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Oral Vs Inhaled Steroids For Asthma

Why Might You Need Oral Corticosteroids

Asthma: When to use inhaled steroids in 60 seconds

You might be prescribed a short course of oral corticosteroid to help regain asthma under control during a flare-up or asthma attack.

Your doctor may include oral corticosteroid medication on your written Asthma Action Plan as a step to take if your asthma worsens. Asthma Action Plans that include instructions for the use of oral corticosteroids as well as instructions to increase the dose of inhaled corticosteroid, are effective in improving lung function and reducing hospital admissions.

Needing two doses of oral corticosteroids in a year is a sign of uncontrolled asthma. If you need to use oral corticosteroids more than twice a year or for long periods, it is important to discuss other options with your doctor for improving your asthma control.

This might include:

  • Checking your inhaler technique to make sure you are getting the most from your preventer
  • Discussing the possibility of add-on therapies for your asthma
  • Addressing other health conditions impacting your breathing.

Introduction And Evolution Of Corticosteroids In The Management Of Asthma: Historical Background

Shortly after the discovery of the structure of adrenal steroid hormones, Hench et al. examined using cortisone to treat arthritis in 1949. The effect was remarkable and that work won the Nobel Prize the next year. It also started a series of trials of corticosteroids in various inflammatory conditions. The first use of corticosteroid to treat acute asthma exacerbation was in 1956. Development of corticosteroids that have less mineralocorticoid activity, like prednisone, and later those that have no mineralocorticoid activity, like dexamethasone, made corticosteroids more attractive therapies to use in asthma. In 1972, Clark showed for the 1st time that inhaled beclomethasone was effective in the management of asthma with less adverse effects than systemic steroids. Numerous reports came afterwards describing the efficacy of oral prednisone and prednisolone , IV methylprednisolone and ICS such as triamcinolone, budesonide, and fluticasone in the management of asthma. These effects are mediated through various genomic and nongenomic mechanisms. Table 2 shows some common systemic corticosteroids and their relative potency.

The Set Mnemonic For Asthma

When providing education for asthmatics, in the respiratory field we use the SET mnemonic. SET stands for Swelling, Excess mucus, and Tightness. These are the three main things that happen during an asthma flare-up or asthma attack. Inflammation in the lungs is what causes the swelling which makes it difficult to breathe. Mucus production is increased and when combined with the swelling and tightness, causes wheezing. Tightness happens from both the swelling and bronchospasm. These three things create a perfect storm when you are exposed to a trigger.

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If You Miss A Dose Or Take Too Much

If you forget to take a dose, take it as soon as you remember. If it’s nearly time for your next dose, skip the one you missed.

Do not take a double dose to make up for a forgotten dose.

Accidentally taking too many puffs from a steroid inhaler is unlikely to be harmful if it’s a one-off. Speak to a doctor, nurse or a pharmacist if you’re worried.

Using a steroid inhaler too much over a long period can increase your chances of getting side effects.

What Is Ocs Overexposed

Inhaled vs Oral Corticosteroid for Asthma: whats the difference?

OCS Overexposed is a national education campaign developed in collaboration with more than 10 patient advocacy and medical societies to raise awareness of appropriate OCS use and reveal OCS overuse for what it often is a treatment plan that is no longer working. The campaign has also developed the Oral Corticosteroid Stewardship Statement.

There are several asthma assessment tools you can use to determine if your asthma is in control or not:

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Common Steroids Used For Asthma Allergies Linked To Brain Decline Study Finds

Taking oral or inhaled glucocorticoids, a type of steroid used to curb inflammation in asthma and other autoimmune disorders, may be linked to damaging changes in the white matter of the brain, a new study found.

This study shows that both systemic and inhaled glucocorticoids are associated with an apparently widespread reduction in white matter integrity, wrote study author Merel van der Meulen, a postdoctoral student at Leiden University Medical Center in the Netherlands, in the study

White matter is the tissue that forms connections between brain cells and the rest of the nervous system. Having less white matter can slow the brains ability to process information, pay attention and remember. Lower levels of white matter have also been connected to psychiatric issues such as depression, anxiety and irritability.

