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1.1 HISTORY Glucocorticosteroids have been used to treat a variety of airway diseases since an initial study in 1950 of Carryer et al1 who reported the benefits of oral cortisone on ragweed pollen-induced hay fever and asthma. This was followed by a report by Gelfand, demonstrating clin-ical benefit from inhaled cortisone in a small group of patients with both allergic or nonallergic asthma. Subsequently, a multicenter trial run by the Medical Research Council in the United Kingdom in 1956 demonstrated improvement in acute severe asthma in a placebo-controlled trial, and reports at that time described benefit in chronic asthma. This demonstrated the unequivocal benefit of corticosteroids in asthma. Subsequently, both oral and inhaled corticosteroids have evolved into the most important and useful drugs currently available to treat asthma (Level IA). The initial studies evaluating the efficacy of inhaled corticosteroids in asthma were per-formed on patients with moderate to severe disease. At the time of their introduction to clin-ical practice in the early 1970s, and for many years after this, their use was mainly limited to patients who had persisting symptoms despite aggressive oral or inhaled bronchodilator use. The increased appreciation, in the mid-1980s, of the central role of airway inflammation in the pathogenesis of all asthma (Level I),provided a rationale for the earlier introduction of inhaled corticosteroids, particularly as the ability of inhaled corticosteroids to reduce airway inflammation (Level I) and improve some of the airway structural abnormalities associated with asthma was being identified (Level I). This has led to a reappraisal of how best to use inhaled corticosteroids in the management of asthma.
Chapter II
Inhaled corticosteroids (ICS), also known as inhaled steroids, are the most potent anti-inflammatory controller medications available for the treatment of your asthma today, and are the current mainstay of treatment once you need more than a rescue inhalerfor your asthma. Inhaled corticosteroids improve asthma control more effectively than any other agent used as a single treatment. Inhaled corticosteroids help prevent chronic asthma symptoms such as:
2.1 Inhaled Corticosteroids: What are they and how do they work?
Inhaled corticosteroids prevent asthma symptoms by doing the following in your lungs:
Blocking the late-phase immune reaction to anallergen Reducing airway hyperresponsiveness Decreasing inflammation and inhibiting inflammatory cells such as mast cells, eosinophils, and basophils
Inhaled corticosteroids, sometimes referred to as inhaled steroids, are the best medication to manage asthma. They are used in all but the mildest cases of asthma. Inhaled corticosteroids are strong anti-swelling medications. People with asthma
have swelling in the airways of their lungs, causing the airways to become more sensitive to asthma triggers such as allergens, dry air, smoke and viruses. Inhaled steroids reduce swelling, which improves symptoms, lung function and airway hyper-reactivity (twitchiness). A recent Canadian study (1) has shown that regular use of inhaled corticosteroids lowers the risk of death from asthma.
You use rescue -agonist treatments, such as Albuterol, more than 2 days per week.
You have asthma symptoms more than twice weekly. You meet certain criteria on spirometry. Your asthma interferes with your daily activities. You have needed oral steroids 2 or more times in the last year.
quality of life asthma attack frequency asthma symptoms asthma control hyperresponsiveness of your airways (decreased)
corticosteroids do not stunt a childs growth and are not related to any other major side effects. Inhaled corticosteroids side effects can be broken down into two types:
Local adverse effects (in only one area of the body) Systemic effects (throughout the body)
Oral Candidiasis or Thrush: Thrush is one of the most common side effects of ICS; up to a third of patients developing this side effect. Lowering the dosage, using a spacer, and appropriately rinsing your mouth following inhalation all help lower your risk of thrush. Thrush also can be treated with topical or oral antifungals, such as nystatin.
Dysphonia: Inhaled steroids can affect your voice, known as dysphonia. It may be prevented by using a spacer, and treated by decreasing the ICS dose temporarily and giving your vocal chords a rest.
Reflex Cough and Bronchospasm: These side effects can be prevented by using a spacer and inhaling in more slowly. If needed, pretreatment with a rescue inhaler can prevent these symptoms.
b.Systemic Inhaled Corticosteroids Side Effects While uncommon, a number of systemic effects can occur with inhaled corticosteroids. Generally, there is a higher risk with increasing doses of inhaled corticosteroids. Potential side effects include:
Poor Growth: While poor growth can result from ICS, poorly controlled asthma can also lead to poor growth in children. In general, low and medium doses of ICS are potentially associated with small, non-progressive but reversible declines in growth of children. As a result, you and your asthma provider should not only carefully monitor growth, but try to use the lowest possible dose that gets good control of your child's asthma. You must weigh the potential benefits of good asthma control with the small but real possible side effect of slowed growth.
