inhaled corticosteroids (unwanted effects)

Last reviewed 01/2018

Inhaled corticosteroids produce fewer adverse effects in comparison with systemic steroids because the dosages used are much lower. Side effects are much more likely to occur with higher doses (>800micrograms per day of beclomethasone or equivalent, in adults) and when inhaler technique is poor (1).

Recognised side effects include:

• local

• Candida albicans infection of the oropharynx
• rarely, bronchospasm related to the flurocarbon carrier; prevented by a powder device or aerosol without carrier
• myopathic weakness of the adductor muscles of the vocal cords leading to dysphonia
• reflex cough  
• sore throat (2)

• systemic

• adrenal suppression, acute adrenal crisis (2)
• bruising and cutaneous thinning
• reduced bone mineral density, osteoporosis, bone fractures
• children may suffer from growth hormone and androgen suppression, retarding growth, with doses of budesonide and beclomethasone of as little as 400 micrograms/square metre (1). However, control of severe asthma should override this concern
• although transient reduction in growth velocity may be observed, the evidence is inconclusive to suggest that the final adult height is affected significantly with the use of inhaled corticosteroids (1)
• eyes – cataracts (usually posterior subcapsular), glaucoma (2)
• pneumonia (1)
• haematological:
• reduction in circulating eosinophils
• increase in circulating neutrophils

There is no evidence of adverse effects on pregnant women, their fetuses, the course of labour or delivery (4). Breast feeding is not contraindicated in patients taking inhaled steroids as these drugs are not present in milk.

Steps to minimize adverse effects of inhaled steroids include:

• use of a spacer device
• rinse the mouth with water after inhalation to minimize the risk of candidiasis
• prescribe the minimum effective dose of inhaled corticosteroids to reduce bone and adrenal cortex effects (3)
• if high doses of steroids are required consider an add on agent (beta-2-agonists) (1).

Reference:

• (1) Regional Drug and Therapeutics Center (RDTC) 2008. Safer medication use. Inhaled corticosteroids
• (2) Anthracopoulos MB, Priftis KN, Russell G. Safety of inhaled corticosteroids. Why the variation in systemic adverse effects? Current Pediatric Reviews 2008;4:198-215
• (3) Regional Drug and Therapeutics Center (RDTC) 2008. Drug update. CFC-free inhaled beclometasone  
• (4) Scottish Intercollegiate Guidelines Network (SIGN) and British Thoracic Society (BTS) 2009. British guideline on the management of asthma: a national clinical guideline (revised 2009).