Inhaled Steroid Options for Treating Asthma

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

Inhaled steroids help prevent symptoms of asthma, including wheezing, shortness of breath, coughing, and tightness in the chest. These inhalers are not effective for treating an acute asthma attack. Instead, they are to be used daily—symptoms or not—to control asthma over time.

When used as prescribed, inhaled steroids can:

  • Reduce the frequency and severity of attacks (exacerbations)
  • Decrease the need for rescue inhalers
  • Improve lung function
  • Decrease hyper-responsiveness of the airways
  • Prevent asthma-related ER visits, hospitalizations, and death
  • Improve quality of life

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

Different treatment options for Asthma.
Laura Porter / Verywell

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 (a situation in which 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.

Common Misunderstanding

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

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 (an allergen such as pet dander, smoke, etc.), your immune system releases cells that cause inflammation in your bronchial tubes (airways). This narrows them and makes it hard to breathe.

Inhaled corticosteroids reduce this inflammation. They also reduce the amount of mucus in your bronchial tubes. The result is clear and open airways that allow you to breathe normally.

Corticosteroid drugs reduce inflammation in a couple of ways. The first is by getting the immune system to halt its attack.

Raising Hormone Levels

In asthma, inflammation of the airways can become chronic. Everyday levels are lower than those during an asthma attack, but that constant state of inflammation means it doesn't take much of a response to challenge your breathing.

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 hyperresponsive immune system.

Steroids block the late-phase immune reaction to allergens,which 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.

Effects of Combination Ingredients

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.

Choosing an Corticosteroid Inhaler

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 into your lungs.
  • Dry powder inhalers (DPIs): The device may be similar to an MDI or be a disc or oval shape, but it 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.

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 the therapeutic effects of 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 results that are superior to either type of inhaler. 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 or reliably, and those who require large doses.

Dosages and Use

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

People with asthma who use an inhaled steroid to control symptoms routinely have been instructed to take one to two puffs once or twice a day—sometimes more.

However, in updated recommendations for asthma management issued in December 2020, the National Institutes of Health advised that for some people with mild to moderate persistent asthma, daily inhaler use may not be necessary.If you use an inhaler daily to manage asthma, talk to your doctor about how the new guidelines might affect your treatment.


It's important to follow the instructions provided to you precisely, as the doses need to be spaced just right for the medication to be effective. Also, taking more medication than directed can cause you to have unpleasant side effects.

Ask your doctor or pharmacist for help if you're not sure how to use your device.

Duration

It's worth repeating: These are long-term medications for daily use, not rescue inhalers that you used to end an asthma attack. Inhaled corticosteroids are intended to be used regularly, likely over the course of many years.

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

The most common side effects, which affect less than 5% of users, fall into this category. You may be able to eliminate or avoid them with a little work.

  • Thrush (oral candidiasis): This fungal infection of the mouth can be prevented by using a spacer, rinsing your mouth after use, or using a lower dosage (with your doctor's OK). Thrush can be treated with antifungal medications, including nystatin.
  • Hoarseness/dysphonia: Voice changes are possible and may be prevented with use of a spacer or a temporary lower dosage, which can allow your vocal cords time to rest.
  • Reflex cough and bronchospasm: Using a spacer or inhaling more slowly can help prevent this. If you are having an attack, using a rescue inhaler first can reduce the risk as well.

Systemic

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

Poor growth is a concern in children with asthma who use inhaled corticosteroids. When growth is impaired, it's usually by less than half an inch. While noteworthy, 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:

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 symptoms may arise when the daily dosage is high—1,000 to 1,500 micrograms (mcg) 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 mcg/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. 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 excreted into breastmilk is likely too small to have any impact on a nursing baby, so it's also 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 weigh 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 or other considerations (such as health coverage and available patient assistance programs).

The "right" inhaler is the one that works for you. It's often necessary to try several to see how they work or if you experience any side effects.

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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