In 1935, the Mayo Clinic reported a research breakthrough that would affect millions of lives. Doctors had isolated the hormone cortisone from the adrenal glands, the walnut sized glands sitting on top of the kidneys. Cortisone produced by the adrenal glands reduces inflammation in the body.
The Mayo Clinic physicians first used cortisone to treat people with severe rheumatoid arthritis. Improvements were so dramatic in soothing swollen joints that patients crippled from the disease were actually able to walk again.
Pharmaceutical companies have since produced corticosteroids medications that mimic the hormone cortisone. For people with asthma, corticosteroids literally can be lifesavers by preventing or reversing inflammation in the airways, making them less sensitive to triggers. The drugs, sometimes referred to as "preventive" or "long term control" medicines, work effectively to keep asthma episodes in check. They are not the same as anabolic steroids, which some athletes take illegally to build muscle mass.
Are Corticosteroids Safe?
Oral, or systemic, corticosteroids quickly help out of control asthma, but more than two weeks of daily use may sometimes lead to serious side effects. Inhaled corticosteroids are considered much safer for lengthier treatment. Unlike the oral forms that must travel throughout your body to reach your lungs, inhaled corticosteroids are delivered directly to the airways in small doses with less chance of reaching other parts of the body. The National Institutes of Health (NIH) calls inhaled corticosteroids "the most effective long-term therapy available for patients with persistent asthma. In general [they] are well tolerated and safe at the recommended dosages."
You have probably read or heard varying reports about the risks of corticosteroid use. The bottom line is that the relatively few side effects are usually balanced by the good they do for your asthma. Steroids are definitely safe when used in the lower dosage range. Problems generally arise with high doses over long periods of time. As consumers and patients, it's important to know what specific side effects may occur and how we can work with our physicians to control them and our asthma.
Oral candidiasis (thrush). Only 10 percent to 30 percent of inhaled steroid doses actually reach the lungs. The remainder is left in the mouth or throat or is swallowed, sometimes resulting in thrush, a fungal infection that produces milky white lesions in the mouth. Clinical thrush is far less common in lower dosages and affects more adults than children.
Physicians recommend using a spacer or holding chamber with your inhaler and rinsing your mouth with water after each treatment to reduce the amount of the inhaled steroid deposited in the mouth and throat. If you develop thrush, your doctor may also prescribe a less frequent dose and/or topical or oral antifungal medication.
Dysphonia (hoarseness). This condition is associated with increasing dosages of inhaled corticosteroids and vocal stress. Treatment may include using a spacer/holding chamber, less frequent dosing, and/or temporarily decreasing medication.
Slowed Growth in Children. Some studies have shown that medium dose inhaled corticosteroids may affect a child's growth. It is not certain that this results in shorter stature in adulthood, but in general, the higher the dose, the greater the risk.
In a 1995 study of 7 to 9yearolds treated daily with 400 mcg of beclomethasone for seven months, growth was significantly decreased in both boys and girls. There was no evidence of catchup growth after a five month period without medication. Yet a 1994 study of inhaled beclomethasone found no significant adverse effects on achieving adult height.
The NIH advises physicians to carefully monitor a young patient's height and to "step down" therapy when possible. NIH notes that even high doses of inhaled corticosteroids with children experiencing severe, persistent asthma create less risk of delayed growth than treatment with oral systemic corticosteroids (pills or capsules).
Osteoporosis (bone disease). In some people, high corticosteroid usage can reduce bonemineral density, leading to osteoporosis. Links have been found between steroid use and inhibiting bone formation, calcium absorption and the production of sex hormones that help keep bones vital. Brief courses of systemic corticosteroids or low dose inhaled steroids are not dangerous, but inhaling 1500 micrograms of beclomethasone per day can lead to bone loss. The doses of other inhaled steroids, which may constitute a risk for osteoporosis, have not been studied.
Even if you need to take steroids for your asthma, you can take measures to protect yourself against osteoporosis. Here are some recommendations:
Take the lowest dose possible and use inhaled steroids rather than oral preparations.
Get about 1,500 mg of calcium daily through nutrition or supplements. Because vitamin D helps the body absorb calcium, it may help to take 800 international units (IU) daily of vitamin D.
Receive replacement female hormone therapy unless prohibited for medical reasons. There are non-hormonalal drugs available (bisphosphonates or calcitonin) that work similarly.
Disseminated Varicella (Chicken pox). The FDA reported that long-term or high-dose oral corticosteroid treatment might place people exposed to chicken pox or measles at increased risk of unusually severe infections or even death. That's because some doses suppress the immune system. "Children who are on immunosuppressant drugs are more susceptible to infections than healthy children," said the FDA. Yet, the NIH Guidelines said there is no evidence that recommended doses of inhaled corticosteroids suppress the immune system.
NIH advises that children who have not had chicken pox and periodically take oral corticosteroids should receive the Varicella vaccine after they've been steroid-free for at least one month. Kids who have finished a short course of prednisone may receive the vaccine immediately. For un-immunized adults and children who are exposed to chicken pox while being treated with immunosuppressive levels of steroids, there are immunoglobulin and acyclovir.
Cataracts. The risk of cataracts in patients taking systemic corticosteroids has been well identified, but reports among those taking inhaled steroids are rare. In a notable exception, the New England Journal of Medicine published findings of a recent Australian study of inhaled corticosteroid users between the ages of 49 and 97. The authors concluded that the use of inhaled steroids is associated with an increased risk for development of cataracts. Patients taking moderate to high doses of inhaled corticosteroids especially should have regular eye exams.
The NIH Guidelines also list a few other rare but potential risks of high dose corticosteroid use. In some cases, oral steroid use has been linked with adrenal suppression, effects on glucose metabolism and hypertension. Serious medical complications have also been recorded in people on high doses of oral steroids with tuberculosis.
None of the above risks have been reported with inhaled corticosteroids. However, their use in moderate to high doses has been found to contribute to thinning and bruising of the skin, especially among women.
Oral (systemic) Corticosteroids
Generally for short-term use.
Quickly controls persistent asthma.
Forms: pills, tablets or liquid (for children)
Medications: Methylprednisolone, Prednisolone, Prednisone
For long-term asthma prevention; suppress, control and reverse inflammation.
Forms: dry powder or aerosol.
Medications: Beclomethasone dipropionate, Budesonide, Flunisolide, Fluticasone propionate,
What are Considered Low, Medium and High Dosages?
A= adult C=child All dosages are daily, in micrograms (MCG).
Source: NIH Guidelines of the Diagnosis and Management of Asthma, April 1997.
SOURCE: This information should not substitute for seeking responsible, professional medical care. First created 1995; fully updated 1998; most recently updated 2005.
© Asthma and Allergy Foundation of America (AAFA) Editorial Board