Inhaled Steriods

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"Steroids" are a family of chemicals normally made within the body. They serve as

hormoneschemical signals that help to regulate the body's growth and function. Some

steroid hormones, like testosterone, stimulate formation of protein and growth of muscle.

Competitive athletes have been known to take illicitly derivatives of these "body-building"

steroids in large amounts to improve their athletic performance. A very different group of

steroid hormones are the corticosteroids, steroid hormones made in the cortex (hence,"cortico-") of the adrenal glands, which sit adjacent to the kidneys. Corticosteroid hormones

have many different affects on body function, including influences on how we use our energy

stores (fat, protein, and sugar) and how we adjust the salt and water content of our body.

Earlier this century it was discovered that corticosteroid hormones, if purified and taken in

large amounts as a medicine, have powerful anti-inflammatory effects. Ever since this

discovery, corticosteroids have been used to treat a great variety of diseases where

inflammation (not infection and not cancer) is the major problemfrom arthritis to psoriasis

to asthma. When you and your doctor talk about steroids to treat your asthma, it is these anti-

inflammatory corticosteroids about which you are speaking.

Steroids Swallowed or Steroids Inhaled

To treat the inflammation of asthma within the bronchial tubes, steroids can be taken in tablet

or liquid form or by inhalation. Occasionally, steroids are given by injection orin

hospitalized personsdirectly into the veins (intravenous infusion). Taken as tablets, liquid,

injection, or intravenous infusion, the steroid medication travels in the blood and is carried

throughout the body, including to the bronchial tubes. Used in this way, steroids have their

most powerful effectsboth for the good (relieving asthmatic symptoms) and for the bad

(undesirable side effects). On the other hand, modern steroid medications inhaled from

pressurized canisters onto the bronchial tubes act directly on these tubes; almost nomedication is carried into the bloodstream. Although not as powerful in their immediate

effects, steroids by inhalation are better suited for long-term use in the treatment of inflamed

bronchial tubes because they are free of major undesirable side effects.

Examples of steroids in tablet form are prednisone (Brand name: Deltasone) and

methylprednisolone (Brand name: Medrol). Examples of steroids by inhalation are

beclomethasone (Brand names: Beclovent, Qvar, and Vanceril); triamcinolone (Brand

name: Azmacort); flunisolide (Brand names: Aerobid and Aerobid-M); budesonide

(Brand name: Pulmicort); and fluticasone (Brand name: Flovent).


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Corticosteroids, Inhaled

Definition

Inhaledcorticosteroidsare glucocorticoids (a class of steroid hormones that are synthesized by the

adrenal cortex and have anti-inflammatory activity) formulated to be used in the respiratory tract

and lungs.

Purpose

Inhaled corticosteroids are glucocorticoid compounds designed to be applied directly to the tissues

of the respiratory tract. There are two types. The intranasal are deposited into the nasal passages

and may be used to treatnasal polyps, perennialallergic rhinitis, seasonal allergicrhinitis, and

recurrent chronicsinusitis.

The second type is used when the steroids are designed for deposition further into the respiratory

tract. These are used for treatment of chronicasthmaand prevention of asthmatic attacks.

Because they have anti-inflammatory effects, corticosteroids are invaluable in treatment of asthma

and other respiratory conditions which are associated with an allergic reaction. In many cases, the

corticosteroids are life saving. But systemic corticosteroids affect all parts of the body and may cause

very severe adverse effects, particularly with long-term use. These reactions include inhibitions of

the adrenal glands and weakening of bones. By administering these drugs by inhalation, it is possible

to target the areas that require treatment and reduce the amount of drug that reaches other parts

of the body. Some patients may be able to do without systemic steroids entirely, while others can

reduce their doses of systemic steroids and thereby reduce the risk and severity of unwanted

effects.

The drugs used as inhaled steroids are all anti-inflammatory corticosteroids and are very similar to

each other in action and use. The way they are formulated, the size of the particles, the design of the

inhaler, and whether the drugs are inhaled by the mouth or nose determine how far into the

respiratory tract the steroids go. The formulations designed for nasal inhalation are only effective for

nasal polyps or rhinitis because the steroid does not penetrate deeply into the respiratory tract. Oral

inhalations, containing the same drug but in different particle size and inhaler design, deposit

medication deeply into the lungs and are of value in treatment of asthma.

Description

As of 2005, there are five corticosteroids designed for inhalation:

beclomethasone dipropionate (Qvar) budesonide (Pulmicort) flunisolide (AeroBID) fluticasone propionate (Flovent) triamcinolone acetonide (Azmacort)

Although the different products vary in potency and duration of action, once dose size and

frequency have been adjusted to offer comparable results, there do not appear to be significant

differences between the drugs. The design of the inhalers, their ease of use, and the training each

patient receives in the proper use of the inhaler may be of greater significance than the drug itself.
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Recommended dosage

Although the different products vary in milligram potency, for practical purposes, doses are

measured in puffs on the inhaler. For example, beclomethasone will deliver 40 micrograms each

time the inhaler is used, while triamcinolone delivers 100 micrograms with each inhalation.

However, the effects are essentially equal.

