When is it preferred to use inhaled steroids (IS) over systemic steroids (SS) for treating wheezing?

When to Use Inhaled Steroids Instead of Systemic Steroids for Wheezing

Inhaled corticosteroids (ICS) are preferred over systemic steroids for treating wheezing in chronic conditions requiring long-term management, while systemic steroids remain the treatment of choice for acute severe exacerbations. 1

Preferred Use of Inhaled Steroids

Chronic Asthma Management

• ICS are the cornerstone of therapy for persistent asthma, targeting the underlying airway inflammation 1, 2
• ICS should be initiated when patients require short-acting β-agonists more than 2-3 times per day 3
• ICS are effective in controlling asthma symptoms, improving lung function, and preventing exacerbations regardless of age or asthma severity 2

Chronic Lung Disease of Infancy (CLDI)

• For infants and children with CLDI, inhaled corticosteroids via MDI and spacer are the preferred route to prevent systemic corticosteroid side effects 3
• Regular use of ICS in prematurely born infants with CLDI reduces symptoms, improves lung function, and lessens the need for bronchodilator therapy 3

Advantages of ICS over Systemic Steroids

• ICS deliver medication directly to the airways with minimal systemic absorption 1
• Low-dose ICS therapy has minimal systemic effects compared to systemic steroids 1, 2
• Side effects are seen much less frequently with ICS than with systemic corticosteroids 3

When Systemic Steroids Are Preferred

Acute Severe Asthma/Exacerbations

• Systemic steroids should be used in exacerbations of asthma 3
• Patients with severe and/or refractory cough due to asthma should receive a short course (1-2 weeks) of systemic (oral) corticosteroids followed by inhaled corticosteroids 3
• For acute exacerbations, oral administration is preferred, as intravenous administration offers no advantages 3

Cough Variant Asthma (CVA)

• For patients with asthmatic cough refractory to ICS and bronchodilators, an LTRA may be added before escalating to systemic corticosteroids 3
• If this approach fails, systemic corticosteroids become necessary 3

Steroid-Dependent Patients

• Patients requiring oral corticosteroids should be gradually weaned while transitioning to ICS 4
• ICS are effective and can allow a reduction of oral steroid dosage in steroid-dependent patients 3

Specific Clinical Scenarios

Infants with Wheezing

• Nebulized budesonide for infants has been approved in the US as an alternative to systemic steroids 3
• ICS begun before 2 weeks of age in ventilator-dependent preterm infants can reduce the need for mechanical ventilation and "rescue" systemic glucocorticosteroids 3

Children with Wheezing

• For children with persistent wheezing, ICS are the preferred initial controller medication 1
• In children under 12 years, combination therapy decisions should be made carefully as fewer studies exist in this population 3

Monitoring and Side Effect Management

Potential Side Effects of ICS

• Monitor for potential steroid side effects including delayed growth, increased blood pressure, osteoporosis, adrenal suppression, and cataracts 3
• Oral candidiasis can occur but can be easily avoided by rinsing the child's mouth after ICS use 3

Systemic Steroid Side Effects to Avoid

• Systemic steroids carry risks of adrenal suppression, growth suppression, and other significant adverse effects 4, 5
• When used in short courses of up to two weeks, the dose of oral steroids does not need to be tapered 3

Common Pitfalls and Caveats

1. Inadequate Inhaler Technique: Poor inhaler technique is a common cause of treatment failure with ICS 1

   • Use spacer devices to increase the effectiveness of inhaled drugs 3

2. Overreliance on Rescue Medications: Patients often rely too heavily on short-acting bronchodilators rather than controller ICS therapy 1

   • Patients requiring short-acting β-agonists more than 2-3 doses per day should be treated with ICS 3

3. Inappropriate Dose Escalation: The dose-response curve to ICS is relatively flat 2

   • Adding another class of therapy (long-acting β-agonists, theophylline, or antileukotrienes) may be preferable to increasing ICS dose in moderate-to-severe asthma 2

4. Abrupt Discontinuation of Systemic Steroids: When transitioning from systemic to inhaled steroids, gradual withdrawal is essential 4

   • Initially, ICS should be used concurrently with the patient's usual maintenance dose of systemic corticosteroid 4
   • Gradual withdrawal should follow, with decrements not exceeding 25% of the prednisone dose 4

5. Failure to Recognize Steroid-Resistant Asthma: A small proportion of patients are resistant to the anti-inflammatory effects of corticosteroids 2

   • For these patients, alternative or additional therapies may be necessary

By following these guidelines, clinicians can optimize the use of inhaled versus systemic steroids for wheezing, maximizing therapeutic benefit while minimizing potential adverse effects.