Can inhaled corticosteroids (ICS) cause tachycardia and anxiety symptoms?

Inhaled Corticosteroids Can Cause Anxiety and Tachycardia, Especially at Higher Doses

Inhaled corticosteroids (ICS) can cause tachycardia and anxiety symptoms, particularly at moderate to high doses, though these side effects are less common than with systemic corticosteroids. 1, 2

Cardiovascular and Psychiatric Effects of ICS

• Inhaled corticosteroids have been associated with psychiatric symptoms including anxiety, nervousness, restlessness, and mood disorders, as documented in FDA labeling and post-marketing reports 2
• Cardiovascular effects including tachycardia can occur with ICS use, particularly at medium to high doses (≥200-599 mcg daily) 3
• A recent large observational study found that moderate-high daily ICS doses were associated with increased risk of major adverse cardiac events (MACE) and arrhythmias, with hazard ratios of 2.21-2.91 for arrhythmias depending on dosage 3
• Corticosteroids can directly increase cellular potassium efflux which shortens action potential duration, potentially contributing to tachycardia 1

Dose-Dependent Risk

• Low-dose ICS therapy is generally not associated with significant systemic side effects 3
• Medium doses (201-599 mcg daily) show hazard ratios of 2.21 for arrhythmias and higher doses (≥600 mcg) show hazard ratios of 2.91 for arrhythmias 3
• The number needed to harm for arrhythmias is 567 patients at medium doses and 396 at high doses over 12 months of treatment 3
• Side effects from corticosteroids can occur with short or long-term use, though frequency increases with longer durations and higher doses 1

Specific Side Effects Related to Anxiety and Heart Rate

• Post-marketing reports for budesonide inhalation suspension specifically list psychiatric symptoms including anxiety, nervousness, and restlessness as potential adverse reactions 2
• Sleep disturbances, which can be associated with anxiety symptoms, occur at an incidence of >30% with corticosteroid therapy 1
• Documented cardiovascular effects of corticosteroids include hypertension and cardiovascular disease 1
• Corticosteroids can cause mineralocorticoid-like effects leading to elevation of atrial pressures, which may contribute to tachycardia 1

Clinical Considerations and Management

• Clinicians should aim for the lowest possible effective dose of ICS to minimize systemic side effects 4, 3
• Different ICS molecules have varying potentials for systemic effects - fluticasone is more likely to cause systemic effects compared to budesonide 4
• Newer ICS molecules such as ciclesonide may be more beneficial in reducing systemic complications on prolonged use 4
• Using spacers with metered dose inhalers can help reduce systemic absorption and associated side effects 1
• Patients with a history of anxiety disorders or cardiovascular conditions should be monitored more closely when initiating or increasing ICS doses 1

Important Caveats

• While ICS can cause these side effects, they occur less frequently than with systemic corticosteroids 1
• No increased risk of arrhythmias overall has been found among users of inhaled steroids in some studies, suggesting individual susceptibility may play a role 1
• Benefits of ICS therapy in controlling respiratory conditions like asthma generally outweigh the risks of side effects when used appropriately 1, 5
• Patients should not discontinue ICS therapy without medical supervision due to risk of respiratory condition exacerbation 5

When patients report racing heart or anxiety symptoms while using ICS, clinicians should evaluate the dose, consider alternative ICS molecules with lower systemic effects, ensure proper inhaler technique, and potentially explore non-corticosteroid controller medications if symptoms persist.