May 2000
SAN DIEGO - Misconceptions exist among clinicians and patients about safety and optimal benefits of inhaled corticosteroids. Among these are the myth that oral and inhaled corticosteroids are equally likely to cause adverse events and that any dose of inhaled corticosteroids carries a significant risk of toxicity.
"In truth, the dose equivalence for chronic asthma control and for toxicity is dramatically different for prednisone and inhaled steroids," said Peyton A. Eggleston, MD, a pediatric allergist at Johns Hopkins University, Baltimore. In a study by Simons and colleagues in a 1993 Lancet article, cataracts were observed in 11% of children taking prednisone compared with none in those taking inhaled steroids.
Likewise, "most side effects are seen only with high doses of inhaled steroids," said Eggleston, who shattered several myths about inhaled corticosteroids at the 56th Annual Meeting of the American Academy of Allergy, Asthma and Immunology here. For example, a study by Agertoft and Pederson, published in a 1994 issue of Respiratory Medicine, on the effects of long-term treatment (three to seven years) with an inhaled corticosteroid on growth and pulmonary function in asthmatic children concluded that the growth in children treated with an inhaled steroid (budesonide, average dose of 447 mg daily) averaged 5.48 cm/year compared with 5.62 cm/year in the control children.
"This was not significantly different," Eggleston said.
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Another study by Allen and colleagues in the Journal of Pediatrics in 1998 evaluated growth in asthmatic children treated with fluticasone propionate. For the study, 96 children were treated with fluticasone (200 mg per day) and 87 children were treated with placebo. The children treated with the inhaled steroid grew 5.76 cm/year compared with 5.94 cm/year in placebo-treated children.
A third misconception about inhaled corticosteroids is that noncorticosteroid asthma therapies are as effective as inhaled corticosteroids, but have fewer risks. "Although few direct comparative studies have been reported, inhaled steroids have provided significant advantages in asthma control compared with other therapies," Eggleston said.
In comparative studies by Agertoft and Pederson, "the number of hospitalizations was significantly reduced among children treated with inhaled steroids compared with those treated with other medications." The use of inhaled steroids also reduced the relative risk of hospitalization by 50% in a retrospective analysis in Boston by Donahue and associates. Moreover, Juniper and colleagues "found that the need for rescue medication was significantly reduced in patients treated with inhaled steroid compared with those treated without inhaled steroids," Eggleston said.
The final myth Eggleston shattered was that there is no way to avoid adverse events caused by corticosteroid use. In reality, "safety is a matter of management," Eggleston said. He stressed the importance of class labeling, mandated by the Food and Drug Administration, which reads: "The growth of children and adolescents receiving orally inhaled corticosteroids should be monitored and the potential growth effects of prolonged treatment should be weighed against clinical benefits obtained and the availability of treatment alternatives. To minimize the systemic effects of orally-inhaled corticosteroids, all patients should be nitrated to the lowest effective dose."
Eggleston recommends that treatment should begin shortly after the diagnosis of persistent asthma.
In addition, "establish control and step down with careful monitoring to maximize efficacy," he said. Adequate control can be maintained with lower doses after the first year. In one study, "the required dose decreased by 10% on average in the first year, then continued to decrease over four years of observation," Eggleston said. However, "in the United States, patients tend to reduce their own dose of inhaled steroids. In 1998, for every prescription written for inhaled steroids, there were only 1.7 refills. In other words, patients on average used less than one inhaler every four months."
Allergen avoidance, tobacco-smoke avoidance and treatment of sinusitis may permit dose reduction without compromising disease control. Periodic re-evaluation visits are also essential, during which time growth in children can be monitored. Furthermore, "encourage behavior that will reduce systemic absorption, such as mouth rinsing and the use of newer devices to increase lung deposition," Eggleston said.
For more information:
- Eggleston PA. Misconceptions about safety and optimizing the benefits of inhaled corticosteroids in the United States. Session 5542. Presented at the annual meeting of the American Academy of Allergy, Asthma and Immunology. March 3-8, 2000. San Diego.
- Allen DB, Bronsky EA, LaForce CF, et al. Growth in asthmatic children treated with fluticasone propionate. J Pediatr. 1998;132:472-477.
- Donahue JG et al. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277:887-891.
- Agertoft L, Pedersen S. Effects of long-term treatment with an inhaled corticosteroid on growth and pulmonary function in asthmatic children. Respiratory Med. 1994;84:373-381.
- Simons FER, Persaud MP, Gillespie CA, et al. Absence of posterior subcapsular cataracts in young patients treated with inhaled glucocorticoids. Lancet. 1993;342:776-778.
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