This new study is particularly interesting in showing the extent to which white matter, which is required for neurons to connect with each other, is affected by medication use, said Thomas Ritz, a professor of psychology at Southern Methodist University who has researched the impact of steroids on people with asthma. He was not involved in the study.

Inhaled Vs Systemic Corticosteroids And Side Effects

Typically, when facing a query like this, I first think about how most of these questions regarding inhaled corticosteroids stem from what people know about the side effects of systemic corticosteroids. First, corticosteroids are typically used for management of inflammation, as we see in asthma. Systemic corticosteroids are taken in much higher doses than inhaled corticosteroids. Because the effects of systemic corticosteroids are not localized to the lungs like inhaled corticosteroids are, they are more likely to cause various side effects with both shorter- and longer-term use.1

Despite both containing the word ‘steroid’ and both acting on inflammation, the side effects of these two different forms of medication dont generally overlap. There is the exception of increased appetite leading to weight gain, which applies only to long-term or high-dose inhaled corticosteroids.1

Otherwise, inhaled corticosteroids typically lead to only cough, sore throat, hoarseness, and oral thrush in regular doses. This differs greatly from the more whole-body side effects of oral corticosteroids. These side effects include mood swings, water retention/swelling, high blood pressure, elevated blood sugar, changes in appetite , and other side effects associated with long-term use.1

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Patients And Study Design

Patients eligible for this study were aged 12-60 years, had 1 full year of baseline and 1 full year of outcome data before and after their first recorded prescription of ICS , and had received 2 or more prescriptions for asthma at any time in their records in addition to the first ICS prescription, including at least 1 more ICS prescription during outcome therefore, all patients included received at least 2 ICS prescriptions. We excluded patients > 60 years old, those with any other recorded chronic respiratory disease, and those prescribed long-acting muscarinic antagonists or maintenance oral corticosteroid therapy during the baseline year.

At the initiation date, patients received a first prescription of ICS delivered using a pMDI as the extrafine-particle ICS ciclesonide or a pMDI fine-particle ICS, either fluticasone propionate or non-extrafine beclomethasone dipropionate .

Other Inhaled Corticosteroid Inhalers

O for Orals vs Inhalers in Asthma | #AtoZofAsthma

Alvesco may not be the best choice for your asthma maintenance plan, but that doesnt necessarily mean that other corticosteroid inhalers wouldnt be. One consideration is age. Alvesco is only approved for those ages 12 and up. However, Flovent Diskus and Flovent HFA are approved in children as young as 4 years old. Alvesco is an aerosol inhaler, meaning it works by releasing the medication in a fine mist. This does require some mechanical technique to time the breath to the actuation of the inhaler. For those that cant do this, a spacer device may be required, or they may find the use of a powder capsule inhaler easier to use, like that of Flovent Diskus. Regardless of the mechanism, all steroid inhalers carry similar warnings for oral fungal infections, so it is important to rinse your mouth after the use of oral steroid inhalers.

Examples: Flovent HFA , Flovent Diskus , Qvar Redihaler , Pulmicort Flexhaler , Asmanex HFA

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What Is Oral Thrush

Everyone has an organism called Candida in their mouths, but sometimes it can overgrow and cause creamy, white lesions on the tongue and inner cheeks. This fungal overgrowth can also affect the roof of the mouth, tonsils, gums, and the back of the throat. 1

Also called oral candidiasis, oral thrush is more common in babies, small children, and older adults due to their reduced immunity, but it can also affect adults who have certain health conditions or who are taking certain medications. 1

Implications Of The Findings

This analysis confirms that the subset of patients with severe, oral corticosteroid-dependent asthma benefit from high or very high doses of ICS . This is illustrated by the 2.5- to eight-fold increase in the probability of oral corticosteroid elimination with ICS dose increase per 1000µg observed for budesonide, fluticasone, mometasone and ciclesonide. However, it is likely that the major component of the steroid-sparing effects of high doses of ICS in this severe subgroup is due to their systemic effects. These may relate to their inhibitory role in the recruitment and survival of inflammatory cells in the airways and are also involved in switching on genes that have anti-inflammatory effects .

