Inhaled corticosteroids for long-term control of asthma

Examples

Generic Name Brand Name
beclomethasone QVAR
budesonide Pulmicort Flexhaler, Pulmicort Respules
ciclesonide Alvesco
flunisolide AeroBid
fluticasone Flovent
mometasone Asmanex Twisthaler
triamcinolone Azmacort

Combinations of an inhaled corticosteroid and a long-acting beta2-agonist:

Generic Name Brand Name
budesonide and formoterol Symbicort
fluticasone and salmeterol Advair

These medicines are used in a metered-dose or dry powder inhaler. Inhalers may be used differently, depending on the medicine used. Always read the directions to be sure you or your child is using the inhaler correctly.

How It Works

All forms of corticosteroids reduce inflammation in the airways that carry air to the lungs (bronchial tubes) and decrease the mucus made by the bronchial tubes. This makes it easier to breathe.

Inhaled corticosteroids treat inflammation in the airway, and only very small amounts of the medicine are absorbed into the body. So these medicines don't tend to cause the serious side effects, such as weakening of the bones, that corticosteroids can cause when taken in liquid, pill, or injection form (systemic corticosteroids).

Why It Is Used

Inhaled corticosteroids are the preferred treatment for long-term control of mild persistent, moderate persistent, or severe persistent asthma symptoms in children, teens, and adults. They help control narrowing and inflammation in the bronchial tubes. In general, they are part of daily asthma treatment and are used every day.

Different types of medicines are often used together in the treatment of asthma. For example, inhaled corticosteroids are often used together with long-acting beta2-agonists for persistent asthma. Medicine treatment for asthma depends on a person’s age, his or her type of asthma, and how well the treatment is controlling asthma symptoms.

  • Children up to age 4 are usually treated a little differently from those 5 to 11 years old.
  • The least amount of medicine that controls the asthma symptoms is used.
  • The amount of medicine and number of medicines are increased in steps. So if asthma is not controlled at a low dose of one controller medicine, the dose may be increased. Or another medicine may be added.
  • If the asthma has been under control for several months at a certain dose of medicine, the dose may be reduced. This can help find the least amount of medicine that will control the asthma.
  • Quick-relief medicine is used to treat asthma attacks. But if you or your child needs to use quick-relief medicine a lot, the amount and number of controller medicines may be changed.

Your doctor will work with you to help find the number and dose of medicines that work best.

How Well It Works

Inhaled corticosteroids are the most powerful and most effective medicine for long-term control of asthma in most people. When taken consistently, they improve lung function, improve symptoms, and reduce asthma attacks and admissions to the hospital for asthma.1

Side Effects

Side effects of inhaled corticosteroids are uncommon at the usual prescribed dose. Side effects (many of which occur only with high doses) may include:

  • Sore mouth, sore throat, or hoarseness.
  • Cough and spasms of the large airways (bronchi).
  • Fungus infection in the mouth (thrush).
  • Temporary delayed growth in children.
  • Decreased bone thickness in adults.
  • Clouding of the lens of the eye (cataract).
  • High blood pressure in the eye or fluid buildup in the eye (glaucoma). This occurs with high doses of inhaled corticosteroids used over a long period of time.

The U.S. Food and Drug Administration (FDA) has reported that salmeterol may make an asthma attack worse and may increase the risk of death. If your or your child's wheezing gets worse after taking this medicine (Advair Diskus), call your doctor right away.

To minimize or prevent side effects of corticosteroids, the person with asthma should:

  • Use a spacer with a metered-dose inhaler. The person should rinse his or her mouth with water after using a corticosteroid inhaler, but should not swallow the water. Swallowing the water will increase the chance that the medicine will get into the bloodstream, increasing the potential for side effects.
  • Keep the dose of inhaled corticosteroids as low as possible while still maintaining asthma control. You may be able to limit corticosteroid use by using a long-acting inhaled beta2-agonist, sustained-release theophylline, or a leukotriene pathway modifier along with inhaled corticosteroids.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

According to the United States National Asthma Education and Prevention Program (NAEPP), inhaled corticosteroids are the preferred long-term treatment for asthma.1 If the inhaled corticosteroid does not control asthma symptoms well enough, other medicines, such as a long-lasting beta2-agonist or leukotriene pathway modifier, may be used.

Mometasone is approved for long-term control of asthma in children as young as 4 years old. It should not be used for quick relief of asthma symptoms or during an asthma attack.

It is not known whether inhaled fluticasone, flunisolide, beclomethasone, or triamcinolone may be harmful to the fetus of a pregnant woman with asthma. Budesonide is not expected to harm a fetus. A review of the animal and human studies on the effects of asthma medicines taken during pregnancy found few risks to the woman or her fetus. It is safer for a pregnant woman with asthma to be treated with asthma medicines than for her to have asthma symptoms and asthma attacks.2 Poor control of asthma is a greater risk to the fetus than asthma medicines are.2 If you are or get pregnant, talk with your doctor but do not immediately stop using your asthma medicine.

It is not known whether inhaled fluticasone, flunisolide, beclomethasone, triamcinolone, or budesonide passes into breast milk. Talk to your doctor if you have asthma and are breast-feeding a baby.

Most doctors recommend that everyone who uses a metered-dose inhaler (MDI) also use a spacer, which is attached to the MDI. A spacer may deliver the medicine to the lungs better than an inhaler alone. And for many people a spacer is easier to use than an MDI alone. Using a spacer with inhaled corticosteroids can help reduce their side effects and result in less use of oral corticosteroids.

Concerns for children

Budesonide (Pulmicort Respules) for use with a nebulizer is approved for use in children ages 1 to 8. But the nebulized medicine is more expensive and may be more inconvenient than a corticosteroid used with an inhaler.

Advair is available for use in children ages 4 and older.

Flunisolide and triamcinolone inhalation medicines are not approved for use by children younger than 6 years of age.

QVAR (beclomethasone) is now approved for maintenance treatment of asthma in children 5 and older.

There has been some worry that children who use inhaled corticosteroids may not grow as tall as other children. In the studies done so far, there was a very small difference in height and growth in children using inhaled corticosteroids compared to children not using them. When these children stopped using inhaled corticosteroids, their growth increased. It is expected that even though using inhaled corticosteroids may slow growth at first, children will still grow to a normal height.3 But no study has gone on long enough for experts to be sure. The difference in height is very small and this effect is rare. But children who use inhaled corticosteroids should have their height checked once or twice a year.

One study noted that children who use inhaled corticosteroids do not have an increased risk for broken bones (fractures) compared to those who are not using the medicine.4

Try to avoid giving your child an inhaled medicine when he or she is crying, because not as much medicine is delivered to the lungs.

Complete the new medication information form (PDF)(What is a PDF document?) to help you understand this medication.

References

Citations

  1. National Institutes of Health (2007). National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (NIH Publication No. 08–5846). Available online: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
  2. National Asthma Education and Prevention Program (2005). Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment Update 2004 (NIH Publication No. 05-5236). Available online: http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.htm.
  3. Guilbert TW, et al. (2006). Long-term inhaled corticosteroids in preschool children at high risk for asthma. New England Journal of Medicine, 354(19): 1985–1997.
  4. Schlienger RG, et al. (2004). Inhaled corticosteroids and the risk of adult fractures in children and adolescents. Pediatrics, 114(2): 469–473.

Last Updated: March 20, 2009

Author: Maria G. Essig, MS, ELS

Medical Review: Michael J. Sexton, MD - Pediatrics & Harold S. Nelson, MD - Allergy and Immunology

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