Inhaled respiratory corticosteroids
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Corticosteroids readily cross cell membranes and bind with high affinity to the glucocorticoid cytoplasmic receptor. The activated receptor binds to glucocorticoid-responsive genes and leads to induction or repression of transcription of potent anti-inflammatory or proinflammatory mediators, respectively. This mechanism takes place over a period of hours to days. For instance, corticosteroids increase the synthesis of secretory leukocyte protease inhibitor in human airway epithelial cells, important in reducing airway inflammation. Moreover, glucocorticoids indirectly inhibit the transcription of several inflammatory cytokines (eg, interleukin-1, tumor necrosis factor-alpha) and chemokines (eg, interleukin-8, monocyte chemotactic protein-1). The latter are chemotactic for leukocytes at the site of inflammation. Down regulation of cytokines leads to a reduction of expression of adhesion molecules on endothelial cells, preventing the adhesion and transmigration of leukocytes to the site of inflammation. The net effect of these processes is a reduction in edema.
Asthma is a chronic bronchial inflammatory disorder associated with increased mucus secretions and peribronchial edema composed of cell infiltrates. Acute symptoms of asthma usually arise from bronchoconstriction; chronic asthma can lead to permanent airway remodeling. The anti-inflammatory actions of inhaled respiratory corticosteroids reduce the bronchial inflammation, thereby treating respiratory symptoms associated with asthma. Asthma is associated with immunoglobulin E (IgE) hypersensitivity; therefore, it is exacerbated in the presence of aeroallergens. The allergens bridge the IgE antibodies on the surface of mast cells and other leukocytes and trigger release of chemotactic substances, which initiate an inflammatory response. This leads to mucus deposition in the lung. Corticosteroids decrease IgE synthesis, thereby reducing the bronchial hyperresponsiveness to allergens.
Dose Ranges and Potency of Inhaled Respiratory Corticosteroids
1 to 4
5 to 11
12 and older
Inhalation powder (e.g., Pulmicort Flexhaler)
Inhalation suspension (e.g., Flovent HFA)
Abbreviation: NA, not approved
aUsual dose recommended by manufacturer. bAfter 1 week of inhaled corticosteroid treatment, begin slow rate of oral steroid withdrawal, not exceeding decrements of 2.5 mg/day of prednisone or equivalent; close patient monitoring is warranted. cMetabolized to an active metabolite that has high potentcy
Inhaled respiratory corticosteroids are similar chemically and structurally but have different pharmacodynamic properties that may result in different clinical effects. For instance, the active metabolite of ciclesonide, des-CIC, undergoes rapid hepatic metabolism into inactive metabolites upon leaving the lung , therefore favoring maximum therapeutic effect in the lung while minimizing the risk of systemic adverse events.
With regard to dosing, in patients with mild or moderate persistent asthma, low doses of inhaled respiratory corticosteroids are equally efficacious for improving symptoms compared with high doses, and the dose-response relationship appears to flatten for most clinical parameters and lung function. Dose adjustments can take place depending on the progression of the asthma severity, with high doses used in patients with severe asthma. Corticosteroid responsiveness is decreased in smokers and in patients with predominantly neutrophilic inflammatory asthma.
Inhaled Respiratory Corticosteroid Comparative Efficacy Trials
All fluticasone vs BDP or BUD
FEV1, and FVC; 1:1 and 1:2 dose ratios:
No significant differences between the groups
1:1 dose ratio
Change from baseline: MD, 6.13 L/min; 95% CI, 1.49-10.77
Change from baseline: MD, 8.57 L/min; 95% CI, 0.00-17.13
1:2 dose ratio
Change from baseline: MD, 7.42 L/min; 95% CI, 4.97-9.87
pm: No significant differences between groups
Hoarseness, sore throat/pharyngitis and other AEs: No significant differences between groups
Sore throat/pharyngitis: Peto OR, 1.45; 95% CI, 1.10-1.92
Any AEs or hoarseness: No significant difference
Fluticasone given at half the equivalent daily dose of BDP or BUD leads to small improvements in measures of airway caliber, but it has a higher risk of causing sore throat.
Manning P, et al. Cochrane Database Syst Rev. 2008;2:CD007031
FEV1, FVC, and PEF rates
No significant differences between the groups;
Candidiasis was less frequent with ciclesonide compared with fluticasone. Other adverse events occurred with similar frequency between ciclesonide and BDP/BUD
OCS-sparing effect compared with placebo
Benefit ratio (BR) for complete elimination of OCS: mometasone, 17.2; BUD, 8.2; BDP and fluticasone, 5.4; triamcinolone, 4.6; ciclesonide, 2.8; and flunisolide, 2.2 (all p<0.05 vs. placebo)
Mometasone > triamcinolone (p=0.02)
Mometasone > ciclesonide (p=0.01)
Mometasone > flunisolide (p=0.01)
BUD > ciclesonide (p=0.02)
BUD > flunisolide (p=0.03)
OCS dose change
BDP < fluticasone (p<0.001)
BDP< flunisolide (p<0.001)
All other comparisons were statistically nonsignificant or did not have data available.
