II. Indications
- Inhaled Corticosteroids are the most important agent in Asthma Management
- Indicated as daily maintenance agents in all persistent Asthma
III. Medications: Active in U.S.
- All steroid Inhalers are approved for children 6 to 11, and age >12 years to adult
- Mometasone DPI (Asmanex Twisthaler) is approved down to age 4 years old
- Inhaled Beclomethasone Dipropionate HFA MDI (QVAR Redihaler)
- Inhaled Budesonide DPI or Neb (Pulmicort, Nebulized Budesonide)
- Inhaled Ciclesonide HFA MDI (Alvesco)
- Inhaled Fluticasone Propionate DPI or HFA (Flovent, ArmonAir)
- Inhaled Fluticasone Furoate DPI (Arnuity Ellipta)
- Inhaled Mometasone DPI or HFA (Asmanex)
IV. Medications: Discontinued
- Listed for historical purposes only (discontinued in U.S. in 2016 at time of CFC Inhaler ban)
- Flunisolide (Aerobid)
- Triamcinolone (Azmacort)
V. Efficacy
- Inhaled Corticosteroids reduce Asthma related death
- Mortality risk decreases with steroid Inhalers/year
- Suissa (2000) N Engl J Med 343:332-6 [PubMed]
- Benefits in COPD and Asthma persist for >5 years
- Costs
- HFA Inhalers are non-generic and costly
- Older CFC Inhalers are no longer available
VI. Adverse Effects
- Dysphonia
- Oral and Esophageal Candidiasis
- Rinse mouth after inhalation
- Use a spacer device
-
Glaucoma Risk of high dosed Inhaled Corticosteroids
- Study: n=9783, age > 66 years
- 1600 ug Beclomethasone
- 1500 ug Flunisolide
- Glaucoma increased 44% over non steroid users
- Not associated with nasal steroids
- Reference
- Study: n=9783, age > 66 years
-
Cataract Risk
- Study: n=3,000, Australian, 49-97yo, Cross-Sectional
- Corticosteroid use conferred:
- Nuclear cataract Relative Risk: 1.5
- Posterior subcapsular Cataracts Relative Risk: 1.9
- Reference
- Bone: Osteoporosis
- Decreased perimenopausal Bone Mineral Density
- Small increased Fracture risk (1 in 83 on high dose Inhaled Corticosteroid for 3 years)
- No effect on pediatric bone by DEXA Scanning
- Prospective Controlled (n=268)
- Daily Inhaled Budesonide 504 ug/d x4.5y (Mean)
- No detectable effect by DEXA on
- Bone Mineral Density, Bone mineral capacity,
- Total bone Calcium or body composition
- References
- Prospective Controlled (n=268)
- Linear growth suppression
- Uncontrolled Asthma reduces linear growth!
- Variable results on Growth Velocity from studies
- Adult height potential may be reduced up to 1/2 inch on long-term Inhaled Corticosteroids
- Adult height potential is not affected
- Short-term linear growth may be affected
- Degree of Growth Delay may be agent specific
- Fluticasone appears to have least growth effect
- De Benedictis (2001) Arch Pediatr Adolesc Med [PubMed]