Before answering the question, let’s define what exactly side effects are. Side effects are secondary, nontherapeutic effects unrelated to the primary treatment intent of a medicine. Unlike treatment effects that occur in every-one, a side effect may or may not develop when a medicine is prescribed. Some medication side effects are unpleasant but bearable, others are limiting or harmful, and occasionally a side effect may be perceived as beneficial. Examples of each follow.
A child prescribed an antibiotic to help eradicate a strep throat infection may develop loose bowel movements or some mild diarrhea while taking the antibiotic. Dietary modifications help relieve the diarrhea, which resolves soon after the antibiotic course is completed.
The side effect (loose bowel movements) is not why the antibiotic was prescribed, yet the symptom can be managed effectively, and therapy can therefore continue until the child recovers from the strep infection. Sometimes, medicines cause unintended effects that are more serious, requiring discontinuance of the medication. The treatment of tuberculosis for example, usually includes a medication called isoniazid, which is known to be metabolized in the liver.
Some persons (not all!) taking isoniazid can develop an inflammation of their liver, a chemical INH hepatitis. The development of INH-related hepatitis requires cessation of INH therapy at the first sign of the hepatitis. A balding middle-aged man with high blood pressure (hypertension) requiring medication for control along with his regular exercise and prudent diet, may hope that he is one of those persons who experiences new hair growth, a well-known side effect of minoxidil!
Returning to asthma therapies, the potential side effects of corticosteroids are well described in the medical literature and are related to four factors. Potential side effects are greatly minimized when corticosteroids are taken by inhalation (MDI, DPI, or nebulizer) rather than by mouth, or orally (pill or liquid) making the route of corticosteroid administration a major factor.
The three other important considerations are the total daily dose taken, the total duration of steroid therapy, and an individual’s particular characteristics. Keep in mind that not everyone prescribed a medicine will inevitably develop a side effect, and that fact is attributed to individual traits.
A person who requires a 40-mg pill of prednisone daily for 6 weeks, for example (an admittedly unusually high and prolonged dose in asthma treatment, but the kind of dose that lung specialists are used to when they treat cer-tain non-asthma chronic lung diseases), can expect to develop different side effects than a person taking a burst of prednisone for an exacerbation of asthma. One exam-ple of a burst regimen (not the only one though!) might be 30 mg of prednisone for one day, 25 mg the next day, then 20 mg the day after, and so forth, tapering down by 5 mg each day for a total of 6 days of therapy altogether.
Oral (pill form) corticosteroids may be expected to affect different people in different ways. Steroids can cause mood elevation and increased energy. Some people may experience insomnia. Steroids stimulate appetite; food tastes better. Because steroids can lead to water retention along with an increase in appetite, weight gain often occurs, particularly with longer duration of use. Steroids may cause blood pressure to rise and can cause glucose intolerance, which makes diabetes harder to control.
With long-term use, steroids can lead to acne and cause the skin to bruise easily. Regular eye checkups with an ophthalmologist are important to monitor for increasing eye pressure (glaucoma) and for the development of cataracts, which may relate to longer durations of corti-costeroid therapy.
Some people develop a rounded facial appearance that, like some other steroid side effects, is not permanent and will disappear after the steroid medication has been tapered and discontinued. Long-term steroid treatment can lead to thinning and weakening of bone, and cause a type of osteoporosis called glucocorticoid-induced osteoporosis (GIO). GIO is being increasingly recognized in adult respiratory patients using steroid therapies, including those treated for cigarette-related lung diseases such as emphysema. There is some uncertainty and controversy regarding what a minimum, safe, daily steroid dose is from the per-spective of bone health.
Clearly, steroids in pill form are of far greater concern than inhaled steroids when it comes to glucocorticoid-induced osteoporosis. Not all persons on glucocorticoids develop bone loss or GIO. Some experts quote a dose of 5 mg of prednisone by mouth daily for 3 to 6 months or more as placing a patient at risk for the development of GIO. Others quote a dose of 7.5 mg in pill form daily. One preliminary study examined bone density in adults with asthma taking inhaled steroids for 6 years and detected reduced bone density in several parts of their skeletons.
