Pros and Cons of Glucocorticoids

Do the benefits outweigh the risks?

Man using inhaler outside

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If you have COPD, your doctor may have prescribed glucocorticoids (also known as corticosteroids, or steroids) as part of your treatment plan. As with other medications, glucocorticoids can have both benefits and risks/side effects.

According to the Global Initiative for Obstructive Lung Disease (GOLD), the role that oral and inhaled glucocorticoids play in the treatment of stable COPD has been controversial, and fortunately new guidelines suggest when they are best used, or instead, when the risks likely outweigh the benefits.

How Do Glucocorticoids Work?

As they pertain to COPD, glucocorticoids work by decreasing swelling and inflammation in the airways of the lungs, which allows for easier breathing.

Pros and Cons of Inhaled Glucocorticoids

Regular treatment with inhaled glucocorticoids has been shown to reduce the frequency of COPD exacerbation and improve health status in people with Stage III (severe) to Stage IV (very severe) COPD.

However, their use does not stop the decline of forced expiratory volume (FEV1) or reduce the mortality rate associated with COPD. In addition, glucocorticoids increase the risk of pneumonia, a risk that is already elevated in people with COPD. When inhaled glucocorticoids are discontinued, withdrawal from the medication can lead to COPD exacerbations as well.

Uses

According to 2020 guidelines, inhaled glucocorticoids are indicated with COPD in two settings:

  1. In people who also have asthma and/or a high eosinophil count
  2. In people without asthma who have one or more COPD exacerbations each year.

For those who are currently being treated with a glucocorticoid inhaler, it's recommended that the medication be discontinued if it has been a year or more since your last exacerbation. Certainly, it's important to talk to your doctor before you make any changes in your medications, and every person is different.

Medications

Commonly inhaled glucocorticoids include the following:

  • Pulmicort (bedesonide)
  • Flovent (fluticasone)
  • Aerospan (flunisolide)
  • Asmanex (mometasone)
  • QVAR (beclomethasone)

Combination Therapy

Using an inhaled glucocorticosteroid that is combined with a long-acting bronchodilator has been shown to reduce the frequency of COPD exacerbation, improve lung function and overall health status in patients with COPD, but again, may also increase the likelihood of pneumonia.

For people who have moderate to severe COPD and experience shortness of breath and/or exercise intolerance, a combination of two bronchodilators (a long-acting beta-agonist and an anticholinergic/muscarinic antagonist) should be used first (unless a person has asthma). Then, a glucocorticoid inhaler may be considered for those who have one more more exacerbations yearly.

Examples of COPD inhalers that contain a glucocorticoid include:

  • Symbicort (formoterol and budesonide)
  • Advair (salmeterol and fluticasone)
  • Brio Ellipta (vilanterol and fluticasone)
  • Dulera (formoterol and mometasone)
  • Trelegy Ellipta (vilanterol, umeclidinium, and fluticasone)

It's important to be familiar with the generic names of the medications you use for COPD, as it's not uncommon for people to end up receiving a medication twice (for example, in a single inhaler and a combination inhaler), with a consequent increased risk of side effects.

Oral Glucocorticoids

Oral glucocorticoids are often used with COPD both in a short-term fashion, and during an acute exacerbation or hospitalization, they may be required (either orally or intravenously).

According to 2020 guidelines, however, routine maintenance use of these medications should be avoided as they failed to improve shortness of breath or reduce hospitalizations, but do have risks such as high blood pressure, high blood sugar, gastrointestinal bleeding, and more. Again, every person is different and it's important to talk to your doctor about what is right for you.

Some of the common oral glucocorticoids that you may be familiar with include:

  • Prednisone
  • Dexamethasone
  • Methylprednisolone
  • Cortisone

Side Effects of Glucocorticoids

While the side effects of oral glucocorticoids are numerous and well-documented, adverse effects associated with inhaled glucocorticoids are fewer and less severe. Included below are some commonly known side effects of oral glucocorticoids:

  • Lowered immune system function (immunosuppression)
  • High blood sugar
  • High blood pressure
  • Gastrointestinal bleeding
  • Weight gain
  • Easy bruising
  • Reduced bone density and osteoporosis
  • Muscle breakdown, weakness
  • Cataracts
  • Glaucoma
  • Adrenal insufficiency (if used for a long period and stopped suddenly)
  • Acute psychosis

Inhaled glucocorticoids are more commonly associated with:

  • Skin bruising
  • Yeast infection of the mouth and pharynx (thrush)
  • Hoarseness of the voice

A Word From Verywell

The most important aspect of any treatment plan is having the willingness to follow it. If you are not able to adhere to your plan of care, your health care provider should try to determine what barriers may be standing in the way. All treatment plans should come with a clear explanation of their purpose and probable outcomes. If your doctor does not provide this information for you, you should clarify it before you leave their office.

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Article Sources
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  1. Nici L, Mammen MJ, Charbek E, et al. Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine. 2020. 201(9). doi:10.1164/rccm.202003-0625ST

  2. Gensler LS. Glucocorticoids: complications to anticipate and preventNeurohospitalist. 2013;3(2):92-97. doi:10.1177/1941874412458678

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