Breath of Fresh Air: Feature Articles

Inhaled steroids are a mainstay of therapy in the treatment of asthma among adults. Yet talk of having to take "steroids" makes many people very apprehensive, because of concern about medication side effects. Inhaled steroids are important for prevention of asthmatic attacks, but are they safe? Two recent medical reports have put these questions in the forefront of our thinking about asthma. One report described a 50% reduction in the risk of hospitalization for asthma among patients prescribed inhaled steroids compared to others who were not taking inhaled steroids. The other report described a 40% increase in the risk of developing glaucoma among some persons taking inhaled steroids. Are these medications friend or foe? Where does the truth lie?

For many persons "steroids" conjure up the image of weight gain, puffy face, mood swings, and thinning bones. These are potential side effects of steroids taken in tablet form, especially when taken for many weeks to months. Steroids in tablet form act by being absorbed from the stomach, entering the bloodstream, and traveling to all parts of the body, including the bronchial tubes of the lungs. At the same time the blood carries them to the eyes, muscles, bones, skin, appetite center -- to all parts of the body, where they can exert their undesirable effects.

Steroids for asthma: friend or foe?

One can avoid most of these potentially harmful side effects by inhaling the steroid medication directly onto the breathing tubes. In this way the inhaled steroids are delivered directly to where they are needed, the inflamed bronchial tubes, and not to the remainder of the body. In the same way that one applies steroid creams to skin rashes without fear of side effects elsewhere in the body, so too one can apply steroid medication from inhalers to the surface of bronchial tubes without fear of generalized adverse side effects -- for the most part.

Depending on how much of the inhaled steroid medication one takes -- that is, depending on the strength of the medication and the number of puffs inhaled each day -- some of it can be absorbed from the mouth and bronchial tubes and pass into the bloodstream. In general, at the usual doses (8-12 puffs or 400-800 micrograms/day), the amount of steroid passing into the bloodstream is trivial, especially if one uses a spacer tube and rinses one's mouth after each use. At standard doses one does not develop any side effects in the eyes, bones, muscles, and elsewhere. Consistent with this understanding, in a recent medical report of some 50,000 persons treated by opthalmologists in Quebec, Canada, high pressure within the eye and its consequences (glaucoma) were overall no more common among persons taking inhaled steroids than among persons not using these medications.

Steroids from inhalers go only to the surface of the bronchial tubes – for the most part.

However, these same doctors found that persons with asthma over the age of 65 years who were taking large doses of inhaled steoids for at least 3 months had a 40% increased chance of developing high eye pressure or glaucoma. Among persons taking large doses of these inhaled steroids, a small amount of the medication can enter the bloodstream and be transported to the eyes. Among persons sensitive to their effects, fluid can build up within the eyes and cause injury to the nerves from the elevated pressure exerted on them.

Persons using large doses of inhaled steroids have a 40% increased chance of developing high pressure in the eyes or glaucoma.

What is considered a large dose of inhaled steroids? The authors of this report used the following criteria to define large doses: for beclomethasone (Vanceril®, Beclovent®), 32 puffs/day or more; for triamcinolone (Azmacort®), 16 puffs/day; for budesonide (Pulmicort®), 8 puffs/day, and for flunisolide (Aerobid®), 6 or more puffs/day. The newer inhaled steroid, fluticasone (Flovent®), was not available at the time of this study, and so what constitutes large doses of inhaled fluticasone was not considered.

Based on this report, it seems reasonable to recommend that persons over the age of 65 who are taking large doses of inhaled steroids see an ophthalmologist for measurement of their eye pressure. This is a painless procedure that takes no more than 5 minutes. It is probably a good idea for all persons over the age of 65 years to be checked for glaucoma; now there is an especially good reason for older persons on high-dose inhaled steroids.

Before you are tempted to give up your inhaled steroid medicine for fear of complications in your eyes or elsewhere, remember that for persons taking any less than the large doses of inhaled, there is no evidence that the inhaled steroids are harmful to the eyes. And remember that your chance of having an attack of asthma severe enough to require hospitalization is reduced in half by your use of inhaled steroids. Used wisely, and in the lowest doses that are effective, these medicines are still the best long-term treatment for the majority of persons with persistent asthma.