Which inhaled corticosteroid (ICS) is less likely to cause hoarseness?

Ciclesonide Causes Less Hoarseness Than Other Inhaled Corticosteroids

Ciclesonide is the inhaled corticosteroid least likely to cause hoarseness compared to other inhaled corticosteroids due to its unique prodrug formulation that activates primarily in the lungs. 1

Mechanism of Hoarseness with Inhaled Corticosteroids

Hoarseness (dysphonia) is a common local side effect of inhaled corticosteroid (ICS) therapy. This occurs due to:

• Deposition of active medication in the oropharynx and larynx
• Development of laryngeal edema and mucosal thickening
• Possible myopathy of the vocal cords 2

Long-term inhaled steroid use is frequently implicated as a cause of hoarseness in patients using these medications 2.

Comparison of Different Inhaled Corticosteroids

Ciclesonide

• Lowest risk of hoarseness due to its prodrug formulation 1, 3
• Only activates to its pharmacologically active form (desisobutyryl-ciclesonide) primarily in the lungs 4
• Minimal formation of active metabolite in the oropharynx 4
• Low oral deposition reduces oropharyngeal adverse events 4
• Delivers smaller, more highly respirable particles (1.1-2.1 μm) compared to fluticasone (2.8-3.2 μm) 5
• Greater percentage deposited in the lungs (52%) vs. fluticasone (12-13%) 5

Other Inhaled Corticosteroids

• Fluticasone, budesonide, and beclomethasone all have higher rates of hoarseness 3
• Dry powder inhalers may cause more hoarseness than metered-dose inhalers with spacers 2

Strategies to Minimize Hoarseness with Any Inhaled Corticosteroid

1. Use a spacer device with metered-dose inhalers to reduce oropharyngeal deposition 1
2. Rinse mouth and gargle after each use of an inhaled corticosteroid 1
3. Change delivery system from a dry powder inhaler to a metered-dose inhaler with spacer if hoarseness develops 2, 1
4. Temporary cessation of the medication may be necessary if dysphonia becomes problematic 1

Clinical Implications

• If hoarseness persists beyond 3 weeks despite preventive measures, laryngoscopy should be performed to rule out other causes 1
• The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely prescribing corticosteroids for patients with dysphonia prior to visualization of the larynx 2
• Clinicians should be aware that all inhaled corticosteroids can cause hoarseness, but the risk varies between different medications 3

Algorithm for Managing ICS-Related Hoarseness

1. First-line approach: For patients requiring an inhaled corticosteroid who are concerned about hoarseness, consider ciclesonide as the first choice
2. For existing hoarseness:
   • Implement preventive measures (spacer, mouth rinsing)
   • If using a dry powder inhaler, switch to metered-dose inhaler with spacer
   • If hoarseness persists, consider switching to ciclesonide
   • If severe or persistent beyond 3 weeks, obtain laryngoscopy to rule out other causes

Remember that while ciclesonide appears to have the most favorable profile regarding hoarseness, all inhaled corticosteroids are effective for asthma management, and the decision should prioritize overall disease control while minimizing side effects.