Inhaled corticosteroids for long-term control of asthma

Examples

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Brand Name	Chemical Name
QVAR	beclomethasone dipropionate

Brand Name	Chemical Name
Pulmicort Turbuhaler	budesonide

Brand Name	Chemical Name
AeroBid	flunisolide

Brand Name	Chemical Name
Flovent	fluticasone propionate

Brand Name	Chemical Name
Asmanex Twisthaler	mometasone furoate

Brand Name	Chemical Name
Azmacort	triamcinolone acetonide

The following medicines combine an inhaled corticosteroid with a long-acting beta₂-agonist in one medication.

Brand Name	Chemical Name
Advair Diskus, Advair HFA	fluticasone propionate and salmeterol

Brand Name	Chemical Name
Symbicort	budesonide and formoterol

These medications are used in a metered-dose or dry powder inhaler. Inhalers may be used differently, depending on the medication used. Always consult the directions to be sure you or your child is using the inhaler correctly.

How It Works

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All forms of corticosteroids reduce inflammation in the airways that carry air to the lungs (bronchial tubes) and decrease the mucus made by the bronchial tubes. This makes it easier to breathe.

Inhaled corticosteroids treat inflammation in the airway, and only very small amounts of the medication are absorbed into the body. Thus, these medications don't tend to cause the serious side effects, such as weakening of the bones, that corticosteroids taken in liquid, pill, or injection form (systemic corticosteroids) can cause.

Why It Is Used

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Inhaled corticosteroids are the preferred treatment for long-term control of mild persistent, moderate persistent, or severe persistent asthma symptoms in children, teens, and adults. They help control narrowing and inflammation in the bronchial tubes. They are generally part of the daily asthma treatment plan and are used every day.

Different types of medications are often used together in the treatment of asthma. For example, inhaled corticosteroids are often used together with long-acting beta₂-agonists for persistent asthma. For more information on how medications may be used together in asthma, see:

• Asthma medications for adults, teens, and children older than age 5.
• Asthma medications for children age 5 and younger.

How Well It Works

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Inhaled corticosteroids are the most powerful and most effective medication for long-term control of asthma in most people. When taken consistently, they improve lung function, improve symptoms, and reduce asthma attacks and admissions to the hospital for asthma.¹

Side Effects

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Side effects of inhaled corticosteroids are uncommon at the usual prescribed dose. Side effects (many of which occur only with high doses) may include:

• Sore mouth, sore throat, or hoarseness.
• Cough and spasms of the large airways (bronchi).
• Fungus infection in the mouth (thrush).
• Temporary delayed growth in children.
• Decreased bone thickness in adults.
• Clouding of the lens of the eye (cataract).
• High blood pressure in the eye or fluid buildup in the eye (glaucoma). This occurs with high doses of inhaled corticosteroids used over a long period of time.

The U.S. Food and Drug Administration (FDA) has reported that salmeterol may make an asthma attack worse and may increase the risk of death. If your or your child's wheezing gets worse after taking this medicine (Advair Diskus), call your health professional right away.

To minimize or prevent side effects of corticosteroids, the person with asthma should:

• Use a spacer with a metered-dose inhaler. The person should rinse his or her mouth with water after using a corticosteroid inhaler, but should not swallow the water. Swallowing the water will increase the chance that the medication will get into the bloodstream, increasing the potential for side effects.
• Keep the dose of inhaled corticosteroids as low as possible while still maintaining asthma control. You may be able to limit corticosteroid use by using a long-acting inhaled beta₂-agonist, sustained-release theophylline, or a leukotriene pathway modifier along with inhaled corticosteroids.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

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According to the United States National Asthma Education and Prevention Program (NAEPP), inhaled corticosteroids are the preferred long-term treatment for asthma. The preferred treatments for the 3 types of persistent asthma in adults, teens, and children older than 5 are:²

• A low dose of an inhaled corticosteroid for mild persistent asthma.
• A low-to-moderate dose of an inhaled corticosteroid and a long-acting beta₂-agonist for moderate persistent asthma.
• A high dose of an inhaled corticosteroid and a long-acting beta₂-agonist for severe persistent asthma. In some cases, a corticosteroid taken by mouth (oral corticosteroid), such as prednisone, may be necessary.

