Is there an inhaled corticosteroid (ICS) that does not cause hoarseness?

Inhaled Corticosteroids and Hoarseness: Options to Minimize Voice Effects

Ciclesonide is the inhaled corticosteroid least likely to cause hoarseness due to its unique prodrug formulation that activates primarily in the lungs rather than the oropharynx. 1, 2

Why Inhaled Corticosteroids Cause Hoarseness

Hoarseness is a common local side effect of inhaled corticosteroids (ICS), occurring through several mechanisms:

• Direct deposition of active medication on the laryngeal tissues
• Local inflammation or myopathy affecting the vocal cords
• Fungal (candidal) infection of the larynx

According to the American Academy of Otolaryngology-Head and Neck Surgery, there are "many reports implicating long-term inhaled steroid use as a cause of hoarseness" 3.

Best Options to Minimize Hoarseness

1. Ciclesonide (Alvesco)

Ciclesonide offers the best profile for minimizing hoarseness because:

• It's delivered as an inactive prodrug that becomes activated primarily in the lungs (on-site activation) 2
• It has minimal activation in the oropharynx, reducing local side effects 1
• It has high pulmonary deposition (50-60%) with a hydrofluoroalkane metered-dose inhaler 2
• Clinical studies show the incidence of local adverse effects is comparable to placebo 2
• Cochrane review data indicates candidiasis (which can contribute to hoarseness) is less frequent with ciclesonide compared to other ICS 4

2. Practical Strategies to Reduce Hoarseness with Any ICS

Regardless of which inhaled corticosteroid is used, these techniques can help minimize hoarseness:

• Use a spacer device with metered-dose inhalers to reduce oropharyngeal deposition 3
• Rinse mouth and gargle after each use
• Change delivery system from dry powder to metered dose inhaler with spacer if hoarseness develops 3
• Temporary cessation of the medication if dysphonia becomes problematic 3

Important Considerations

• All inhaled corticosteroids can potentially cause hoarseness, but the risk varies by medication, dose, and delivery system
• According to the American College of Chest Physicians, local side effects such as hoarseness occur with all inhaled corticosteroids but may be less common with ciclesonide 3
• If hoarseness develops, it is typically intermittent and resolves with temporary cessation of the medication 3
• For patients who develop hoarseness, changing from a dry-powder inhaler to a metered dose inhaler with spacer may resolve the issue 3

Comparative Risk of Hoarseness Among ICS

From highest to lowest risk of causing hoarseness:

1. Higher risk: Dry powder formulations (generally)
2. Moderate risk: Standard metered-dose inhalers without spacers
3. Lower risk: Metered-dose inhalers with spacers
4. Lowest risk: Ciclesonide (due to prodrug formulation)

Caution

While ciclesonide appears to have the most favorable profile for minimizing hoarseness, some research suggests its clinical advantages may be overstated. A systematic review by a Cochrane group indicates that ciclesonide may not have a significantly better overall adverse effect profile than other inhaled corticosteroids when used at equivalent doses 5.

If hoarseness persists beyond 3 weeks despite these measures, laryngoscopy should be performed to rule out other causes, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6.