Topics this issue

Which inhalers contain steroids?
How steroids work
When to take them
Stopping steroids
Side effects of inhaled steroids
Minimising side effects
Research
Customer feedback

WHICH INHALERS CONTAIN STERIODS?

Most inhalers are color coded to help you identify them easily. The usual color for steroid inhalers is brown, orange or purple. The steroids come in various strengths, in different types of inhaler devices and have different names that can seem confusing at first, but all contain a similar kind of steroid-based medication that works in the same way. If you are unsure ask you doctor or pharmacist.

HOW STERIODS WORK

People with asthma have airways that are inflamed and swollen inside. This makes the airways narrow, twitchy and sensitive. Steroid medications work directly to reduce this swelling to make the airways more normal. This reduces or completely eliminates asthma symptoms. Steroid medications are therefore called 'preventers' as they work to prevent asthma symptoms from coming on. They do not cure asthma but in most cases can control it completely.

WHEN TO TAKE THEM

Preventers are generally prescribed to people who need their reliever once a day or more. They must be used regularly every day as prescribed or they will not work. Most preventers are now inhaled steroids, which are the most successful preventer available. They are usually taken twice a day, morning and evening. The dose and duration of treatment will depend on your individual asthma and how bad it is. Some people, particularly children with mild asthma, only need
a preventer when they get a cold or flu. Others will be on a regular preventer for years or all their lives. A small group of people with severe asthma will need steroid tablets on a daily basis.
It usually takes 7-10 days on first beginning treatment to see an improvement in symptoms. This is because the medication works over time. Inhaled steroids are not bronchodilators and will not provide relief during an acute asthma episode. Many people mistakenly believe their reliever medications are 'better' and 'more effective' as they work so quickly. However, establishing underlying control of asthma is just as important: this is the role of the preventer.

STOPPING STERIODS

Never stop taking your steroids without direction from your health professional. Unless you are on a low dose of inhaled steroid the amount you take would usually be decreased in steps. Monitoring your asthma is the best way to ensure you are well enough to do this and also to keep check that your asthma does not worsen on doing so.

The exception to this rule is if you have been taking a short course of steroid tablets for a few weeks. In this case your doctor may tell you to stop them completely at the end of the course.

SIDE EFFECTS

Many investigations have been carried out into the safety of inhaled steroids since their introduction 30 years ago. Although identified, there is still dispute as to how significant these side effects are in the long term. Assessment will require studies over a longer period.

· Side effects from steroid tablets are much greater than from inhaled steroids where the doses are much smaller.
· Doses of up to 800 micrograms in children and 1500 micrograms in adults are generally considered safe.
· People vary in their sensitivity to steroids. Some will show side effects at lower doses than others.

Local Side Effects

Hoarseness of the voice. This can be reduced by using an aerosol with spacer device.

Oral Candidiasis

More commonly called thrush, a yeast infection of the mouth and throat. This can be treated with special antibiotic tablets. Can also be reduced by using and aerosol and spacer.

Coughing, an irritated throat and mild constriction of the airways. This can occur when using an aerosol inhaler. The effect is due to surfactants found in this type of device and seems to disappear on switching to a dry powder device.

SYSTEMIC (AFFECTING THE WHOLE BODY) SIDE EFFECTS

Adrenal Suppression

The production of natural hormones from the adrenal glands can be suppressed at high doses. Easy bruising with inhaled steroid use has been found in the elderly but not in children.

Immunosuppression

Low dose prolonged treatment or moderate to high dose treatment over varying time spans have been linked to suppression of the immune system.

Bone density

May cause a reduction in bone mass and osteoporosis at high doses. This is particularly true in post-menopausal women who have been taking inhaled steroids for a long time.

Cataracts

A 1997 study showed that people taking long-term inhaled steroids are more likely to develop cataracts.

Effect on growth

Children with asthma seem to grow for longer, but their final height is normal. A number of studies over time indicate no significant effect of inhaled steroids on growth in children up to a dose of 800 micrograms daily. In children taking inhaled steroids over long periods of time, regular growth checks are recommended. It is important to remember that uncontrolled asthma can stunt growth.

Glaucoma

There is a possible increased risk of developing glaucoma, particularly in the elderly. Glaucoma is a disorder in which the pressure in the eyeball increases which can affect vision.

MINIMISING SIDE EFFECTS

In general, the benefits of taking steroids outweigh the risks of uncontrolled asthma. There are a number of ways you can minimise potential side effects:

Staying on the minimum amount of medication needed to keep you well

The following will help you achieve this:

1. Have your inhaler technique checked regularly by your health professional. If your technique is poor, more medicine will end up in your mouth and stomach than in your lungs. You will then need a higher dose to compensate for this.
2. If you take your steroid using an aerosol you should also use a spacer. This delivers a greater dose of the medication to your lungs and also reduces the incidence of hoarseness and thrush.
3. Monitoring your asthma may enable you to decrease your dose when you are well. Reduction should be done under the guidance of your health professional and/or according to your current self-management plan.

Adding a non-steroid preventer to your treatment regime

It may be possible to keep your dose of inhaled steroid down by adding in a different kind of preventer which does not contain steroid. This will not be a suitable option for everyone.

Good oral hygiene

Even if your inhaler technique is good, a large proportion of the medication hits your mouth and throat. You can reduce the amount which is swallowed and absorbed into you body by brushing your teeth immediately after using your inhaler. Follow by rinsing your mouth and gargling. Spit out the liquid and do not swallow.

Care with nebulised steroids

If you take steroids using a nebuliser you should use goggles to protect your eyes and wash your face immediately afterwards. The skin may otherwise be damaged and there is a greater risk of glaucoma.

RESEARCH

A group of researchers in Scotland recently reviewed and analysed reports dealing with the systemic effects of inhaled corticosteroids on the adrenal gland (cortisol production), growth, bone, skin and eyes. The reports spanned 1966 to 1998.

Their results can be summarised as follows:

· Adrenal suppression (cortisol) occurs with high doses above 1500 ug/day (750ug for fluticosone propionate). There is a considerable degree of variation between individuals.
· Doses above 1500ug/day (750ug for fluticosone propionate) may be associated with a significant reduction in bone density
· The risk of osteoporosis can be decreased by post-menopausal estrogen replacement therapy.
· 400ug/day of beclomethasone dipropionate was shown to have a suppressive effect on growth in medium-term studies but there was no evidence to support significant effects on final adult height.
· High doses over long periods of time increase the risk of cataracts and to a much lesser degree, high blood pressure and glaucoma.
· Skin bruising is most likely to occur at high doses.