Bone Density: Low doses of ICS do not appear to effect bone density, but there are more effects as doses are increased. If you have risk factors for osteoporosis or already have a low bone density, you may want to consider taking calcium and vitamin D supplements or a bone protecting treatment like a bisphophonate.
Disseminated Varicella: This is when the chickenpox virus spreads throughout your body. While there is a theoretical risk, no cases of disseminated varicella have been reported with ICS. Kids who do not have the chicken pox during their first year of life should receive the varicella vaccine.
Easy Bruising: Bruising and thinning of the skin occur in patients using ICS. The effect is dose dependent so decreasing the dose may be helpful.
Cataracts and Glaucoma: Low and medium doses of ICS have not been associated with cataracts in kids, but a cumulative, lifetime effect associated with increased risk of cataract has been noted in adults. Only patients with a family history of glaucoma (elevated eye pressure) appear to have an increased risk of glaucoma with ICS use. As a result, patients on ICS should have periodic eye exams, especially if you are taking high doses or you have a family history of elevated eye pressure.
Adrenal Gland Suppression: This potential side effect is extremely rare, but can occur in some people and usually at higher ICS doses.
Elevated Blood Sugar: ICS rarely cause elevation in blood sugar, and, if this side effect dose occur, it is almost always at higher doses of ICS.
Conclusion
Asthma is a chronic condition involving persistent inflammation of the bronchial tubes. Of the medicines available to treat this inflammation, steroids by inhalation are the most effective without causing the major side effects seen with long-term use of steroids in tablet form. Because the inflammation of the bronchial tubes persists even at times when ones asthma is quiet, it is important to continue to use your inhaled steroids even when feeling well. Your doctor may advise you as to when it is appropriate to stop your inhaled steroids; but for many persons with asthma, the asthmatic condition is lifelong and inhaled steroids should beand can safely becontinued indefinitely. Corticosteroids, when taken properly, are a very good way to treat asthma. They are safe and should be considered the first choice in asthma management for most cases of asthma
REFERENCE
1. National Heart, Lung, and Blood Institute. Accessed: August 16, 2009. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma 2. Apgar, Barbara. Tips Dari Jurnal lain: Efek samping dari Inhalasi kortikosteroid Terapi Amerika Dokter Keluarga (review).. (1999) 60 (5). 13 Januari 2008 <http://www.aafp.org/afp/991001ap/tips/6.html> 3. Barnes, NC "Karakteristik Inhalasi Kortikosteroid:. Persamaan dan Perbedaan" Primary Care Respiratory Journal (2007) 16 (3) :149154 <http://www.thepcrj.org/journ/view_article.php?article_id=476 >
4. Suissa S, Ernst P. Benayoun S. Baltzan M. Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med 2000:343:332-6. 5. Agertot L. Pedersen S. Effect of long-term treatment with inhaled budesonide on adult height in children with asthma. N Engl J Med 2000; 343:1064-9 6. The Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000:343;1054-63.
Question: Is Preventing Inhaled Corticosteroids Side Effects Possible? Answer: While most people will not develop side effects from inhaled corticosteroids, there is still risk. There are a number of things that can assist you in preventing inhaled corticosteroid side effects: Using a spacer or valved holding chamber -- devices that help deliver the
medication -- can decrease your risk of local side effects like oral candidiasis (fungal infection),dysphonia (voice change due to the inhaled steroid), or bronchospasm (acute asthma symptoms brought on by inhalation). Rinsing and spitting after each inhalation. If your asthma symptoms are poorly controlled after low-dose inhaled
steroids, talk to your doctor about adding a long-acting beta agonist instead of increasing the dose of your inhaled steroid. Lower doses of medication mean less chance of developing side effects. If it is your child who is on an inhaled steroid, make sure to regularly see
your pediatric healthcare provider to ensure that proper growth is being maintained. Both male and female adult patients should consider 1000 to 15000
milligrams of calcium and 400 to 800 units of vitamin D supplementation per day. If you are at high risk forosteoporosis or already have osteopenia, you and your healthcare provider may want to consider sparing treatments like bisphophonates. While the risks are low, these tips will help in preventing inhaled corticosteroids side effects.