Inhaled Steroid Options for Treating Asthma

Woman using an inhaler.
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The acute narrowing of the airways that occurs with asthma and results in coughing, wheezing chest tightness, and/or shortness of breath is typically treated with a combination of oral and inhaled medications. Of these, corticosteroids (steroids) are generally considered the most effective treatment for long-term control of asthma symptoms. When used as prescribed, inhaled corticosteroids can reduce the frequency and severity of attacks (exacerbations), improve lung function, prevent hospitalization, and decrease the need for rescue inhalers.

How Corticosteroids Work

Asthma medications work in different ways to relieve asthma symptoms caused by the inflammation that results from a trigger, such as a common allergen or irritant in the air. Beta-agonists found in both long- and short-term inhalers temper inflammation by mimicking the hormone adrenaline (epinephrine) naturally produced by the body. Anticholinergics, also used in long-term inhalers, block the action of neurotransmitters associated with bronchial spasms and constriction.

Corticosteroid drugs work in an entirely different way. They are synthetic versions of the hormone that regulates many of the body's key metabolic functions, including inflammation and the immune response. When corticosteroid drugs reach levels higher than your body usually produces, the immune system will effectively "take its foot off the accelerator," thereby reducing inflammation. This anti-inflammatory response is central to achieving long-term control.

Typically speaking, when you are diagnosed with asthma, your doctor will prescribe a rescue inhaler to deal with acute attacks and a second drug is taken daily to reduce your sensitivity to airborne triggers. Inhaled corticosteroids are the first-line drug of choice in the daily management of symptoms, according to the National Heart, Lung, and Blood Institute.

The drugs are delivered either with a dry-powder inhaler (DPI), and aerosolized metered dose inhaler (MDI), or a machine called a nebulizer, which delivers the drug in an inhalable mist.

Corticosteroids are also vital to combination therapies used in people with poorly controlled asthma symptoms. They not only lower the risk of side effects associated with long-term beta-agonists (LABAs), they almost entirely mitigate the likelihood of drug tolerance (when the beta-agonist suddenly stops working).

Oral corticosteroids like prednisone are only prescribed in severe cases and solely for short-term use due to the risk of serious side effects.

Treatment Options

There are a number of corticosteroid options commonly used for the long-term control of asthma. These include:

Among some of the more commonly prescribed combination, therapies are Advair (which combines the LABA salmeterol with the corticosteroid fluticasone) and Symbicort (which combines the LABA formoterol with the corticosteroid budesonide).

While corticosteroid drugs tend to work in the same way with similar efficacy, there are advantages and disadvantages to each.

Drug Delivery

When choosing an inhaler, one of the main considerations is how much of the drug exiting the inhaler is actually deposited in the air passages of the lungs.

By and large, DPIs like Alvesco, Flovent Diskus, Pulmicort Flexihaler, and Qvar RediHaler tend to deliver more active drug than MDIs like Asmanex and Flovent HFA.

This doesn't necessarily mean that the therapeutic effects of the MDIs are any less than that of the DPIs; they generally aren't. It may only pose a problem if a spacer is used. In such case, a DPI like Alvesco or Qvar RediHaler, both of which deliver 50 percent of the active drug to the lungs, may be less impacted by a spacer than an MDI like Asmanex, which delivers only 11 percent.

By comparison, nebulizers can sometimes deliver superior results than either of the inhalers. However, their use is limited by the fact that the machine is costly and not portable. Moreover, several of the newer corticosteroids like Alvesco and Asmanex cannot be delivered by nebulizer. Despite this, nebulizers may be a better option for children, people who are unable to operate inhalers comfortably, and those who require larger doses.

Side Effects

Generally speaking, inhaled corticosteroids have a relatively low risk of side effects, particularly when compared to oral corticosteroids. The most common side effects, thrush (oral candidiasis), sore throat (pharyngitis), and hoarseness, affect less than 5 percent of users and may require the use of a spacer to help alleviate symptoms.

In some children, inhaled corticosteroids may impair growth, usually by less than a half inch. Normal doses usually don't have this effect, however. (It is important to note, though, that poor asthma control itself is also associated with impaired growth.)

Serious systemic symptoms may arise when the daily dosage is high (1,000 to 1,500 micrograms per day), increasing the risk of weight gain, insomnia, mood swings, thinning of the skin, cataracts, glaucoma, and osteoporosis.

Fortunately, most of the inhaled corticosteroids used today fall well beneath this threshold. Comparatively speaking, a high corticosteroid dose without a spacer is defined as:

  • Alvesco: 320 micrograms per day
  • Asmanex: 440 micrograms per day
  • Pulmicort Flexihaler: 400 micrograms per day
  • Flovent HFA: 440 micrograms per day
  • Flovent Diskus: 440 micrograms per day
  • QVAR RediHaler: 672 micrograms per day

By contrast, older drugs like Azmacort (triamcinolone) and Aerobid (flunisolide) required 1,200 and 1,250 micrograms, respectively. Both have been discontinued in the United States.

Cost

Generally speaking, corticosteroid inhalers delivered between 120 to 240 doses (actuations) per canister. Based on the retail price, the average price per puff breaks down as follows:

  • Alvesco: 120 doses at $2.15 per actuation
  • Asmanex:: 125 doses at $1.85 per actuation
  • Pulmicort Flexihaler: 200 doses at $1.45 per actuation
  • Flovent HFA: 120 doses at $1.65 per actuation
  • Flovent Diskus: 120 doses at $1.55 per actuation
  • QVAR RediHaler: 120 doses at $1.55 per actuation

The daily cost of using a corticosteroid inhaler can vary based on how many puffs you require per day. Asmanex is the first inhaled corticosteroid approved by the U.S. Food and Administration to be used as a once-daily starting dose. This may cut your costs compared to other drugs, which typically require twice-daily doses.

Still, other corticosteroids require more puffs per day to manage symptoms. For severe cases, four puffs of Flovent per day may be enough, while Qvar may require as many as eight to achieve the same effect.

Other Considerations

Of the listed medications, Pulmicort Flexihaler is considered the preferred inhaled corticosteroid during pregnancy with a category "B" rating.

Choosing the Best Option

There are many factors to consider when selecting the right corticosteroid for your asthma. Some may be based on the known differences between the drugs; others may be based on personal preference. Oftentimes, it is necessary to try several inhalants to see how they work or if you experience any side effects. Price, as well as health coverage and patient assistance programs, may also play a part.

In the end, the "right" inhaler is the one that works for you as an individual. While your first instinct may be to go with the latest drug, remember that "new" doesn't always mean "best." Opt for the corticosteroid inhaler that uses the lowest dose that controls your symptoms with the fewest side effects.

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