In the Journals

Inhaled corticosteroids safe, effective, but systemic complication concerns remain

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.

“[A]lthough 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.” – by Jeff Craven

Disclosure: The researchers report no relevant financial disclosures.

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.

“[A]lthough 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.” – by Jeff Craven

Disclosure: The researchers report no relevant financial disclosures.