Safey Issues Related to Inhaled and Systemic Corticosteroids

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The NHLBI document states that inhaled corticosteroids are the most effective therapy for long-term control of mild, moderate, and severe persistent asthma and are well tolerated at recommended dosages. The overwhelming evidence demonstrating their efficacy far outweighs the small risks of adverse effects. Local adverse effects of ICS include oral candidiasis, dysphonia, reflex cough, or bronchospasm with inhalation. Spacer devices are recommended to prevent dysphonia and oral candidiasis. The key recommendations for reducing the potential adverse effects of ICSs are: (i) administer ICS drugs with holding chambers or spacers; (ii) patients should be instructed to rinse their mouths with tap water after each dose; (iii) use the lowest effective doses; (iv) consider adding a LABA to a low or medium dose of ICS rather than increase ICS dose; (v) monitor growth in children; and (vi) recommend supplemental calcium (1000-1500 mg/day) and vitamin D in postmenopausal women receiving ICS therapy (2).

The GINA document states that, in adults, systemic side effects rarely occur with daily doses of <500 mg of BDP or equivalent doses of other ICSs. Higher doses of ICSs are associated with increased risk for bruising, cutaneous laxity, cataracts and glaucoma (in some studies), decreased bone mineral density and adrenal suppression. The expert committee admits that the actual clinical impact of ICS agents on osteoblastic activity and on adrenal suppression has not yet been determined (5). For this reason, specific recommendations for prevention of osteoporosis (in contrast to NAEPP) are not provided.

A major issue has arisen about the possible effects of ICS on reduction in growth velocity in preadolescent children. Presumably concern over adverse growth effects of ICS agents in young children may have a negative impact on physician compliance with published guidelines. The 2002 NAEPP update acknowledges that treatment with low-moderate doses of ICS may reduce growth velocity by 1 cm/yr during the first year of treatment (2). This effect is not believed to continue during subsequent years of treatment, and available evidence indicates that final predicted adult height is attained in children receiving long-term ICS. The committee also reported that long-term observational studies in children receiving ICS therapy for six years failed to show significant effects on bone mineral density or on incidence of subcapsular cataracts or glaucoma. The GINA committee could identify no evidence to support a risk of fracture in young children on ICS agents. However, most of the studies examining growth effect have not been performed in children and infants below the age of six, highlighting the need for future safety studies of ICS therapy in age appropriate subjects (5).

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