The dose equivalence between oral corticosteroid and ICS for effects on adrenal function provides a useful guide for prescribers in clinical practice. Despite the uncertainty in the estimates, available data suggest that 1000µg fluticasone propionate has similar systemic effects as 5mg prednisone , and that 2500µg budesonide has similar systemic effects as 5mg prednisone . It would be reasonable to suggest that prescribers should advise patients of this bioequivalence to enable the patient to put the risk into perspective.

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When Does Oral Thrush Clear Up

Should asthmatics ever develop oral thrush, a form of antifungal medication will be prescribed to bring the Candida levels back down to normal levels and alleviate symptoms. The primary healthcare provider may also look into alternative inhaler types to lessen the chance of developing oral thrush in the future since not all asthma inhalers increase the risk of developing oral thrush.2,3

Although no one wants to develop oral thrush as a result of using their asthma medications, its possible to prevent an oral thrush infection with a little bit of daily maintenance. And if your doctor is anything like mine, shell keep a close on you just to make sure your mouth and throat stay healthy.

How And When To Use A Steroid Inhaler

Asthma: Oral v/s inhaled corticosteroids for treatment

There are several types of steroid inhaler, which are used in slightly different ways.

A doctor or nurse will show you how to use your inhaler. Make sure you use it exactly as advised. The Asthma UK website has videos explaining how to use the different types of inhaler.

You’ll usually need to take 1 or 2 puffs from your inhaler in the morning and 1 or 2 puffs in the evening.

It’s important to keep using your inhaler, even if you feel better. It will only stop your symptoms if it’s used every day.

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Adherence And Inhaler Technique

Of the 274 asthma patients using high dose OCS, 130 patients were not adherent to ICS . Among a random sample of 60 adherent patients, only 41.6% showed adequate inhaler technique . Thus, only 21.9% of patients were adherent to ICS therapy and used their inhalers correctly, implying that 78.1% of patients with severe or uncontrolled asthma could be falsely labeled as candidates for biologic therapy.

Fig. 2.

Therapy adherence and inhalation technique in GINA 45 asthma patients who use high doses of OCSs. From a pharmacy database of 500,000 Dutch patients, 274 were identified with severe or uncontrolled asthma using high doses of OCSs. Of these 78.1% were considered nonadherent or having poor inhalator technique, only 21.9% were truly refractory to inhaled asthma therapy. Adherence rates were derived from prescription refills inhalation technique was verified by pharmacists in a sample of 60 adherent patients. OCS, oral corticosteroid.

How Do Immunomodulators Work To Improve Asthma Control

Mepolizumab is a biologic therapy that has been found to control the blood cells that often trigger asthma. Nucala targets Interluken-5 which regulates the levels of blood eosinophils . Genetically engineered, Nucala keeps IL-5 from binding to eosinophils and, thereby, lowers the risk of a severe asthma attack.

Nucala is administered by injection once every 4 weeks and is meant to be used in conjunction with other asthma treatments as a maintenance medication. By using Nucala, patients have been found to not only experience fewer asthma incidents, but they are able to reduce the amount of their other asthma medications. Side effects include headache and a hypersensitivity reaction that can cause swelling of the face and tongue, dizziness, hives, and breathing problems.

Omalizumab, an immunomodulator, works differently from other anti-inflammatoryà medications for asthma . Xolair blocks the activity of IgE before it can lead to asthma attacks. Immunomodulator treatment has been shown to help reduce the number of asthma attacks in people with moderate to severe allergic asthma whose symptoms are not controlled with inhaled steroids.

