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inhaled glucocorticoid

Indications: 1) prophylaxis - reduction in need for 'rescue' beta-adrenergic agonists 2) acute exacerbations of asthma Dosage: 1) prophylaxis (see specific agent) a) 100-500 ug beclomethasone equivalents b) intermittent therapy may be appropriate for some patients with mild asthma [7] 2) acute exacerbations of asthma a) high dose (4X prophylactic dose) in combination with beta-adrenergic receptor agonists [3] b) reduce to prophylactic dose after acute exacerbation resolves [4] c) no benefit in doubling dose [5] for patients on inhaled glucocorticoid alone (no beta-adrenergic agonist) Pharmacokinetics: - some is systemically absorbed Adverse effects: 1) cataracts 2) glaucoma 3) easy bruising 4) osteoporosis a) long-term use of moderate-dose (< 400 ug/day) NOT associated with increased risk of fractures in the elderly [2,9] b) 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] c) 3 years of inhaled glucocorticoids does not affect bone mineral density [10] d) long-term is associated with a modest increased risk of fracture in patients with COPD [13,18] e) no increased risk of fractures in children with asthma [17] 5) weight gain with high doses 6) diabetes mellitus & diabetes progression (dose-dependent) [11] (RR=1.6 at highest doses) 7) increased risk of hyperglycemia when used in high doses, i.e. fluticasone 1000 ug/day 8) maintenance inhaled glucocorticoids stunt growth in asthmatic children - 1.2 cm mean adult height difference [15] 9) adrenal suppression [19] 10) higher body mass index (BMI) in children [19] 11) risk of pneumonia may be dependent on comorbidities - no increased risk of pneumonia [12] - increased risk of pneumonia in patients with COPD - discontinuation of inhlaed glucocorticoid in patients with COPD lowers risk for pneumonia 37% [16] Drug interactions: 1) in patients taking ritonavir, abrupt withdrawal of glucocorticoids metabolized by cyt-P450 3A4 including inhaled glucocorticoids fluticasone & budesonide can result in adrenal insufficiency - no abdominal hyperpigmentation [20]

Interactions

drug adverse effects of glucocorticoids monitor with drug (more general terms)

Related

metered dose inhaler (MDI)

Specific

Triamcinolone Inhalation (Azmacort)

General

glucocorticoid aerosolized agent

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: 10791523 Sambrook PN Inhaled corticosteroids, bone density, and risk of fracture. Lancet 355:1385, 2000 PMID: 10791519
  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: 14551165
  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 PMID: 12763981 http://bmj.com/cgi/content/full/326/7399/1115
  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: 14751699
  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: 15065610 - 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: 14711795
  7. Prescriber's Letter 12(6): 2005 As-Needed Inhaled Corticosteroids for Mild Persistent Asthma Detail-Document#: 210608 (subscription needed) http://www.prescribersletter.com
  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: 16227047
  9. Hubbard R et al. Use of inhaled corticosteroids and the risk of fracture. Chest 2006 130:1082-8 PMID: 17035441
  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: 19581353
  11. Suissa S et al. Inhaled corticosteroids and the risks of diabetes onset and progression. Am J Med 2010 Nov; 123:1001. PMID: 20870201
  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: 20889908
  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: 21602540
  14. Prescriber's Letter 18(10): 2011 Hyperglycemia Associated with Non-oral and Locally Injected Corticosteroids Detail-Document#: 271022 (subscription needed) http://www.prescribersletter.com
  15. Kelly HW et al. Effect of inhaled glucocorticoids in childhood on adult height. N Engl J Med 2012 Sep 3 PMID: 22938716 http://www.nejm.org/doi/full/10.1056/NEJMoa1203229
  16. Suissa S et al. Discontinuation of inhaled corticosteroids in COPD and the risk reduction of pneumonia. Chest 2015 Nov; 148:1177 PMID: 26110239 http://journal.publications.chestnet.org/article.aspx?articleid=2363032
  17. Gray N, Howard A, Zhu J et al Association Between Inhaled Corticosteroid Use and Bone Fracture in Children With Asthma. JAMA Pediatr. Published online November 13, 2017 PMID: 29131874 https://jamanetwork.com/journals/jamapediatrics/article-abstract/2661821
  18. Gonzalez AV, Coulombe J, Ernst P, Suissa S et al. Long-term use of inhaled corticosteroids in COPD and the risk of fracture. Chest 2018 Feb; 153:321. PMID: 28716642 http://journal.chestnet.org/article/S0012-3692(17)31243-6/fulltext - Cho YJ, Sin DD. Inhaled corticosteroids and fractures in COPD: Can we finally put this to bed? Chest 2018 Feb; 153:293. PMID: 29406210 http://journal.chestnet.org/article/S0012-3692(17)31481-2/fulltext
  19. Kunoe A, Sevelsted A, Chawes BL et al. Associations between inhaled corticosteroid use in the first 6 years of life and obesity-related traits. Am J Respir Crit Care Med 2021 Sep 15; 204:642. PMID: 33975528 https://www.atsjournals.org/doi/10.1164/rccm.202009-3537OC
  20. NEJM Knowledge+ Complex Medical Care

Component-of

LABA glucocorticoid combination LABA/LAMA glucocorticoid combination (triple therapy)