Let's Talk Corticosteroids: History, Side Effects, and Benefits

A top-line treatment for asthma is inhaled corticosteroids (ICS). A second-line treatment for asthma is systemic corticosteroids. How are they used for asthma? Do you need to be concerned about side effects? Here's all you need to know. 

A little history

In 1949, reports surfaced of the benefits of systemic steroids (they were usually given orally or by intramuscular injection) for rheumatoid arthritis, and this spawned excitement in the medical community. Researchers tried the medicine for a variety of diseases, including asthma. Beginning in 1951, studies started showing the benefits of steroids for asthma. So, when the first corticosteroids were introduced to the market by the mid to late 1950s, asthma doctors began to liberally prescribe them for their asthmatic patients. This medicine was initially hailed as a miracle drug, not just for asthma, but for rheumatoid arthritis and so many other chronic diseases. 

A big problem

However, within a few short years the harsh side effects of steroids were recognized. Long-term use, especially of high doses, resulted in fluid retention, moon face, thin skin, easy bruising, acne, hypertension, diabetes, stunted growth, osteoporosis, weight gain, obesity, glaucoma, and even death (usually from rapid withdrawal from high doses). Once these side effects became apparent, physicians were quick to cease prescribing them except for in cases of severe asthma attacks.

Introducing inhaled corticosteroids

Thankfully, researchers didn’t give up in their quest to find the ideal asthma medicine. During the 1960s, they decided to perform studies on inhaled corticosteroids, which are sometimes referred to as glucocorticosteroids or sometimes just steroids. They soon realized that direct application to the airways allowed them to use a significantly lower doses. Low dose ICS were soon recognized to improve asthma control with negligible side effects.

Corticosteroid inhalers hit the market

The first ICS were approved for sale during the early 1980s. They were prescribed for many asthmatics, although some physicians, especially pediatricians, were reluctant (or hesitant) to prescribe them except during acute asthma episodes. Once you felt better you were told to stop using them. This was probably a precautionary strategy based on the 1950s scare.

Inhaled corticosteroids found to be safe and effective

However, by the late 1980s, research clearly showed that daily ICS use greatly improved asthma control for many asthmatics, and side effects were confirmed as negligible. Inhaled corticosteroids became a top-line treatment for helping asthmatics obtain better asthma control, even among the pediatric population.

How do inhaled corticosteroids work?

Over time, researchers realized that  low doses of inhaled steroids suppress asthma genes responsible for the abnormal immune response that causes airway inflammation. 1 They learned all (or most) asthmatics have some degree of underlying airway eosinophilic inflammation. Exposure to asthma triggers makes this inflammation worse, causing asthma symptoms. By suppressing the immune response, inhaled corticosteroids make airways less responsive to asthma triggers. 

Do they affect other medicines?

Studies show that corticosteroids also increase the number of beta 2 (B2) receptors lining airways, making beta agonist medicines like albuterol (Ventolin) work better. 1  The combination of this and anti-inflammatory effects work to prevent asthma attacks, or make them less severe and easier to control when they do occur. By the late 1980s, researchers understood that daily use of inhaled corticosteroids helped many asthmatics obtain ideal asthma control. This gave birth to the term asthma controller medicine. ICS remain the most commonly prescribed asthma controller medicine. 

Systemic side effects

While most of the medicine inhaled acts locally on the airways, a small amount (10-40%) comes into contact with blood vessels in your lungs and can get into your circulatory system. A small amount of medicine impacts into your oral cavity and may be swallowed. In either case, it is broken down by the liver and may potentially cause some systemic side effects. Such side effects are generally considered negligible, and may include bruising, stunted growth (children), osteoporosis (adults), cataracts, and sometimes pneumonia.1-3 The most common side effects are from the medicine impacting in your oral cavity, and include thrush and dysphonia (hoarse voice).

Can side effects be prevented? 

Studies show that using a spacer with a metered dose inhaler (such as Flovent or Qvar) prevents large particles from impacting your upper airway, thereby preventing side effects. When a spacer is not available (such as when the Advair Diskuss is used) rinsing, followed by gargling and spitting, significantly reduces the risks for side effects. 1,3 The best strategy might be to rinse, swish, gargle, and spit after each treatment with any asthma inhaler in order to reduce the risk of side systemic side effects.

Why do ICS sometimes not work?

Some asthmatics (about 10-15%) present with a different type of airway inflammation, which sometimes may be neutrophilic inflammation. The same is true for most COPD patients. This type of inflammation responds poorly to ICS therapy, often requiring the highest doses. Some don't respond to ICS at all, requiring researchers and physicians to search for alternative asthma treatments to help these asthmatics obtain ideal asthma control. Such rare cases may result in a diagnosis of severe asthma.

How are systemic corticosteroids used today? 

Short-term boosts of systemic corticosteroids are sometimes needed to help asthmatics obtain good asthma control. You are usually given a bolus on day one, and then you are gradually weaned off the medicine over the course of several days to prevent serious side effects. Low doses are sometimes prescribed long-term for severe asthmatics. The most common side effects are increased appetite and weight gain. Other side effects include fluid retention, moon face, diabetes, osteoporosis, and hypertension.

What can we conclude here?

Low dose systemic steroids are always available when needed for controlling asthma when it gets out of control. The risks for side effects are always there, although these are minimized by low doses and short durations. Inhaled corticosteroids remain a standard medicinal option for treating asthma every day. The side effects are generally considered negligible, and the benefits often include improved asthma control and an opportunity to live a normal life with asthma.

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