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What Can I Take In Place Of Alvesco

You may have a few different options when looking for an alternative to Alvesco. Your age may determine what options are appropriate for you. There are other corticosteroid inhalers available, some of which are available generically. Alvesco does not currently have a generic on the market. Some inhalers have different delivery mechanisms, oral mists versus oral powder inhalers. There are combination inhalers that add long-acting beta-agonists to the corticosteroids for additional activity to control the asthma symptoms. If you are struggling with the technique of using an oral inhaler or just prefer an oral solid dosage form, those are available as well. Below are some options you could speak to your doctor about when planning out your asthma maintenance plan. Do not stop your current treatment plan before speaking to your healthcare professional.

Who Can Use Steroid Inhalers

Adrenal Suppression from Inhaled Corticosteroids

Most people can use steroid inhalers.

Tell your doctor before starting treatment if you:

  • have had an allergic reaction to steroids in the past
  • have tuberculosis or another infection of your lungs or airways
  • are pregnant, breastfeeding or trying for a baby

Steroid inhalers are normally safe to use while breastfeeding and during pregnancy, but it’s a good idea to get medical advice first.

If you need to take a high dose during pregnancy, you may need regular check-ups to check for any side effects.

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Design And Study Population

This is a cross-sectional study using data from a pharmacy database with prescription data from 65 community pharmacies in the Netherlands, including 500,500 patients from the general population. This database was also used in a previous study on the prevalence of severe asthma by Hekking et al. . First, patients with at least 1 ICS prescription between January 1, 2011, and January 1, 2012 , were identified. From these patients, patients with severe or uncontrolled asthma were identified. This included subjects with at least 1 prescription of high dose ICS or medium-high dose combined with maintenance OCS therapy . All these patients were sent questionnaires, which included questions on demographics, medical history, medication consumption, smoking history, and asthma control. A total of 2,312 patients completed and returned questionnaires . Table 1 shows characteristics of responders and nonresponders: mean age, ICS, and OCS dose were similar between responders and nonresponders however, nonresponders were slightly younger and less often adherent to ICS than responders. Based on the data from the questionnaires, we selected adult patients with a diagnosis of asthma . Patients with other self-reported pulmonary diagnoses, such as sarcoidosis, cystic fibrosis, or bronchiectasis, were excluded.

Table 1.

Patient characteristics of responders and nonresponders to the questionnaires

Possible Side Effects Of Oral Corticosteroids

Side effects are more likely if youre on long-term oral corticosteroid tablets, compared to if you only take a short course when your symptoms get worse. Your doctor will be aware of the possible side effects of steroid tablets and will monitor the doses and medicines you need for your asthma. To reduce the risk of side effects, your doctor will keep you on the lowest possible dose of steroid tablets.

Side effects associated with short term use include:

  • changes to the immune system
  • changes in behaviour
  • changes in the eyes.
  • changes in bone which can result in an increased chance of fractures due to brittleness or softening of the bone
  • changes in hormone levels in your body
  • changes in the bodys ability to handle glucose
  • effects on the parathyroid and thyroid glands which control calcium and body metabolism
  • increased amounts of cholesterol in the blood
  • increased blood pressure

Some of these changes can only be detected by a doctor, so if you are on long-term oral corticosteroids your doctor may arrange extra monitoring.

Please discuss all side effects with your doctor.

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Safety Of Steroids For Asthma

Inhaled steroids are the most effective controller therapy available for asthma. They are the gold standard to which all other asthma medicines are compared. They have been used extensively around the world for over 20 years.

Steroids to treat asthma are not the same as steroids taken and abused by athletes to grow bigger and stronger.

Inhaled steroids are generally well-tolerated and safe at the recommended dosages, even when taken for prolonged periods. However, like all medications there may be side effects. In general, side-effects are more likely to occur at higher doses, though there may be some individual variations. You can make follow-up visits to your health care provider to decrease the dose of inhaled steroids that your child is taking . This will minimize the chance of a side-effect.

The following possible side-effects need to be weighed against the risk of untreated asthma.


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