Minimizing risks of corticosteroids for asthma

The risks for growth suppression and adrenal insufficiency with the use of inhaled corticosteroids for asthma in children are relatively small and can be minimized with proper administration, according to Mitchell E. Geffner, MD, speaking at a session titled “Inhaled and systemic corticosteroid therapy: effects on growth and adrenal suppression,” held Saturday, October 11.

Geffner, professor of pediatrics at the Saban Research Institute, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, said that inhaled corticosteroids are widely used as effective first-line treatments for asthma, allergic rhinitis, and other chronic respiratory illnesses. Although inhaled corticosteroids have a more favorable safety profile than oral corticosteroids, widespread concern about systemic complications persists.

Systemic absorption of corticosteroids results from the proportion of drug deposited in the mouth and thus swallowed, and perhaps more significantly from the amount deposited in the lungs, he explained. In children, long-term use of oral corticosteroids can lead to compromised linear growth and bone mineralization, diabetes mellitus, Cushing syndrome, obesity, and suppression of the hypothalamic-pituitary-adrenal axis. Inhalation of corticosteroids can cause the same issues, but less frequently and in a less severe form.

Patient characteristics, including age and pubertal status, dose and duration of therapy, delivery method, pharmacokinetic and pharmacodynamic properties of the drug, and use of concomitant drugs, such as intranasal or transdermal corticosteroids, all affect the likelihood of adverse effects. Continuous high-dose treatment, use of excessive doses, and even particularly good patient compliance increase the risk. 

Studies of the effects of inhaled corticosteroids on height in children suggest that use of clinically equivalent doses of agents with more efficient first-pass hepatic inactivation can reduce the risk of growth suppression. Titration to the lowest effective dose will also minimize the already low risk.

Adrenal insufficiency attributed to use of inhaled corticosteroids is rare and appears to be related to use of greater-than-recommended doses, lack of follow-up, and lack of a subspecialty consultation, Geffner said.

Growth monitoring in children is a sensitive means of assessing significant systemic effects of inhaled corticosteroids and can enhance a family’s confidence in the safety of the treatment, he continued. When long-term, high-dose therapy is required, periodic evaluations of adrenal function and possibly bone density may be advisable. -Karen Rosenberg