Abbreviations: AE, adverse events; BDP, beclomethasone; BUD, budesonide; FEV1, forced expired volume in 1 second; FVC, forced vital capacity; MD, mean difference; OCS, oral corticosteroid; OR, odds ratio; PEF, peak expiratory flow.
Positive throat cultures of Candida can be identified in 45-58% of patients treated with inhaled respiratory corticosteroids; however, clinical thrush is diagnosed in < one-third of patients. Thrush is more frequent in adults and with higher doses of inhaled respiratory corticosteroids. In order to reduce potential of thrush, a spacer or VHC can be used with inhalers and patients are advised to rinse their mouths after inhalation. Topical antifungal agents are used to treat active infections.
Dysphonia is reported in up to half of patients who use an inhaled respiratory corticosteroid and is associated with vocal stress and increasing doses of inhaled respiratory corticosteroids. Spacer or valved holding chamber use, temporary reduction of inhaled respiratory corticosteroid dose, or rest from vocal stress can reduce and treat dysphonia.
Although low or medium doses of inhaled respiratory corticosteroids may potentially decrease or delay growth velocity in children or adolescents, the effects are small, nonprogressive, and may be reversible. Physicians should monitor the growth of children and adolescents taking inhaled respiratory corticosteroids and should weigh the benefit–risk profile of inhaled respiratory corticosteroid therapy if growth appears slowed.
In adults, use of inhaled respiratory corticosteroids is associated with a small dose-dependent reduction in bone mineral density (BMD) scores, as calcium absorption is reduced. It is recommended that in patients with a low BMD or risk factors for osteoporosis, BMD be measured every 1 to 2 years and concomitant bone-protecting therapies used, e.g., bisphosphonates, if necessary. In perimenopausal women taking inhaled respiratory corticosteroids, supplements of calcium and vitamin D are recommended.
Corticosteroids can produce skin changes such as loss of subcutaneous tissue, making skin fragile, transparent, and less resistant to trauma, and increasing skin bruising.
High cumulative lifetime exposure to inhaled respiratory corticosteroids may increase the prevalence of cataracts or the risk for glaucoma in patients with family history of glaucoma. Thus, periodic assessments for increased intraocular pressure in patients who use high doses of hnhaled respiratory corticosteroids and have a family history of glaucoma are warranted.
Although the risk is very low with low or medium dose inhaled corticosteroids, suppression of the hypothalamus-pituitary-adrenal (HPA) axis is possible, depending on the individual’s susceptibility to the effect, dose, frequency, and duration of therapy.
Corticosteroids are substrates of the cytochrome P450 3A4 (CYP3A4) isoenzyme and therefore inhibitors (eg, ketoconazole) or inducers (eg, barbiturates) of CYP3A4 may increase or reduce serum concentrations of inhaled respiratory corticosteroids and their metabolites, respectively.
Patients taking inhaled respiratory corticosteroids are immunocompromised; therefore, their immune response to vaccines may be low compared with healthy subjects. Higher doses or more frequent boosters of vaccines may be required. In general, patients with severe immunosuppression due to large doses of corticosteroids should not receive vaccination with live-virus vaccines.
Corticosteroids should be discontinued prior to and during testing with metyrapone (for the diagnosis of adrenal insufficiency), as they can interfere with the test results.
Inhaled respiratory corticosteroids are controller medications for asthma; they should not be used to treat an acute attack as they will not help acute bronchospasm. Inhaled respiratory corticosteroids can cause acute bronchospasm during inhalation of therapy; if bronchospasm occurs, treat the acute attach with a short-acting bronchodilator.
Corticosteroid therapy can mask the symptoms of viral, fungal, or bacterial infection and should be initiated or continued in patients with an active infection only if the appropriate anti-infective treatment is instituted.
Because of the risks associated with higher doses of inhaled respiratory corticosteroids if patients older than 12 years require more than low-dose inhaled corticosteroids alone to control asthma, it is recommended to add long-acting beta2-agonists rather than increasing the dose of the steroid. The safety and efficacy of inhaled respiratory corticosteroids have not been studied adequately in children younger than 5 years. However, the National Asthma Education and Prevention Program Expert Panel recommends low-dose inhaled respiratory corticosteroids for the daily long-term therapy in children 0-4 years of age, along with close monitoring of the response to therapy.
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Nave R, Bethke TD, van Marle SP, Zech K. Pharmacokinetics of [14C]ciclesonide after oral and intravenous administration to healthy subjects. Clin Pharmacokinet. 2004;43(7):479-486.
Adams N, Lasserson TJ, Cates CJ, Jones PW. Fluticasone versus beclomethasone or budesonide for chronic asthma in adults and children. Cochrane Database Syst Rev. 2007(4):CD002310.
Manning P, Gibson PG, Lasserson TJ. Ciclesonide versus other inhaled steroids for chronic asthma in children and adults. Cochrane Database Syst Rev. 2008(2):CD007031.
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Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), et al. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146:1217-1270.
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Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) 2023. Available from: https://ginasthma.org/. Accessed May 22, 2023.
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