Can Steroids Cause Cough?
Yes, inhaled corticosteroids can directly cause or exacerbate cough as a side effect, occurring in approximately 10-30% of patients, with the mechanism likely related to constituents of the aerosol dispersant rather than the steroid molecule itself. 1, 2
Mechanism of Steroid-Induced Cough
The cough is triggered by components of the aerosol delivery system, not the corticosteroid molecule itself. For example, beclomethasone dipropionate causes cough more frequently than triamcinolone acetonide due to differences in the dispersant formulation. 1
This adverse effect is classified as a topical side effect of inhaled corticosteroids, alongside oral candidiasis and dysphonia, affecting 10-30% of patients. 2
The FDA drug label for budesonide inhalation suspension lists cough as an adverse reaction occurring at 5-9% incidence in clinical trials, higher than the vehicle placebo rate of 5%. 3
Clinical Recognition and Management Algorithm
Step 1: Identify the Pattern
Suspect steroid-induced cough when a patient develops new or worsened cough immediately after initiating inhaled corticosteroid therapy, particularly within the first few doses. 1
Distinguish this from the underlying condition being treated (asthma, eosinophilic bronchitis) by temporal relationship—steroid-induced cough occurs immediately with inhalation, not gradually over weeks. 1
Step 2: Exclude Other Causes Before Escalating Therapy
Before increasing the steroid dose or adding oral corticosteroids, systematically rule out three critical alternative explanations: 1
- Improper inhaler technique causing upper airway irritation rather than lung deposition
- Gastroesophageal reflux disease making asthma difficult to control and mimicking treatment failure
- Another concurrent etiology such as post-nasal drip or ACE inhibitor use
Step 3: Switch Formulations Rather Than Discontinue
Change to a different inhaled corticosteroid formulation or delivery device rather than abandoning inhaled steroid therapy entirely. 1
Consider switching from metered-dose inhalers to dry powder inhalers, as the propellant-free delivery may reduce irritation. 1
Trial a different corticosteroid molecule (e.g., from beclomethasone to fluticasone or budesonide) as individual patient tolerance varies. 1
Step 4: Use Spacer Devices
- Large volume spacers with metered-dose inhalers reduce oropharyngeal deposition and may minimize local irritation causing cough. 1
Important Caveats and Pitfalls
Common Diagnostic Error
The most critical pitfall is misinterpreting steroid-induced cough as treatment failure and inappropriately escalating to oral corticosteroids. 1 This exposes patients to systemic side effects (immunosuppression, hyperglycemia, osteoporosis) when the solution is simply switching formulations. 4
Paradoxical Situation
Inhaled corticosteroids are the first-line treatment for cough variant asthma and eosinophilic bronchitis, yet they can simultaneously cause cough as a side effect. 1, 5 This creates a clinical dilemma requiring careful temporal assessment—therapeutic benefit typically requires 4-8 weeks, while steroid-induced cough occurs immediately with each dose. 1, 5
Short-Term Use Appears Safer
Research evidence suggests that short-term inhaled budesonide (1 month at 400 mcg twice daily) does not cause negative voice effects and effectively treats persistent cough in selected patients. 6 However, the 10-30% incidence of cough as a topical side effect remains relevant even with short-term use. 2
Efficacy Depends on Underlying Pathology
Inhaled corticosteroids only suppress cough when sputum eosinophilia is present. 7, 8 In patients with chronic cough without sputum eosinophilia, budesonide treatment showed no effect on cough severity or inflammatory markers. 8 This emphasizes that steroid-induced cough may be particularly problematic when the drug is ineffective for the underlying condition, creating a situation where patients experience only adverse effects without therapeutic benefit.