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Major side effects of inhaled glucocorticoids

Authors
Kenneth G Saag, MD, MSc
Daniel E Furst, MD
Peter J Barnes, DM, DSc, FRCP, FRS
Section Editors
Bruce S Bochner, MD
Robert A Wood, MD
Deputy Editor
Helen Hollingsworth, MD

INTRODUCTION

Inhaled glucocorticoids (also called inhaled corticosteroids or ICS) have fewer and less severe adverse effects than orally-administered glucocorticoids, and they are widely used to treat asthma and chronic obstructive pulmonary disease (COPD) [1]. However, there are concerns about the systemic effects of ICS, particularly as they are likely to be used over long periods of time, in infants, children, and older adults [2,3]. The safety of ICS has been extensively investigated since their introduction for the treatment of asthma 30 years ago [4-9].

This topic review will present the local and systemic side effects of ICS, and address other concerns that are often raised by patients regarding these medications. The various types of inhalers used for asthma therapy and the numerous side effects of orally administered glucocorticoids are reviewed in detail separately. (See "The use of inhaler devices in adults" and "The use of inhaler devices in children" and "Major side effects of systemic glucocorticoids".)

EFFECTS OF LOCAL DEPOSITION

Side effects due to the local deposition of inhaled glucocorticoid in the oropharynx and larynx may occur. The frequency of complaints depends on the specific drug, dose, frequency of administration, inhaler technique, and the delivery system used.

Dysphonia — Dysphonia (hoarse voice) is a common complaint among users of inhaled glucocorticoids (ICS). Reported incidences vary from 1 to 60 percent, depending on the patient population, device, dose, length of observation, and manner of data collection [10-13]. Limited data are available for hydrofluoroalkane (HFA)-based metered dose inhalers (MDIs), but it appears that HFA-based inhalers have a lower risk for dysphonia than older, mostly discontinued chlorofluorocarbon (CFC)-based MDIs [13]. Dysphonia is sometimes reduced by using a spacer with the MDI, although results are variable [12,13]. The risk of dysphonia may be lower with budesonide dry powder inhaler (DPI) compared with CFC-MDIs or fluticasone DPI, although it is difficult to compare across drugs, doses, and devices [11]. In one study of patients using fluticasone DPI, the rate of dysphonia was 20 percent overall and 36 percent among women over the age of 65 [14].

The mechanism of ICS-associated dysphonia may involve factors such as myopathy of laryngeal muscles (manifest as incomplete closure or bowing of the vocal cords on adduction), mucosal irritation, and laryngeal candidiasis [15]. Dysphonia due to myopathy or mucosal irritation is reversible when treatment is withdrawn [15]. Dysphonia may be disabling in singers and lecturers, although it is not troublesome for many patients.

                       

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