Is it safe to use inhaled corticosteroids (ICS) while vaping and taking anabolic steroids?

Safety of Inhaled Corticosteroids While Vaping and Taking Anabolic Steroids

Using inhaled corticosteroids (ICS) while vaping and taking anabolic steroids is not recommended due to significant health risks, including potential respiratory complications and hormonal disruptions.

Vaping and Respiratory Health Risks

• Vaping itself is associated with serious lung injuries, as evidenced by the E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak in 2019, which demonstrated the potential for severe respiratory damage from vaping 1
• Vaping can cause various pulmonary conditions including granulomatous disease, which may present with cough, dyspnea, and micronodular opacities on imaging 2
• The long-term respiratory effects of chronic vaping remain largely unknown, with emerging evidence suggesting negative impacts on respiratory health 3

Inhaled Corticosteroids and Vaping

• Inhaled corticosteroids are associated with local adverse effects including oropharyngeal candidiasis, throat irritation, and increased risk of pneumonia 4
• The oxidative stress from vaping may reduce the anti-inflammatory effectiveness of inhaled corticosteroids, as similar mechanisms have been observed with smoke exposure 4
• Combining vaping with ICS could potentially increase the risk of respiratory infections, as ICS alone increases the risk of pneumonia (OR, 1.56; 95% CI, 1.30-1.86) 4

Hormonal Considerations with Anabolic Steroids and ICS

• Inhaled corticosteroids, especially at high doses, can suppress endogenous testosterone production, though to a lesser extent than oral corticosteroids 5
• High-dose ICS therapy has been shown to reduce testosterone levels by approximately 18% in males, while oral corticosteroids can reduce levels by 33% 5
• Female patients on high-dose ICS show more pronounced suppression of endogenous anabolic androgenic steroids compared to males 6
• The combination of exogenous anabolic steroids with ICS could further disrupt the hypothalamic-pituitary-adrenal axis, potentially leading to unpredictable hormonal effects 5, 6

Specific Concerns for Combined Use

• Anabolic steroids may mask the anti-inflammatory effects of ICS, potentially leading to undertreatment of underlying respiratory conditions 4
• The combination of vaping, ICS, and anabolic steroids has not been specifically studied, but each component individually carries risks that could potentially be additive or synergistic 4, 3, 5
• Patients using anabolic steroids may have altered responses to bronchodilators, which are often used alongside ICS in respiratory conditions 4

Recommendations

• Discontinue vaping, as cessation has been shown to lead to resolution of vaping-related pulmonary symptoms and radiographic abnormalities 2
• If ICS therapy is medically necessary for a respiratory condition:
  • Consider the lowest effective dose of ICS to minimize systemic effects 4
  • Monitor for signs of adrenal suppression, especially if also taking anabolic steroids 5, 6
  • Regular assessment of lung function is essential to evaluate treatment efficacy 4
• Patients should disclose all substance use, including vaping and anabolic steroids, to healthcare providers to ensure appropriate management of potential drug interactions 4

Potential Complications to Monitor

• Increased risk of oropharyngeal candidiasis and throat irritation with ICS use 4
• Potential for pneumonia, which is already elevated with ICS use alone 4
• Hormonal imbalances, including further testosterone suppression beyond what would be expected with either ICS or anabolic steroids alone 5, 6
• Cardiovascular effects, as both vaping and anabolic steroids can independently increase cardiovascular risk 4, 3