FCAAIA Notes: Inhaled corticosteroids (ICS) are the treatment of choice for persistent asthma as defined in every guideline or practice parameter EVER published (the first was published nearly 25 years ago).  Over the years, numerous studies reported potential of side effects from this important class of mediation.  But, none has actually shown the side effects to really be clinically relevant.  Of course, since statistics cannot prove a negative thing, only studies with positive results get any attention.

As is pointed out in this study, the risks of poorly controlled asthma far out-weigh any potential risk of the medications used to treat it. Our guidelines and experience tell us other things not to be ignored.  Asthma should be treated with the least amount of medication necessary to control it.  Stepping down mediation doses gradually as tolerated is a basic tenet of asthma care. That is why, follow-up visits are necessary even if you are feeling well. In addition, the use of a holding chamber or gargling, swishing, and spitting after using your ICS will decrease the amount that can get absorbed from the inside of your mouth, further decr4easing the negligible systemic risk of these medications.

Allergy shots and in some patients adding montelukast can decrease the ICS requirement.

(Source:  January 26, 2016. Adapted from Kapadia CR, et al. JAMA Pediatr. 2015;doi:10.1001/jamapediatrics.2015.3526.)

Researchers who reviewed the evidence behind guidelines for administering inhaled corticosteroids to children observed that, although generally safe and effective, there may be adverse effects to consider

“Inhaled corticosteroids are generally safe, effective drugs, but adverse endocrine effects may occur,” Chirag R. Kapadia, MD, of the Phoenix Children’s Hospital in Arizona, and colleagues wrote. “Although adverse effects and the thresholds defined as high dose by asthma guidelines do not precisely correlate, for the sake of clinical practice, high dose for any particular compound is similar to that defined by the National Asthma Education and Prevention Program.”

Kapadia and colleagues weighed the strength of guidelines presented by the Pediatric Endocrine Society Drugs and Therapeutics Committee by grading the evidence associated with the recommendations. The researchers agreed that inhaled corticosteroids were effective as first-line treatment drugs, but raised concerns about the systemic complications the drugs would have on children.

“Although efforts to reduce oral deposition have resulted in fewer local adverse effects, the effort to reduce systemic adverse effects may ultimately need to focus on increasing protein binding, more rapid clearance, and decreasing lipophilicity,” Kapadia and colleagues wrote.

Researchers also raised a concern about the risk for adrenal insufficiency in patients taking high doses of inhaled corticosteroids, particularly in patients with diabetes mellitus (types 1 and 2).

“We agree with the step-up and step-down approach put forth in these guidelines, meaning that patients with poor asthma control need an increase in dosing, followed by reductions in dosing when adequate asthma control is achieved,” Kapadia and colleagues wrote. “We do not recommend decreasing the [inhaled corticosteroid] dose if it is deemed necessary to prevent pulmonary exacerbations and recurrent treatment with oral corticosteroids.

“Our recommendations include greater vigilance in testing adrenal function than current standard practice,” Kapadia and colleagues wrote. “In patients with diabetes mellitus (types 1 and 2), an increase in glucose levels is likely, and diabetes medication adjustment may be needed when initiating or increasing [inhaled corticosteroids].”

The researchers also recommended monitoring bone mineral density and linear growth in high risk patients, which also include testing bone mineral density in patients with diabetes mellitus.

“Data on linear growth and bone mineral density (BMD) are generally reassuring, but height attainment should be carefully monitored, and testing for BMD should be considered in high-risk patients,” Kapadia and colleagues wrote. “Deteriorating blood glucose level control in patients with preexisting diabetes mellitus (types 1 and 2) is common with [inhaled corticosteroids], and [diabetes mellitus] medication dose adjustments are likely required at the initiation of [inhaled corticosteroid] treatment and with [inhaled corticosteroid] dose increases.”

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