"Steroids" are a family of chemicals normally made within the body.

They serve as hormoneschemical signals that help to regulate the body's growth and function. Some steroid hormones, like testosterone, stimulate formation of protein and growth of muscle. Competitive athletes have been known to take illicitly derivatives of these "body-building" steroids in large amounts to improve their athletic performance. A very different group of steroid hormones are the corticosteroids, steroid hormones made in the cortex (hence, "cortico-") of the adrenal glands, which sit adjacent to the kidneys. Corticosteroid hormones have many different affects on body function, including influences on how we use our energy stores (fat, protein, and sugar) and how we adjust the salt and water content of our body. Earlier this century it was discovered that corticosteroid hormones, if purified and taken in large amounts as a medicine, have powerful anti-inflammatory effects. Ever since this discovery, corticosteroids have been used to treat a great variety of diseases where inflammation (not infection and not cancer) is the major problemfrom arthritis to psoriasis to asthma. When you and your doctor talk about steroids to treat your asthma, it is these antiinflammatory corticosteroids about which you are speaking.

Steroids Swallowed or Steroids Inhaled

To treat the inflammation of asthma within the bronchial tubes, steroids can be taken in tablet or liquid form or by inhalation. Occasionally, steroids are given by injection orin hospitalized personsdirectly into the veins (intravenous infusion). Taken as tablets, liquid, injection, or intravenous infusion, the steroid medication travels in the blood and is carried throughout the body, including to the bronchial tubes. Used in this way, steroids have their most powerful effectsboth for the good (relieving asthmatic symptoms) and for the bad (undesirable side effects). On the other hand, modern steroid medications inhaled from pressurized canisters onto the bronchial tubes act directly on these tubes; almost no medication is carried into the bloodstream. Although not as powerful in their immediate effects, steroids by inhalation are better suited for long-term use in the treatment of inflamed bronchial tubes because they are free of major undesirable side effects. Examples of steroids in tablet form are prednisone (Brand name: Deltasone) and methylprednisolone (Brand name: Medrol). Examples of steroids by inhalation are beclomethasone (Brand names: Beclovent, Qvar, and Vanceril); triamcinolone (Brand name: Azmacort); flunisolide (Brand names: Aerobid and Aerobid-M); budesonide (Brand name: Pulmicort); and fluticasone (Brand name: Flovent).

Corticosteroids, Inhaled Definition Inhaled corticosteroids are glucocorticoids (a class of steroid hormones that are synthesized by the adrenal cortex and have anti-inflammatory activity) formulated to be used in the respiratory tract and lungs. Purpose Inhaled corticosteroids are glucocorticoid compounds designed to be applied directly to the tissues of the respiratory tract. There are two types. The intranasal are deposited into the nasal passages and may be used to treat nasal polyps, perennial allergic rhinitis, seasonal allergic rhinitis, and recurrent chronic sinusitis. The second type is used when the steroids are designed for deposition further into the respiratory tract. These are used for treatment of chronic asthma and prevention of asthmatic attacks. Because they have anti-inflammatory effects, corticosteroids are invaluable in treatment of asthma and other respiratory conditions which are associated with an allergic reaction. In many cases, the corticosteroids are life saving. But systemic corticosteroids affect all parts of the body and may cause very severe adverse effects, particularly with long-term use. These reactions include inhibitions of the adrenal glands and weakening of bones. By administering these drugs by inhalation, it is possible to target the areas that require treatment and reduce the amount of drug that reaches other parts of the body. Some patients may be able to do without systemic steroids entirely, while others can reduce their doses of systemic steroids and thereby reduce the risk and severity of unwanted effects. The drugs used as inhaled steroids are all anti-inflammatory corticosteroids and are very similar to each other in action and use. The way they are formulated, the size of the particles, the design of the inhaler, and whether the drugs are inhaled by the mouth or nose determine how far into the respiratory tract the steroids go. The formulations designed for nasal inhalation are only effective for nasal polyps or rhinitis because the steroid does not penetrate deeply into the respiratory tract. Oral inhalations, containing the same drug but in different particle size and inhaler design, deposit medication deeply into the lungs and are of value in treatment of asthma. Description As of 2005, there are five corticosteroids designed for inhalation:

beclomethasone dipropionate (Qvar) budesonide (Pulmicort) flunisolide (AeroBID) fluticasone propionate (Flovent) triamcinolone acetonide (Azmacort)

Although the different products vary in potency and duration of action, once dose size and frequency have been adjusted to offer comparable results, there do not appear to be significant differences between the drugs. The design of the inhalers, their ease of use, and the training each patient receives in the proper use of the inhaler may be of greater significance than the drug itself.

