What instructions should a healthcare provider give to patients starting inhaled corticosteroids (ICS) for asthma management, particularly those with a history of oral thrush or other fungal infections?

Patient Education for Inhaled Corticosteroids

Patients should rinse their mouths out after using the inhaled corticosteroid to prevent thrush. This is the correct and essential instruction that must be provided to all patients starting ICS therapy.

Why Mouth Rinsing Is Critical

• Oral candidiasis (thrush) is a well-documented local adverse effect of inhaled corticosteroids, occurring in approximately 9.5% of patients using these medications 1
• The mechanism involves local immunosuppression and anti-inflammatory effects of corticosteroids deposited in the oropharynx, creating an environment conducive to fungal overgrowth 1, 2
• Rinsing the mouth immediately after ICS use—performed at least twice and followed by spitting—effectively prevents oral candidiasis and hoarseness 1, 3

Proper Technique for Mouth Rinsing

• The American Journal of Respiratory and Critical Care Medicine recommends timing ICS use just before tooth brushing twice daily, which naturally incorporates mouth rinsing into the routine 1
• Patients should gargle and rinse immediately after inhalation, repeating at least twice, then spit out the water 3
• Using a spacer device with metered-dose inhalers reduces oropharyngeal deposition and further minimizes local side effects 4

Why the Other Options Are Incorrect

Tripling the dose during colds is NOT recommended:

• The National Asthma Education and Prevention Program explicitly states that patients adherent to daily ICS should NOT increase their dose during mild respiratory illness, as controlled trials show no significant reduction in exacerbation rates or improvement in asthma quality of life 5
• A study of 254 children found no benefit from quintupling ICS dose at early signs of worsening control, with a concerning trend toward reduced growth rate 5
• Patients should continue their maintenance ICS regimen unchanged and use short-acting beta-agonists as needed for symptom relief 5

ICS are NOT used during exacerbations—they are maintenance therapy:

• Inhaled corticosteroids must be used daily as controller medication for persistent asthma, not intermittently during exacerbations 1, 4
• During acute exacerbations, systemic corticosteroids (oral prednisone 30-40 mg daily) are indicated, not increased ICS doses 1
• The American Academy of Family Physicians emphasizes that ICS monotherapy is the preferred first-line controller medication for mild to moderate persistent asthma, administered twice daily regardless of symptom status 6

Live vaccines are NOT contraindicated with ICS:

• Inhaled corticosteroids at standard doses (low to medium) do not cause clinically significant systemic immunosuppression 1
• The Mayo Clinic Proceedings reports that even doses 5 times higher than those advised for mild asthma had only minimal, transient effects on cortisol production, with normal baseline cortisol and response to stimulation after 2 years 1
• Unlike systemic corticosteroids, ICS do not have clinically important adverse effects on immune function that would contraindicate live vaccines 1

Additional Essential Patient Education Points

• Verify proper inhaler technique at every visit, as most patients use inhalers incorrectly, which mimics inadequate dosing 4
• For metered-dose inhalers, always use a spacer or valved holding chamber to increase lung deposition and reduce oropharyngeal side effects 4
• Continue ICS daily even when asymptomatic—asthma is a chronic inflammatory disease requiring consistent anti-inflammatory treatment 1
• Monitor for hoarseness, which occurs in some patients and has a 60% recurrence rate upon rechallenge 7

Common Pitfall to Avoid

• A survey found that only 11% of patients correctly performed all four elements of proper mouth washing (awareness of side effects, gargling/rinsing habit, repeating at least twice, and doing so immediately after inhalation) 3
• Pharmacists and providers must explicitly demonstrate and verify the mouth-rinsing technique, not simply mention it in passing 3