What to know about inhaled steroids
Inhaling medication is often the optimal method of treating lung disease. An inhaler is a device that helps deliver drugs into the airways.
This article provides an overview of inhaled steroids, including their uses and types. We also describe how to take them, how long these medications last, and their side effects.
What are inhaled steroids?
A doctor may prescribe inhaled steroids to treat asthma and COPD.
Inhaled steroids are treatments for breathing disorders.
There are several advantages to inhaling steroids, rather than taking them by mouth. Inhalation allows high levels of the drugs to reach the airways and low levels to reach the rest of the body. Taken orally, steroids have more wide-ranging effects.
Some advantages to using inhaled steroids include smaller dosages and fewer adverse effects. Using inhaled steroids may also reduce the need for oral steroids.
Children and adults with asthma can use inhaled steroids alone or in combination with long-acting bronchodilators.
The Global Initiative For Asthma (GINA) recognize inhaled steroids as the most effective anti-inflammatory type of drug for asthma. GINA recommend inhaled steroids because they can:
- reduce the frequency of symptoms
- slow lung damage
- improve the quality of life
- result in fewer hospital admissions
- reduce the risk of dying from asthma
People with COPD often use a combination of an inhaled steroid and long-acting bronchodilator.
Or, they may use a combination inhaler that contains a steroid, a long-acting bronchodilator, and a long-acting muscarinic antagonist (LAMA).
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend inhaled steroids plus long-acting bronchodilators for treating COPD. They also recommend a combination of an inhaled steroid, a long-acting steroid, and a LAMA for COPD.
A doctor will determine which inhaled steroid is most suitable, depending on the condition.
Common types of inhaled steroids include:
- beclomethasone (Qvar)
- budesonide (Pulmicort)
- budesonide/formoterol (Symbicort) – a combination of a steroid plus a long-acting bronchodilator drug
- ciclesonide (Alvesco)
- fluticasone (Flovent HFA)
- fluticasone propionate (Flovent Diskus)
- fluticasone furoate (Arnuity Ellipta)
- fluticasone propionate/salmeterol (Advair) — a combination of a steroid plus a long-acting bronchodilator
- fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta) — a combination of a steroid, an anticholinergic, and a long-acting bronchodilator drug
- mometasone furoate (Asmanex)
- mometasone/formoterol (Dulera) — a combination of a steroid plus a long-acting bronchodilator drug
How do they work?
In people with asthma or COPD, inflammation narrows the airways and restricts breathing.
To combat this, inhaled steroids block inflammatory cells and cut off inflammatory signals. This reduces the narrowing and opens the airways.
How to use inhaled steroids
To be effective, the right amount of drug needs to reach the right part of the lungs. All of this depends on the drug, the inhaler, and how consistently a person uses it.
People should use inhaled steroids consistently to minimize airway inflammation and prevent symptoms. A study from 2017 reported that 6% of people with COPD used their inhaler regularly and correctly.
People of different ages face different challenges when using their inhalers. For example:
- Younger children may not have the coordination to use a metered dose inhaler.
- Older children may face peer criticism or reduced access to medication during school hours.
- Adolescents may also face peer criticism, and changes to behavior and mental health can play a role.
- Older adults may experience limited vision or physical strength, which can lead to incorrect inhaler use.
The correct use of an inhaler is critical for controlling symptoms. Incorrect use can cause a person to experience more symptoms, leading to more doctor visits, antibiotic use, and oral corticosteroid use.
Results of a study published in the American Journal of Respiratory and Critical Care Medicine indicated that coaching could reduce hospital admissions among people with COPD.
Because each inhaler device is different, people should carefully read the instructions. Healthcare providers should coach people on the correct use, point out the most common errors, and review the correct use at each appointment. A person should also receive this guidance if they change devices.
Many people need more than one inhaler to control symptoms. In these cases, coaching on the proper use of inhalers becomes even more critical because of the added complexity of using more than one device.
It is crucial that healthcare providers recommend the most suitable type of inhaler. For example, while metered dose inhalers require a higher level of coordination, dry powder inhalers do not.
If an inhaled steroid alone does not control asthma symptoms, a doctor may recommend an increased dosage or the addition of a drug that acts as a long-acting bronchodilator.
