Can a 78-year-old patient with a history of steroid-induced retinopathy be started on an inhaler with corticosteroids (steroids)?

From the Guidelines

Starting a 78-year-old patient with a history of steroid-induced retinopathy on an inhaled corticosteroid (ICS) may be possible with careful consideration and monitoring, as the benefits of ICS in managing respiratory conditions like asthma often outweigh the risks, especially when using low-dose regimens and proper inhaler techniques 1. When considering the initiation of inhaled corticosteroids in such patients, it's crucial to weigh the potential benefits against the risks, particularly the risk of exacerbating retinopathy. Key points to consider include:

• The choice of inhaled corticosteroid: Options like fluticasone, budesonide, or beclomethasone have minimal systemic absorption, which reduces the risk of worsening retinopathy.
• Dosing: Starting with the lowest effective dose, such as fluticasone 44 mcg/puff or budesonide 80 mcg/puff, with 1-2 puffs twice daily, can help minimize systemic effects.
• Monitoring: Regular ophthalmologic check-ups every 3-6 months are vital to detect any progression of retinopathy early.
• Alternative treatments: Considering non-steroid options like long-acting bronchodilators if clinically appropriate can be beneficial.
• Proper inhaler technique: Using a spacer and rinsing the mouth after inhaler use can further reduce systemic absorption of the steroid. Given the evidence from the NAEPP guidelines and the understanding that inhaled corticosteroids are the most potent and consistently effective long-term control medication for asthma 1, the decision to start an inhaled steroid in a patient with a history of steroid-induced retinopathy should be made on a case-by-case basis, prioritizing the management of the respiratory condition while closely monitoring for any adverse effects on the eyes.

From the FDA Drug Label

Glaucoma and cataracts may occur with long-term use of inhaled corticosteroids. Consider referral to an ophthalmologist in patients who develop ocular symptoms or use Wixela Inhub® long term. (5.15) The patient has a history of steroid-induced retinopathy, and the label warns of potential ocular side effects, including glaucoma and cataracts, with long-term use of inhaled corticosteroids.

• Given the patient's history, it is recommended to exercise caution when considering the use of an inhaler with steroids.
• A referral to an ophthalmologist should be considered before starting the treatment to assess the patient's current ocular health and monitor for any potential side effects.
• The decision to start the patient on an inhaler with steroids should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history 2.

From the Research

Steroid-Induced Retinopathy and Inhaler Use

• A 78-year-old patient with a history of steroid-induced retinopathy is considered for inhaler treatment with steroids.
• The primary concern is whether inhaled steroids can exacerbate or trigger retinopathy in this patient.

Existing Research on Inhaled Steroids and Ocular Effects

• Studies 3, 4 investigated the effects of inhaled fluticasone propionate on ocular functions in children with asthma.
• These studies found no significant correlation between inhaled fluticasone propionate and ocular side effects, including retinopathy.
• Another study 5 evaluated the effects of nasal topical steroids, including fluticasone propionate, on intraocular pressure and found variations within normal limits.

Considerations for Patient Treatment

• While the existing research suggests that inhaled steroids may not have significant ocular side effects, the patient's history of steroid-induced retinopathy warrants caution.
• The patient's age and potential comorbidities should be considered when evaluating the risk-benefit ratio of inhaler treatment with steroids.
• Studies 6, 7 provide insight into the risks associated with corticosteroid use, including osteonecrosis and adrenal suppression, but do not directly address the patient's specific condition.

Key Findings

• Inhaled fluticasone propionate does not appear to cause significant ocular side effects in children with asthma 3, 4.
• Nasal topical steroids, including fluticasone propionate, may cause variations in intraocular pressure, but within normal limits 5.
• The patient's history of steroid-induced retinopathy and potential comorbidities should be carefully considered when evaluating treatment options 6, 7.