Mometasone furoate was recently approved for use in long-term control of asthma in 2005 for those 12 and older. It should not be used for quick relief of asthma symptoms or during an asthma attack.

It is not known whether inhaled fluticasone, flunisolide, beclomethasone, or triamcinolone may be harmful to the fetus of a pregnant woman with asthma. Budesonide is not expected to harm a fetus. A review of the animal and human studies on the effects of asthma medications taken during pregnancy found few risks to the woman or her fetus. It is safer for a pregnant woman with asthma to be treated with asthma medications than for her to have asthma symptoms and asthma attacks.³ Poor control of asthma is a greater risk to the fetus than asthma medications are.³ If you are or get pregnant, talk with your health professional but do not immediately stop using your asthma medication.

It is not known whether inhaled fluticasone, flunisolide, beclomethasone, triamcinolone, or budesonide passes into breast milk. Talk to your health professional if you have asthma and are breast-feeding a baby.

Most health professionals recommend that everyone who uses a metered-dose inhaler (MDI) also use a spacer , which is attached to the MDI. A spacer may deliver the medication to the lungs better than an inhaler alone, and for many people is easier to use than an MDI alone. Using a spacer with inhaled corticosteroids can help reduce their side effects and result in less use of oral corticosteroids.

Concerns for children

Budesonide (Pulmicort Respules) for use with a nebulizer is approved for use in children ages 1 to 8. However, the nebulized medication is more expensive and may be more inconvenient than a corticosteroid used with an inhaler.

Advair is available for use in children ages 4 and older.

Flunisolide and triamcinolone inhalation medicines are not approved for use by children younger than 6 years of age.

QVAR (beclomethasone dipropionate) is now approved for maintenance treatment of asthma in children 5 and older.

There has been some worry that children who use inhaled corticosteroids may not grow as tall as other children. In the studies done so far, there was a very small difference in height and growth in children using inhaled corticosteroids compared to children not using them. When these children stopped using inhaled corticosteroids, their growth increased. It is expected that even though using inhaled corticosteroids may slow growth at first, children will still grow to a normal height.^{4, 5} But no study has gone on long enough for experts to be sure. The difference in height is very small and this effect is rare, but children using inhaled corticosteroids should have their height checked once or twice a year.

One study noted that children who use inhaled corticosteroids do not have an increased risk for broken bones (fractures) compared to those who are not using the medication.⁶

Try to avoid giving your child an inhaled medication when he or she is crying; in this case, not as much medication is delivered to the lungs.

Complete the new medication information form (PDF) (What is a PDF document?) to help you understand this medication.

References

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Citations

1. National Institutes of Health (1997). Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Clinical Practice Guidelines (NIH Publication No. 97-4051). Bethesda, MD: U.S. Department of Health and Human Services.

2. National Institutes of Health (2002). National Asthma Education and Prevention Program Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. Clinical Practice Guidelines (NIH Publication No. 02–5075). Bethesda, MD: U.S. Department of Health and Human Services.

3. National Asthma Education and Prevention Program (2005). Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment Update 2004 (NIH Publication No. 05-5236). Available online: http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.htm.

4. Guilbert TW, et al. (2006). Long-term inhaled corticosteroids in preschool children at high risk for asthma. New England Journal of Medicine, 354(19): 1985–1997.

5. The Childhood Asthma Management Program Research Group (2000). Long-term effects of budesonide or nedocromil in children with asthma. New England Journal of Medicine, 353(15): 1054–1063.

6. Schlienger RG, et al. (2004). Inhaled corticosteroids and the risk of adult fractures in children and adolescents. Pediatrics, 114(2): 469–473.

Credits

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Author	Maria G. Essig, MS, ELS
Editor	Susan Van Houten, RN, BSN, MBA
Associate Editor	Denele Ivins
Primary Medical Reviewer	Michael J. Sexton, MD - Pediatrics
Specialist Medical Reviewer	Harold S. Nelson, MD - Allergy and Immunology
Last Updated	March 22, 2007