People should start and stop using inhaled steroids under the supervision of a physician. A doctor should also monitor any switch from an oral to an inhaled steroid.
People should not use inhaled steroids for immediate symptom relief.
The following dosages are based on recommendations from the National Library of Medicine:
|Drug||Age||Condition||Recommended starting dosage||Maximum dosage|
|beclomethasone (Qvar)||adults and adolescents||asthma||40–160 micrograms (mcg)||320 mcg twice daily|
|ages 5–11||asthma||40 mcg twice daily||80 mcg twice daily|
|budesonide (Pulmicort Flexhaler)||adults||asthma||360 mcg twice daily||720 mcg twice daily|
|ages 6–17||asthma||180 mcg twice daily||360 mcg twice daily|
|ciclesonide (Alvesco)||adults and ages 12+||asthma||80 mcg twice daily||320 mcg twice daily|
|fluticasone (Flovent HFA)||adults and ages 12+||asthma||88 mcg twice daily||880 mcg twice daily|
|ages 4–11||asthma||88 mcg twice daily|
|fluticasone propionate (Flovent Diskus)||adults and ages 12+||asthma||100 mcg twice daily||1,000 mcg twice daily|
|ages 4–11||asthma||50 mcg twice daily||100 mcg twice daily|
|fluticasone furoate (Arnuity Ellipta)||adults and ages 12+||asthma||one daily inhalation of Arnuity Ellipta 100 mcg or Arnuity Ellipta 200 mcg|
|ages 5–11||asthma||one daily inhalation of Arnuity Ellipta 50 mcg|
|fluticasone/salmeterol (Advair Diskus)||adults and ages 12+||asthma||one inhalation of Advair Diskus 100/50, 250/50, or 500/50 twice daily||500/50 twice daily|
|ages 4–11||asthma||one inhalation of 100/50 twice daily|
|adults||COPD||one inhalation of 250/50 twice daily|
|fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipa)||adults||COPD||one daily inhalation|
|mometasone furoate (Asmanex)||adults and ages 12+||asthma||220 mcg once daily in the evenings||440 mcg per day|
|ages 4–11||asthma||110 mcg once daily in the evenings||110 mcg per day|
|mometasone/formoterol (Dulera)||adults and ages 12+||asthma||two inhalations twice daily of 100/5 mcg or 200/5 mcg|
How long do they stay in your system?
Most inhaled steroids have a beneficial effect for 12 hours. The exceptions are Arnuity Ellipta, Asmanex, and Trelegy Ellipa, which last for 24 hours.
The most common side effects from inhaled steroids are infections in the sinuses, airways, or mouth.
In general, inhaled steroids are safer and people tolerate them better than oral steroids. The most common adverse events are infections in the sinuses, airways, or mouth.
Also, inhaled steroids may raise the overall risk of infection. Anyone using this type of medication should avoid exposure to chickenpox and measles. If exposed, they should seek medical advice immediately.
Although it is uncommon, people with COPD who use inhaled steroids have a higher risk of pneumonia. It is important to consider this risk in proportion to the risk of COPD symptoms.
Also, inhaled steroids may interfere with a child's growth, but the extent of growth suppression may vary among drugs, devices, dosages, and the duration of use.
An inhaled steroid may reduce bone density, putting a person at risk of fractures and osteoporosis. Healthcare providers should screen adults for risk factors, run regular bone density tests, and request routine follow-ups.
To reduce the likelihood of adverse effects, healthcare providers should screen for possible drug interactions.
Rarely, inhaled steroids can cause hives, swelling, and a rash that requires immediate medical attention.
Other side effects can include:
- increased blood glucose levels
- increased blood pressure
- increased bruising
- suppression of the hypothalamic-pituitary-adrenal axis, or HPA axis
Inhaled steroids are a crucial treatment for asthma and COPD. They deliver targeted doses of drugs to the airways and ensure that only small amounts reach the rest of the body. This can help control the symptoms of asthma or COPD while causing few adverse effects.
Given the variety of inhaled steroids available, doctors and people receiving treatment should work together to decide upon the right medication and device.
Each situation will be unique. Healthcare professionals should provide continued coaching and assessments to improve inhaled steroid effectiveness and minimize the risk of adverse effects.