Steroid Inhalers for Respiratory Conditions
Inhaled corticosteroids (ICS) are the steroid-containing inhalers used for asthma and COPD, available as single agents or in fixed-dose combinations with long-acting bronchodilators.
Common ICS Medications
The primary inhaled corticosteroids include:
- Budesonide - used alone or in combination with formoterol 1, 2
- Fluticasone propionate - commonly combined with salmeterol (as in Advair Diskus® or Wixela Inhub™) 3, 4
- Beclomethasone - available in various formulations 1
ICS Combination Products
Fixed-dose ICS/LABA (long-acting beta-agonist) combinations represent the most important treatment approach for chronic airways diseases 2:
- Fluticasone/Salmeterol - FDA-approved for asthma (age ≥4 years) and COPD maintenance treatment 3, 4
- Budesonide/Formoterol (Symbicort) - positioned at Step 3 and higher for asthma management per NAEPP guidelines 5
- Triple therapy combinations - ICS + LABA + LAMA (long-acting muscarinic antagonist) for severe disease 1
Clinical Positioning by Disease
For Asthma
- ICS forms the basis for treatment of asthma of all severities, improving control, lung function, and preventing exacerbations 2
- LABAs should NEVER be used as monotherapy for asthma - they must always be combined with ICS 5
- ICS-LABA combinations are preferred adjunctive therapy for patients ≥12 years at Step 3 and higher 5
For COPD
ICS use in COPD should be reserved for specific patient populations 1, 6:
- Patients with FEV1 <50-60% predicted AND frequent exacerbations (≥2 moderate or ≥1 severe per year) 1
- Those with blood eosinophils >300 cells/µL 7
- Patients with concomitant asthma (asthma-COPD overlap syndrome) 1
- ICS should NOT be used as monotherapy in COPD 1, 7
Important Clinical Caveats
Appropriate Use
- Triple therapy (ICS/LABA/LAMA) is recommended for symptomatic COPD patients at high risk of exacerbations, preferably administered as single-inhaler triple therapy 1
- ICS reduces exacerbations by approximately 25% in appropriate COPD patients 6
- In asthma, budesonide 800 µg daily reduced severe exacerbations by 49%, and adding formoterol increased this to 63% 2
Risks and Overuse
- Up to 50-80% of COPD patients are prescribed ICS inappropriately, putting them at unnecessary risk 6
- Pneumonia risk is higher with ICS use, particularly in patients with older age, lower BMI, higher ICS doses, and blood eosinophils <100 cells/µL 7
- Other side effects include oral candidiasis, hoarseness, easy bruising, and potential bone density reduction at doses >1,000 µg/day 1
- ICS monotherapy is NOT recommended as preferred treatment for stable COPD due to side effect concerns 1
Monitoring
- Large-volume spacers or dry-powder systems should be used for high ICS doses (≥1,000 µg/day) 1
- Mouth rinsing after use minimizes oral candidiasis and hoarseness 1
- Patients should be reassessed for continued need, as dual bronchodilation (LABA/LAMA without ICS) shows better outcomes in patients with infrequent exacerbations 6