Inhaled Glucocorticoid

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Contents 1 More Specific Terms 2 Indications 3 Dosage 4 Pharmacokinetics 5 Adverse-effects 6 More General Terms 7 Additional Terms 8 References

More Specific Terms

• beclomethasone (Vancenase, Beconase, Vanceril, Beclovent, Qvar)
• budesonide (Rhinocort, Pulmicort, Turbuhaler, Flexhaler, Entocort EC)
• flunisolide (Nasalide, Nasarel AeroBid)
• fluticasone (Flonase, Veramyst, Flovent, Cutivate)
• mometasone (Elocon, Asmanex, Nasonex)
• triamcinolone (TAC, Aristocort, Arsitospan, Kenacort, Kenalog, Nasocort, Azmacort, Trivaris)

Indications

• prophylaxis

• reduction in need for 'rescue' beta-adrenergic agonists

• acute exacerbations of asthma

Dosage

• prophylaxis (see specific agent)

• 100-500 ug beclomethasone equivalents
• intermittent therapy may be appropriate for some patients with mild asthma [7]

• acute exacerbations of asthma

• high dose (4X prophylactic dose) for in combination with beta-adrenergic receptor agonists [3]
• reduce to prophylactic dose after acute exacerbation resolves [4]
• no benefit in doubling dose [5] for patients on inhaled glucocorticoid alone (no beta-adrenergic agonist)

Pharmacokinetics

• some is systemically absorbed

Adverse-effects

• cataracts
• glaucoma
• easy bruising
• osteoporosis

• long-term use of moderate-dose (< 400 ug/day) NOT associated with increased risk of fractures in the elderly [2,9]
• high-dose in the elderly may be associated with increased risk of fracture [6,9] (> 700 ug beclomethasone equivalents/day) [6] (> 600 ug /day) [9]
• 3 years of inhaled glucocorticoids does not affect bone mineral density [10]
• long-term is associated with a modest increased risk of fracture in patients with COPD [13]

• weight gain with high doses
• diabetes mellitus & diabetes progression (dose-dependent) [11] ( RR=1.6 at highest doses)
• increased risk of hyperglycemia when used in high doses, i.e. fluticasone 1000 ug/day
• maintenance inhaled glucocorticoids stunt growth in asthmatic children
• no increased risk of pneumonia [12]
  
• drug adverse effects of glucocorticoids
• drug adverse effects of immunosuppressive agents

More General Terms

• glucocorticoid

Additional Terms

• glucocorticoid
• metered dose inhaler (MDI)

References

1. Journal Watch 20(11):88, 2000 Wong CA et al Inhaled corticosteroid use and bone-mineral density in patients with asthma. Lancet 355:1399, 2000 PMID: [1] Sambrook PN Inhaled corticosteroids, bone density, and risk of fracture. Lancet 355:1385, 2000 PMID: [2]
2. Journal Watch 24(4):34, 2004 Suissa S et al Inhaled and nasal corticosteroid use and the risk of fracture. Am J Respir Crit Care Med 169:83, 2004 PMID: [3]
3. Prescriber's Letter 8(5):29 2001
4. Journal Watch 23(14):114, 2003 Hawkins G et al Stepping down inhaled corticosteroids in asthma: randomised controlled trial. BMJ 326:1115, 2003 <PubMed> PMID: [4] <Internet> [5]
5. Prescriber's Letter 11(3):15 2004 Journal Watch 24(5):40, 2004 Harrison TW et al, Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet 363:271, 2004 PMID: [6]
6. Journal Watch 24(10):81-82, 2004 Kemp JP, Osur S, Shrewsbury SB, Herje NE, Duke SP, Harding SM, Faulkner K, Crim CC. Potential effects of fluticasone propionate on bone mineral density in patients with asthma: a 2-year randomized, double- blind, placebo-controlled trial. Mayo Clin Proc. 2004 Apr;79(4):458-66. PMID: [7]
   - Lee TA, Weiss KB. Fracture risk associated with inhaled corticosteroid use in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004 Apr 1;169(7):855-9. Epub 2004 Jan 07. PMID: [8]
7. Prescriber's Letter 12(6): 2005 As-Needed Inhaled Corticosteroids for Mild Persistent Asthma Detail-Document#: [9] (subscription needed) [10]
8. Jani M, Ogston S, Mukhopadhyay S. Annual increase in body mass index in children with asthma on higher doses of inhaled steroids. J Pediatr. 2005 Oct;147(4):549-51. PMID: [11]
9. Hubbard R et al. Use of inhaled corticosteroids and the risk of fracture. Chest 2006 130:1082-8 PMID: [12]
10. Ferguson GT et al. Prevalence and progression of osteoporosis in patients with COPD: Results from the Towards a Revolution in COPD Health Study. Chest 2009 Dec; 136:1456. PMID: [13]
11. Suissa S et al. Inhaled corticosteroids and the risks of diabetes onset and progression. Am J Med 2010 Nov; 123:1001. PMID: [14]
12. O'Byrne PM et al. Risks of pneumonia in patients with asthma taking inhaled corticosteroids. Am J Respir Crit Care Med 2011 Mar 1; 183:589 PMID: [15]
13. Loke YK et al. Risk of fractures with inhaled corticosteroids in COPD: Systematic review and meta-analysis of randomised controlled trials and observational studies. Thorax 2011 Aug; 66:699 PMID: [16]
14. Prescriber's Letter 18(10): 2011 Hyperglycemia Associated with Non-oral and Locally Injected Corticosteroids Detail-Document#: [17] (subscription needed) [18]

inhaled glucocorticoid