GIO can be prevented or reversed with early and timely treatment. Ways to prevent and treat GIO include taking the smallest effective dose of steroids, favoring inhaled steroids for asthma treatment rather than oral steroids adding calcium (in the range of 1200–1500 mg/day) and vitamin D (in the range of 800 to 1000 IU/day) supplements daily, performing regular weight-bearing exercise, speaking to your physician about the possible need for bone density measurement tests, and taking a class of medicines called bisphosphonates for the prevention and/or treatment of GIO, if medically appropriate.
The FDA has approved risedronate (Actonel) for the prevention and treatment of GIO, and the medicine alen-dronate (Fosamax) for the treatment of GIO. A third medicine, zoledronic acid (Reclast) is FDA approved for the prevention and treatment of GIO in the case where daily treatment with oral glucocorticoid will be long term (more than 12 months in duration). Such long courses of treatment are not characteristic of asthma and are more likely in the treatment of rheumatologic conditions, like lupus or other autoimmune diseases.
Inhaled corticosteroids (ICS) have the best safety profile of all steroid preparations used to treat asthma. Inhaled corticosteroids are prescribed in one of three different forms: as an MDI, as a DPI, or as a solution to be administered through a nebulizer. Inhaled corticosteroids are cornerstone asthma medications because they are the most effective anti-inflammatory asthma treatments available. They are extremely useful maintenance controller medicines and help prevent asthma symptoms.
Physicians who specialize in asthma care generally will prescribe an inhaled form of corticosteroid for maintenance or daily therapy, reserving oral (pill or liquid) steroids for treating an asthma flare or exacerbation.
Possible side effects of the inhaled corticosteroids include reversible hoarseness, throat irritation, and thrush. Thrush is a mild yeast infection that occurs in the back of the throat and looks like small white patchy blotches. Its treatment consists of an antifungal mouth rinse or occasionally a prescription for an anti-fungal pill. Using a valved holding chamber device with the MDI form of steroids, paying proper attention to careful inhalation technique, and gargling with water or a mouthwash after using the inhaler reduce the risk for developing any of the throat side effects.
All persons who inhale corticosteroids, regardless of whether the medication is administered through an MDI or DPI or by jet nebulizer, should rinse their mouth, gargle, and spit after each dose. The gargling and rinsing procedure will remove any residual steroid particles that may be trapped in the mouth or throat. If these steps are followed regularly after each dosing, the possibility of developing thrush or hoarseness decreases significantly.
You may find it practical to keep your MDI corticosteroid in the bathroom. You can then take your medication, brush your teeth, rinse your mouth, gargle, and spit. Since you likely brush your teeth at least twice a day, you can encourage the regular use of your ICS controller medication by piggybacking onto that already established habit pattern. Note, however, that humid environments like bathrooms that become steamed up after showering are not good environments in which to store any of the DPIs. The bathroom’s high humidity can cause the DPI’s fine medication particles to clump together and to lose their efficacy.
One question that often comes up in treating asthma in children relates to a possible effect of inhaled steroids on a child’s growth. Uncontrolled or poorly controlled asthma affects children’s growth and will decrease final adult height. The most recent data show that children with asthma who are treated with inhaled corticosteroids do ultimately reach their predicted adult height, but that it is reached at a later age. In particular, current evidence indicates that the rate of a child’s growth may slow during the first year of inhaled steroid use. During the second year, most children who have experienced a decreased growth rate enter a catch-up growth phase.
It is extremely important to understand that the long-term benefits associated with well-controlled asthma in virtually every case far outweigh the potential for developing harmful side effects associated with the proper use of inhaled steroids. It is a fact that poorly controlled asthma results in a long list of adverse outcomes.
If you think that one of your asthma medicines, be it an inhaled corticosteroid or any another drug, is causing you to experience side effects, the next step is to review your concerns with your treating physician. It is important never to stop any prescribed medication on your own.
Both the GINA and the NAEPP encourage practitioners caring for persons with asthma of any age to ask about potential medication side effects at every visit and to prescribe the smallest dose of medicine required for asthma control in order to minimize the possible risk of side effects.