Inhaled Steroid Options for Treating Asthma

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Inhaled corticosteroids, also called inhaled steroids, are potent asthma medications. They're currently the preferred treatment for people with asthma who need more treatment than a rescue inhaler can offer and they're considered more effective than other options.

When used as prescribed, inhaled corticosteroids can:

  • Reduce the frequency and severity of attacks (exacerbations)
  • Improve lung function
  • Decrease hyper-responsiveness of airways
  • Prevent asthma-related ER visits, hospitalization, and death
  • Decrease the need for rescue inhalers
  • Improve quality of life
Different treatment options for Asthma.
Laura Porter / Verywell

Inhaled steroids help prevent symptoms of asthma, including:

  • Wheezing
  • Shortness of breath
  • Coughing
  • Tightness in the chest

Not Anabolic Steroids

The word "steroid" scares some people because they think a corticosteroid is the same as the potentially dangerous anabolic steroids used by some athletes. Despite the similar name, these are very different drugs and corticosteroids are much safer than anabolics.

Your doctor may recommend an inhaled steroid for your asthma if any of these factors apply:

  • You need a ß-agonist inhaler (e.g., albuterol) more than two days a week
  • Symptoms of asthma recur more than twice a week
  • Asthma interferes with daily activities
  • You've needed oral steroids (such as prednisone) more than once in the previous year

Types of Inhaled Steroids

Your doctor will choose an inhaled steroid for your asthma based on many factors, including how severe your asthma is and how healthy you are overall.

Some steroid inhalers contain only a corticosteroid while others contain a steroid and another medication. Common inhaled steroids include:

Combination therapies are for people with poorly controlled asthma symptoms. They lower the risk of side effects associated with long-term beta-agonists (LABAs) and all-but-eliminate the possibility of drug tolerance (when the beta-agonist suddenly stops working).

While corticosteroid drugs tend to work in the same way with similar efficacy, there are advantages and disadvantages to each. Your doctor can help you choose the right one for you.

How Inhaled Steroids Work

Asthma is essentially an overactive response of the immune system to something in your environment.

When you come in contact with an asthma trigger (allergens, smoke, etc.), your immune system releases cells that cause inflammation in your airways, which shrinks them down and makes it hard to breathe.

Inhaled corticosteroids reduce the inflammation in your bronchial tubes (airways) that causes asthma symptoms. They also reduce the amount of mucus in your bronchial tubes. Less inflammation and mucus means your airways are clear and open so you can breathe normally.

Corticosteroid drugs reduce inflammation in a couple of ways. The first is by, essentially, getting the immune system to back off.

Raising Hormone Levels

In asthma, inflammation of the airways can become chronic. It's at lower levels than during an asthma attack, but that constant state of inflammation means it takes less of a response to make it hard for you to take in oxygen.

Your body produces hormones that regulate the immune response and inflammation, and steroids are synthetic versions of those hormones. When you take a corticosteroid, your body detects high levels of the hormone and stops producing it, effectively "taking its foot off the accelerator."

Blocking Allergy Response

Another major contributor of inflammation is allergies, which are common in people with asthma and also the product of a hyper-responsive immune system.

Steroids block something called the late-phase immune reaction to allergens, and in doing so, it lowers inflammation, decreases the over-responsiveness of your bronchial tubes, and blocks the immune system's inflammatory cells.

The excess mucus associated with asthma comes directly from the bronchial tubes as part of the inflammatory response, so lowering inflammation can help lessen mucus, as well.

This anti-inflammatory response is central to achieving long-term control of your asthma.

How Other Asthma Drugs Work

ß-agonists, which are found in both long- and short-term inhalers, treat asthma by relaxing the smooth muscles in your airways. Anticholinergics, also used in long-term inhalers, block the action of neurotransmitters associated with bronchial spasms and constriction.

How to Use Inhaled Steroids

Inhaled steroids come in three different types of devices:

  • Metered dose inhalers (MDIs): A small pressurized canister contains the medication and a propellant spray. You push down on the canister and the propellant delivers the medication through a plastic mouthpiece and into your lungs.
  • Dry powder inhalers (DPIs): The device may be similar to an MDI or be a disc or oval shape, but doesn't contain a propellant. The medication is a dry powder, which you release by taking a deep, fast breath.
  • Nebulizer: Nebulizers turn liquid medicine into a mist that you inhale. They come in electric or battery-run versions with either a mouthpiece or a mask.