Recommended dosage Although the different products vary in milligram potency, for practical purposes, doses are measured in puffs on the inhaler. For example, beclomethasone will deliver 40 micrograms each time the inhaler is used, while triamcinolone delivers 100 micrograms with each inhalation. However, the effects are essentially equal. The appropriate dose of inhaled corticosteroids depends on the severity of the case, and in some instances, on what treatment has been used prior to starting inhaled steroid therapy. The doses listed are typical of the inhaled steroids used for asthma therapy but do not represent all possible cases:

beclomethasone: one to two puffs two times a day budesonide: one to two puffs two times a day flunisolide: two puffs two times a day fluticasone propionate: available in forms that deliver either 50 or 100 micrograms of fluticase in each puff; typical initial dose, 100 micrograms two times a day, representing either one puff of the 100 microgram product or two puffs of the 50 microgram product triamcinolone acetonide: two puffs three or four times a day or four puffs twice a day, not to exceed 16 puffs daily

Precautions Particular care is essential for patients who are transferred from systemic corticosteroids to inhaled steroids. Because the long-term use of oral steroids lowers the output of these compounds from the adrenal gland and normal production does not recur for several months, patients who have their oral doses reduced are at risk of adrenal insufficiency. This condition may become particularly serious in the event of trauma, surgery, or infections. While inhaled steroids may provide adequate control of asthma during these periods, the inhaled drugs do not replace the systemic compounds. In the event of stress or a severe asthma attack, oral therapy must immediately begin. Regular testing for cortisol levels is essential until the normal levels have been resumed. For patients who had been on systemic therapy and are being switched to corticosteroid inhalation, the immediate period during which the oral dose is reduced may cause symptoms, including joint or muscle pain, tiredness, and depression. Continuous monitoring is required until normal functions have been resumed. It is essential that patients learn proper use of inhalers. If inhalers are not used properly, the corticosteroids may not reach their intended site of action. Instead, they may be left in the mouth or swallowed and be deposited in the digestive tract. This situation may increase the risk of adverse effects, while reducing the protection from asthmatic attacks. Inhaled corticosteroids are not for treatment of acute asthmatic attacks or rapid relief of bronchospasm. Inhaled corticosteroids are designated as pregnancy category C. This designation means one of two levels of knowledge concerning the drugs adverse effects. In one instance, studies on animals show adverse fetal effects but there are no controlled studies on women. In the other instance, no studies on animals and women are not available.

Side effects It can be difficult to evaluate the side effects of inhaled corticosteroids because many of the reported adverse effects are closely associated with dose reduction or discontinuation of systemic steroids. Not all of the adverse reactions listed have been associated with all of the marketed inhaled steroids, but because of the similarities between these drugs, an adverse reaction reported with one must be considered possible for the others. The most common severe problem is white patches in the mouth due to localized infection. Additional common side effects are:

cough general aches and pains or general feeling of illness greenish-yellow mucus in nose headache hoarseness or other voice changes loss of appetite runny, sore, or stuffy nose unusual tiredness weakness

Very rare but severe adverse effects include the following:

blindness, blurred vision, eye pain large hives bone fractures diabetes mellitus (increased hunger, thirst, or urination) excess facial hair in women fullness or roundness of face, neck, and trunk growth reduction in children or adolescents heart problems high blood pressure hives and skin rash impotence in males lack of menstrual periods muscle wasting numbness and weakness of hands and feet weakness swelling of face, lips, or eyelids tightness in chest, troubled breathing, or wheezing

Interactions Because inhaled steroids do not reach therapeutic levels in the blood stream, there are no serious interactions. Ketoconazole (Nizoral), an antifungal agent, has been reported to increase blood levels of budesonide and fluticasone, but it is unclear whether this has any importance when the steroids are administered by inhalation.

