Inhaled glucocorticosteroids

Inhaled glucocorticosteroids (ICS), as metered dose inhalers, powder inhalers or solutions for use with nebulisers are well-tolerated, locally anti-inflammatory, anti-allergic and immunosuppressive substances that play an important role in the long-term treatment of bronchial asthma, chronic bronchitis and chronic obstructive pulmonary disease (COPD) (Barnes PJ et al. 1992; Djukanović R et al. 1992; Jeffery PK et al. 1992)

Inhaled glucocorticoids are not suitable for the treatment of acute asthma attacks. They only show their full effect after 1 week.

Combinations:

There is now a wide range of fixed combinations for the treatment of asthma patients.

As a preferred treatment option, patients in therapy stage II should receive regular therapy with a low-dose inhaled glucocorticosteroid and, if necessary, the use of a short-acting inhaled beta-2 sympathomimetic (SABA).

In Therapy Stage III, adult patients are to receive regular long-term therapy with a fixed combination of a low-dose ICS with a LABA and the use of a short-acting inhaled beta-2 sympathomimetic (SABA) as required, or a fixed combination of a low-dose ICS (budesonide or beclomethasone) with the LABA formoterol for long-term and on-demand therapy.

In Therapy Stage IV, adult patients should receive either a fixed combination of a low-dose ICS with LABA formoterol for long-term and demand therapy or regular long-term therapy with a fixed combination of a medium or high dose of ICS with a LABA and the use of a short-acting inhaled beta2 sympathomimetic (SABA) as required.

The combination of the leukotriene receptor antagonist montelukast with the glucocorticosteroid fluticasone appears to be as effective and as well tolerated as fluticasone plus salmeterol (study with almost 1500 patients). (BMJ 327, 2003, 891).

In patients with exclusively seasonal allergic asthma (e.g. sensitization to tree and/or grass pollen), therapy with ICS can be started immediately upon onset of the first asthma symptoms on exposure to allergens. ICS therapy should be continued for 4 weeks after the end of the allergen season.

Among the most common possible ADRs are candidiasis of the oropharynx and pharyngitis; headaches and hoarseness are less frequent. At long-term doses, >1mg/day in adults, systemic side effects must be expected such as suppression of the adrenal cortex, osteoporosis, cataract formation.

Only about 30% of the active ingredient in the metered dose inhaler reaches the respiratory tract. The major part is deposited in the oropharynx. The danger of thrush colonization is a western side effect. It can be reduced by applying the aerosol immediately before meals. Subsequent mouth rinses are recommended.

In children, growth retardation is already detectable at doses >0.5mg/day. In a larger study (1041 children) observed into adulthood, it was shown that adults treated with budesonide in childhood were on average 171.1 cm tall at the end of the follow-up study compared to 172.3 cm in the placebo group (Kelly HW et al. 2012).

Pulmonary tuberculosis; other mycotic and bacterial respiratory infections.

Beclometasone (Sanasthmax®) average daily dose for adults: 500-1000ug

Budesonide (Pulmicort®) average daily dose for adults: 400-800ug

Ciclesonide (Alvesco®) average daily dose for adults: 160-320ug

Fluticasone (Flutide®) average daily dose for adults: 250-500ug

Mometasone (Asmanex®) average daily dose for adults: 220-440ug

Triamcinolone average daily dose for adults: 1000-2000ug

It is recommended to test the minimum effective dose in each individual case. Active substances and inhalation systems with a high therapeutic index should also be used.

The use of an inhalation aid (spacer) for inhalation of glucocorticosteroid as a metered dose inhaler can be recommended to improve pulmonary deposit and to prevent oropharyngeal side effects.

If spasticity is present, the use of beta2-adrenergic drugs is recommended first and then ICS after the onset of bronchospasmolysis.

1. Barnes PJ et al (1992). Efficacy and safety of inhaled corticosteroids in asthma. Report of a workshop held in Eze, France, October 1992. At Rev Respir Dis 148: S1-26 191
2. Djukanović R et al (1992) Effect of an inhaled corticosteroid on airway inflammation and symptoms in asthma. At Rev Respir Dis 145: 669-674
3. Jeffery PK et al (1992) Effects of treatment on airway inflammation and thickening of basement membrane reticular collagen in asthma. A quantitative light and electron microscopic study. At Rev Respir Dis 145: 890-899
4. Kelly HW et al (2012) Effect of inhaled glucocorticoids in childhood on adult height. N Engl J Med 367:904-912.https://www.ncbi.nlm.nih.gov/pubmed/22938716
5. S2k guideline for diagnosis and therapy of patients with asthma: https://www.awmf.org/uploads/tx_szleitlinien/020-009l_S2k_Asthma_Diagnostik_Therapie_2017-11_1.pdf