Choosing an Inhaler

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% of the active drug to the lungs, may be less impacted by a spacer than an MDI like Asmanex, which delivers only 11%.

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.

Dosages

Dosages of inhaled corticosteroids varies widely depending on the specific drug, your age, and the severity of your asthma symptoms.

In general, most inhaled medications are used once or twice a day, with one or two puffs at a time. Some medications may be prescribed for several more puffs per day.

Be sure you read and follow the doctor's instructions, and ask your doctor or pharmacist for help if you're not sure how to use the device. Taking more medication than directed can cause you to have unpleasant side effects.

Duration

These are long-term medications for daily use, not rescue inhalers that you used to end an asthma attack. You're intended to use your inhaler regularly, probably over the course of many years.

It's important to follow the instructions on your inhaler precisely, as the doses need to be spaced just right for the medication to be effective.

Be sure you talk to your doctor before stopping your medication for any reason.

Side Effects

Generally speaking, inhaled corticosteroids have a relatively low risk of side effects, particularly when compared to oral corticosteroids.

Some side effects result from the medication and/or propellant being in contact with the tissues in your mouth and throat. Others are systemic, meaning they stem from the medication circulating through your body.

Mouth and Throat

These include the most common side effects, which affect less than 5% of users. You may be able to eliminate or avoid them with a little work. Side effects include:

Thrush (oral candidiasis):

  • A fungal infection of the mouth.
  • Can be prevented by using a spacer, rinsing your mouth after use, or lowering dosage.
  • Can be treated with antifungal medications, including nystatin.

Hoarseness/dysphonia:

  • Voice changes are possible.
  • Can be prevented with a spacer or temporary lower dosage to allow vocal cords time to rest.

Reflex cough and bronchospasm:

  • Can be prevented with a spacer or inhaling more slowly.
  • Using a rescue inhaler first (if you're having an attack) can reduce the risk.

Systemic

Systemic, or body-wide, side effects are possible but uncommon with inhaled steroids. The risk of them is generally higher with a higher dose.

Poor growth:

  • This is of particular concern in children with asthma.
  • When growth is impaired, it's usually by less than half an inch.
  • This is especially rare at normal doses.
  • Children who go off of the drug generally "catch up" in height.

Talk to your pediatrician if you have concerns about your child's growth. It's also important to consider, though, that poorly controlled asthma can also impair growth.

Other systemic side effects can include:

  • Osteoporosis
  • Easy bruising
  • Cataracts and glaucoma

Again, these are less common at typical dosages. If you already have a high risk of any of these things, are concerned about them, or suspect you're experiencing one, talk to your doctor.

Serious Systemic Effects

Serious systemic symptoms may arise when the daily dosage is high (1,000 to 1,500 micrograms per day), increasing the risk of the above side effects plus:

  • Weight gain
  • Insomnia
  • Mood swings
  • Thinning of the skin

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 (mcg) per day
  • Asmanex: 440 mcg/day
  • Pulmicort Flexihaler: 400 mcg/day
  • Flovent HFA: 440 mcg/day
  • Flovent Diskus: 440 mcg/day
  • QVAR RediHaler: 672 mcg/day

Some older drugs (e.g., Azmacort, Aerobid) required high doses and therefore had a greater risk of side effects, but they've been discontinued in the United States.

Pregnancy and Breastfeeding

Research suggests that inhaled corticosteroids do not increase the risk of birth defects and that they're safe to use in low doses throughout pregnancy.

Doctors generally believe the amount of inhaled steroids that are excreted into breastmilk are likely too small to have any impact on a nursing baby, so it's considered safe to use these medications when you're breastfeeding.

Your doctor may recommend one drug over another based on absorption levels.

A Word From Verywell

You have a lot of factors to consider when selecting the right inhaled corticosteroid for your asthma. Some may be based on the known differences between the drugs; others may be based on personal preference.

It's often 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.

The "right" inhaler is the one that works for you. While your first instinct may be to choose the latest drug, remember "new" doesn't always mean "best." Opt for the drug that controls your symptoms with the lowest dose and fewest side effects.

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Article Sources
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