The appropriate dose of inhaled corticosteroids depends on the severity of the case, and in some

instances, on what treatment has been used prior to starting inhaled steroid therapy. The doses

listed are typical of the inhaled steroids used for asthma therapy but do not represent all possible

cases:

beclomethasone: one to two puffs two times a day budesonide: one to two puffs two times a day flunisolide: two puffs two times a day fluticasone propionate: available in forms that deliver either 50 or 100 micrograms of

fluticase in each puff; typical initial dose, 100 micrograms two times a day, representingeither one puff of the 100 microgram product or two puffs of the 50 microgram product

triamcinolone acetonide: two puffs three or four times a day or four puffs twice a day, not toexceed 16 puffs daily

Precautions

Particular care is essential for patients who are transferred from systemic corticosteroids to inhaled

steroids. Because the long-term use of oral steroids lowers the output of these compounds from the

adrenal gland and normal production does not recur for several months, patients who have their

oral doses reduced are at risk of adrenal insufficiency. This condition may become particularly

serious in the event of trauma, surgery, or infections. While inhaled steroids may provide adequate

control of asthma during these periods, the inhaled drugs do not replace the systemic compounds.

In the event ofstressor a severe asthma attack, oral therapy must immediately begin. Regular

testing for cortisol levels is essential until the normal levels have been resumed.

For patients who had been on systemic therapy and are being switched to corticosteroid inhalation,

the immediate period during which the oral dose is reduced may cause symptoms, including joint or

musclepain, tiredness, and depression. Continuous monitoring is required until normal functions

have been resumed.

It is essential that patients learn proper use of inhalers. If inhalers are not used properly, the

corticosteroids may not reach their intended site of action. Instead, they may be left in the mouth or

swallowed and be deposited in the digestive tract. This situation may increase the risk of adverse

effects, while reducing the protection from asthmatic attacks.

Inhaled corticosteroids are not for treatment of acute asthmatic attacks or rapid relief of

bronchospasm.

Inhaled corticosteroids are designated aspregnancycategory C. This designation means one of two

levels of knowledge concerning the drugs adverse effects. In one instance, studies on animals show

adverse fetal effects but there are no controlled studies on women. In the other instance, no studies

on animals and women are not available.
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Inhaled Corticosteroids for Long-Term Control of Asthma

Examples

Generic Name Brand Name

beclomethasoneQVAR

budesonide Pulmicort

ciclesonide Alvesco

flunisolide AeroBid

fluticasone Flovent

mometasone Asmanex Twisthaler

triamcinolone Azmacort

Combinations of an inhaled corticosteroid and a long-acting beta2-agonist:

Generic Name Brand Name

budesonide and formoterol Symbicort

fluticasone and salmeterol Advair

mometasone and formoterolDulera

These medicines are used in a metered-dose or dry powderinhaler. Inhalers may be used

differently, depending on the medicine used. Always read the directions to be sure you or

your child is using the inhaler correctly.

How It Works

All forms of corticosteroids reduceinflammation in the airways that carry air to thelungs

(bronchial tubes) and decrease themucusmade by the bronchial tubes. This makes it easier to

breathe.

Inhaled corticosteroids treat inflammation in the airway, and only very small amounts of the

medicine are absorbed into the body. So these medicines don't tend to cause the serious side

effects, such as weakening of the bones, that corticosteroids can cause when taken in liquid,

pill, or injection form (systemic corticosteroids).
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Why It Is Used

Inhaled corticosteroids are the preferred treatment for long-term control ofmild persistent,moderate persistent, orsevere persistentasthma symptomsin children,teens, and adults.

They help control narrowing and inflammation in the bronchial tubes. In general, they are

part of dailyasthma treatmentand are used every day.

Different types of medicines are often used together in the treatment ofasthma. For example,

inhaled corticosteroids are often used together with long-acting beta2-agonists for persistent

asthma. Medicine treatment for asthma depends on a person?s age, his or hertype of asthma,

and how well the treatment is controlling asthma symptoms.

Children up to age 4 are usually treated a little differently from those 5 to 11 years old. The least amount of medicine that controls the asthma symptoms is used. The amount of medicine and number of medicines are increased in steps. So if asthma is not

controlled at a low dose of one controller medicine, the dose may be increased. Or another

medicine may be added. If the asthma has been under control for several months at a certain dose of medicine, the

dose may be reduced. This can help find the least amount of medicine that will control the

asthma.

Quick-relief medicine is used to treatasthma attacks. But if you or your child needs to usequick-relief medicine a lot, the amount and number of controller medicines may be changed.

Your doctor will work with you to help find the number and dose of medicines that work

best.

How Well It Works

According to the United States National Asthma Education and Prevention Program

(NAEPP), inhaled corticosteroids are the preferred long-term treatment for asthma.1If the

inhaled corticosteroid does not control asthma symptoms well enough, other medicines, such

as a long-lasting beta2-agonist or leukotriene pathway modifier, may be used.

Inhaled corticosteroids are the most powerful and most effective medicine for long-term

control of asthma in most people. When taken consistently, they improve lung function,

improve symptoms, and reduceasthma attacksand admissions to the hospital for asthma.1

Side Effects

All medicines have side effects. But many people don't feel the side effects, or they are able

to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side

effects are also listed in the information that comes with your medicine.

Here are some important things to think about:

Usually the benefits of the medicine are more important than any minor side effects. Side effects may go away after you take the medicine for a while. If side effects still bother you and you wonder if you should keep taking the medicine, call

your doctor. He or she may be able to lower your dose or change your medicine. Do notsuddenly quit taking your medicine unless your doctor tells you to.
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Side effects of inhaled corticosteroids are uncommon at the usual 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 theeye(cataract). Highbloodpressure 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.
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Inhaled Steriods