From the Guidelines
Inhaled corticosteroids generally do not present with the typical adverse effects associated with systemic corticosteroid therapy when used at recommended doses. The study by Kemp et al, as discussed in the Mayo Clinic Proceedings 1, found that low doses of inhaled corticosteroids, such as fluticasone, had no adverse effects on bone mineral density, function of the hypothalamic-pituitary-adrenal axis, or development of cataracts or glaucoma. Even at higher doses, the effects on cortisol production were minimal and transient. This is in contrast to oral glucocorticoids like prednisone, which can have significant adverse effects on bone mineral density, cortisol production, and glucose metabolism.
Some key points to consider when using inhaled corticosteroids include:
- They are designed to act locally in the lungs with minimal systemic absorption, reducing the risk of common systemic corticosteroid side effects such as weight gain, hyperglycemia, hypertension, adrenal suppression, osteoporosis, and immunosuppression.
- Local side effects, such as oral thrush (candidiasis), dysphonia (hoarse voice), and cough, can occur, but can be minimized by using a spacer device with metered-dose inhalers and rinsing the mouth after use.
- At higher doses or with long-term use, some systemic absorption may occur, potentially leading to mild systemic effects, particularly in children (growth suppression) or elderly patients (increased risk of cataracts or glaucoma).
- The favorable safety profile of inhaled corticosteroids is due to their high first-pass metabolism in the liver, which inactivates most of the small amount that reaches systemic circulation, making them much safer for long-term management of conditions like asthma and COPD compared to oral or injectable corticosteroids, as supported by the study 1.
From the FDA Drug Label
Systemic and inhaled corticosteroid use may result in the following: Candida albicans infection Hypersensitivity reactions including anaphylaxis Immunosuppression Hypercorticism and adrenal suppression Reduction in bone mineral density Growth effects in pediatric patients Glaucoma, increased intraocular pressure and cataracts Eosinophilic conditions and Churg-Strauss syndrome
Inhaled corticosteroids, including budesonide, may present with the typical adverse effects of corticosteroid therapy, such as:
- Hypercorticism and adrenal suppression
- Reduction in bone mineral density
- Growth effects in pediatric patients
- Glaucoma, increased intraocular pressure, and cataracts
- Immunosuppression
- Hypersensitivity reactions, including anaphylaxis 2 2
From the Research
Adverse Effects of Inhaled Corticosteroids
- Inhaled corticosteroids can present with systemic adverse effects, although the safety profile is generally better than that of oral corticosteroid therapy 3.
- These adverse effects may include:
- Acute decrease in growth velocity in children, which appears to be temporary and may have no effect on final adult height 3, 4, 5.
- Bone mineral loss leading to osteoporosis, particularly with high doses of inhaled corticosteroids 3, 6, 4, 5.
- Increased risk of cataracts, glaucoma, skin atrophy, and vascular changes that increase the risk of ecchymoses 3, 7, 4, 5.
- Hypothalamic-pituitary-adrenal axis suppression, reduction in growth velocity, osteoporosis, diabetes, and respiratory infections, particularly in patients with severe asthma 7.
- Oropharyngeal candidiasis and dysphonia, which are the most commonly recognized adverse effects of therapy, but cause no significant morbidity and are easily managed 4.
Comparison to Oral Corticosteroids
- The systemic adverse effects of inhaled corticosteroids are less than those associated with a comparable dose of oral corticosteroids 5.
- However, high doses of inhaled corticosteroids can still cause significant systemic adverse effects, including adrenal suppression and bone density loss 3, 6, 4, 5.
Factors Influencing Adverse Effects
- Dose and potency of the inhaled corticosteroid: higher doses and more potent corticosteroids, such as fluticasone propionate, are associated with a greater risk of systemic adverse effects 3, 6, 4, 5.
- Duration of treatment: long-term use of inhaled corticosteroids can increase the risk of adverse effects, such as osteoporosis and cataracts 3, 6, 4, 5.
- Individual susceptibility: patients may vary in their susceptibility to adverse effects, and some may experience more severe effects than others 3, 4.