Inhaled Corticosteroids for Long-Term Control of Asthma

Examples Generic Name Brand Name

beclomethasone QVAR budesonide ciclesonide flunisolide fluticasone mometasone triamcinolone Pulmicort Alvesco AeroBid Flovent Asmanex Twisthaler Azmacort

Combinations of an inhaled corticosteroid and a long-acting beta2-agonist:

Generic Name Brand Name

budesonide and formoterol Symbicort fluticasone and salmeterol Advair

mometasone and formoterol Dulera

These medicines are used in a metered-dose or dry powder inhaler. Inhalers may be used differently, depending on the medicine used. Always read the directions to be sure you or your child is using the inhaler correctly.
How It Works

All forms of corticosteroids reduce inflammation in the airways that carry air to the lungs (bronchial tubes) and decrease the mucus made by the bronchial tubes. This makes it easier to breathe. Inhaled corticosteroids treat inflammation in the airway, and only very small amounts of the medicine are absorbed into the body. So these medicines don't tend to cause the serious side effects, such as weakening of the bones, that corticosteroids can cause when taken in liquid, pill, or injection form (systemic corticosteroids).

Why It Is Used

Inhaled corticosteroids are the preferred treatment for long-term control of mild persistent, moderate persistent, or severe persistent asthma symptoms in children, teens, and adults. They help control narrowing and inflammation in the bronchial tubes. In general, they are part of daily asthma treatment and are used every day. Different types of medicines are often used together in the treatment of asthma. For example, inhaled corticosteroids are often used together with long-acting beta2-agonists for persistent asthma. Medicine treatment for asthma depends on a person?s age, his or her type of asthma, and how well the treatment is controlling asthma symptoms.

Children up to age 4 are usually treated a little differently from those 5 to 11 years old. The least amount of medicine that controls the asthma symptoms is used. The amount of medicine and number of medicines are increased in steps. So if asthma is not controlled at a low dose of one controller medicine, the dose may be increased. Or another medicine may be added. If the asthma has been under control for several months at a certain dose of medicine, the dose may be reduced. This can help find the least amount of medicine that will control the asthma. Quick-relief medicine is used to treat asthma attacks. But if you or your child needs to use quick-relief medicine a lot, the amount and number of controller medicines may be changed.

Your doctor will work with you to help find the number and dose of medicines that work best.
How Well It Works

According to the United States National Asthma Education and Prevention Program (NAEPP), inhaled corticosteroids are the preferred long-term treatment for asthma.1 If the inhaled corticosteroid does not control asthma symptoms well enough, other medicines, such as a long-lasting beta2-agonist or leukotriene pathway modifier, may be used. Inhaled corticosteroids are the most powerful and most effective medicine for long-term control of asthma in most people. When taken consistently, they improve lung function, improve symptoms, and reduce asthma attacks and admissions to the hospital for asthma.1
Side Effects

All medicines have side effects. But many people don't feel the side effects, or they are able to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side effects are also listed in the information that comes with your medicine. Here are some important things to think about:

Usually the benefits of the medicine are more important than any minor side effects. Side effects may go away after you take the medicine for a while. If side effects still bother you and you wonder if you should keep taking the medicine, call your doctor. He or she may be able to lower your dose or change your medicine. Do not suddenly quit taking your medicine unless your doctor tells you to.

Side effects of inhaled corticosteroids are uncommon at the usual dose. Side effects (many of which occur only with high doses) may include:

Sore mouth, sore throat, or hoarseness. Cough and spasms of the large airways (bronchi). Fungus infection in the mouth (thrush). Temporary delayed growth in children. Decreased bone thickness in adults. Clouding of the lens of the eye (cataract). High blood pressure in the eye or fluid buildup in the eye (glaucoma). This occurs with high doses of inhaled corticosteroids used over a long period of time.