Long-Term Effects of Inhaled Corticosteroids in Children with Asthma
When used at recommended doses, inhaled corticosteroids do not cause long-term, clinically significant, or irreversible adverse effects in children with persistent asthma, and their benefits in controlling asthma far outweigh the small potential risks. 1
Growth Effects
The most documented long-term effect is a small reduction in growth velocity during the first year of treatment:
- Children treated with ICS grow approximately 0.48 cm/year less than untreated children during the first year of therapy 2
- This growth suppression is maximal in the first year and becomes less pronounced in subsequent years of treatment 3, 2
- One long-term study following children into adulthood showed that prepubertal children treated with budesonide 400 μg/day for a mean of 4.3 years had a mean reduction of 1.20 cm in final adult height compared with placebo 2
- The magnitude of growth suppression appears more strongly associated with the specific ICS molecule used than with dose (in the low-to-medium range) or delivery device 3, 2
Important clinical context: The National Asthma Education and Prevention Program emphasizes that this potential but small risk of delayed growth is well balanced by the effectiveness of ICS in improving health outcomes 1
Other Systemic Effects at Recommended Doses
The evidence from clinical trials following children for up to 6 years demonstrates:
Bone Mineral Density
- No clinically significant effects on bone mineral density at low-to-medium doses 1
- The FDA label notes children at increased risk (inactive, family history of osteoporosis, poor nutrition, or taking bone-thinning medications) require monitoring 4
Adrenal/Pituitary Axis Suppression
- Low-to-medium dose ICS have no clinically significant effects on hypothalamic-pituitary-adrenal axis function in most children 5
- Adrenal insufficiency is rare and confined to children receiving high doses 6
- The FDA warns that deaths due to adrenal insufficiency have occurred during transfer from systemic corticosteroids 4
Ocular Effects
- No clinically significant ocular toxicity at recommended doses during the study periods reviewed 1
- The FDA recommends regular eye examinations for long-term users due to potential increased risk of cataracts or glaucoma 4
Immune Function
- Rare individuals may show increased susceptibility to infections even at conventional doses 5
- The FDA warns about potential worsening of tuberculosis, fungal, bacterial, viral, or parasitic infections 4
Risk Minimization Strategy
To minimize potential adverse effects while maintaining asthma control:
- Use the lowest effective dose needed to maintain control 7, 6
- Titrate down once control is established and sustained for 2-4 months 8
- Have children rinse mouth after each treatment to reduce systemic absorption 5, 4
- Select agents with efficient first-pass hepatic inactivation of swallowed drug 6
- Monitor growth velocity closely in all children on ICS 4, 3
- Consider adding adjuvant treatments (long-acting beta2-agonists or leukotriene receptor antagonists) to allow lower ICS doses in children not controlled on low-dose ICS alone 1, 7
High-Dose Concerns
High doses of ICS carry increased risk and require heightened vigilance:
- Dose-related systemic effects become more apparent at high doses 5, 6
- Risk is compounded in children with concomitant allergic conditions requiring multiple forms of topical corticosteroids 6
- Potential for significant adrenal suppression and adrenal crisis exists at high doses 9
Critical Clinical Pitfall
The most important caveat: The risks of poorly controlled asthma (including potential irreversible airway injury, impaired lung function, and increased morbidity/mortality) clearly outweigh the small potential adverse effects of ICS therapy at recommended doses 1, 6