000, Australian, 49-97yo, Cross-Sectional
    2. Corticosteroid use conferred:
      1. Nuclear cataract Relative Risk: 1.5
      2. Posterior subcapsular Cataracts Relative Risk: 1.9
    3. Reference
      1. Cumming (1997) N Engl J Med, 337:8-14 [PubMed]
  5. Bone: Osteoporosis
    1. Decreased perimenopausal Bone Mineral Density
      1. Ip (1994) 105:1722 [PubMed]
    2. Small increased Fracture risk (1 in 83 on high dose Inhaled Corticosteroid for 3 years)
      1. Loke (2011) Thorax 66:699-708 [PubMed]
    3. No effect on pediatric bone by DEXA Scanning
      1. Prospective Controlled (n=268)
        1. Daily Inhaled Budesonide 504 ug/d x4.5y (Mean)
        2. No detectable effect by DEXA on
        3. Bone Mineral Density, Bone mineral capacity,
          1. Total bone Calcium or body composition
      2. References
        1. Agertoft (1998) Am J Respir Crit Care 157:178 [PubMed]
  6. Linear growth suppression
    1. Uncontrolled Asthma reduces linear growth!
    2. Variable results on Growth Velocity from studies
      1. Adult height potential may be reduced up to 1/2 inch on long-term Inhaled Corticosteroids
        1. Kelly (2012) N Engl J Med 367:904-912 [PubMed]
      2. Adult height potential is not affected
        1. Agertoft (2000) N Engl J Med 343:1064-9 [PubMed]
      3. Short-term linear growth may be affected
        1. Degree of Growth Delay may be agent specific
        2. Fluticasone appears to have least growth effect
        3. De Benedictis (2001) Arch Pediatr Adolesc Med [PubMed]

VII. References

  1. (2022) Comparison of Asthma Medications, Presc Lett, #381217
  2. (2020) Drugs for Asthma, Med Lett Drug Ther 62: 193-200

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