Inhaled corticosteroids: Uses, common brands, and safety info

Asthma is a chronic disease of the lungs that affects the airways. The airways carry air in and out of the lungs. In people with asthma, the airways can become narrow and inflamed, causing symptoms like wheezing, cough, and chest tightness. Asthma can affect people of any age but often starts in childhood or adolescence. Symptoms can range in intensity and frequency. Asthma is very common. According to the latest data from the Centers for Disease Control and Prevention (CDC), in 2019, over 25 million people in the United States reported having asthma. 

Your healthcare professional will create an asthma treatment plan. The plan will help prevent asthma attacks and manage symptoms and usually includes a combination of trigger avoidance, quick-relief medications (often called “rescue inhalers”), and control medications. Control medications are taken daily to help prevent asthma symptoms. Inhaled corticosteroids are commonly used to prevent asthma symptoms. This article will review inhaled corticosteroids—names, uses, side effects, warnings, and other important information.  

Because combination drugs have several ingredients and thus different side effects and warnings, this article will focus on single-ingredient inhaled corticosteroids listed in the above chart entitled “List of inhaled corticosteroids.” 

What are inhaled corticosteroids?

Inhaled corticosteroids (ICS) are used as first-line treatment of asthma in preventing asthma exacerbation and helping asthma control. ICS are not used to stop an asthma attack (exacerbation). People with persistent asthma have:

• Symptoms > 2 days a week

• >3 nighttime awakenings per month

• >2 times a week rescue inhaler usage, or

• Any limitation of activity because of asthma.

Regular use of an ICS helps improve airflow and lung function by reducing the frequency of asthma symptoms, risk of severe exacerbation, and bronchial hyperresponsiveness. It also improves the quality of life in asthma patients. 

Inhaled corticosteroids are commonly used in conjunction with other asthma medications, such as long-acting beta-agonists. Short-acting beta-agonists (quick-acting bronchodilators) are used as a rescue medication when needed. ICS are also prescribed off-label for chronic obstructive pulmonary disease (COPD), helping to reduce exacerbations. In COPD patients, ICS are commonly used along with long-acting beta-agonists. However, ICS are not as effective in COPD as they are in asthma. 

How do inhaled corticosteroids work?

Asthma is a long-term condition where the airways can become narrowed and inflamed, causing symptoms such as wheezing, cough, and chest tightness. Inhaled corticosteroids work on cells that cause inflammation, such as mast cells and histamine. ICS have an anti-inflammatory effect, reducing inflammation and mucus, and helping control asthma symptoms. ICS do not work for an acute asthma attack. An inhaled corticosteroid must be taken every day, and may take several weeks or longer to start controlling symptoms. ICS are often taken in combination with other medications to control asthma, such as a rescue inhaler when needed, and other medications to help open up the airways.

What are inhaled corticosteroids used for?

Inhaled corticosteroids may be used for:

• Prevention of asthma exacerbations in people with persistent asthma 

• Off-label management of chronic obstructive pulmonary disease (COPD)

ICS are NOT indicated to relieve an acute exacerbation of asthma. 

Depending on the condition, inhaled corticosteroids are often used along with other medications to manage symptoms. These medications may include short-acting beta-agonists (such as albuterol), long-acting beta-agonists (such as salmeterol), and/or oral medication (such as Singulair). Note: a long-acting beta-agonist (LABA) should never be used alone and must always be prescribed in combination with an ICS. 

Types of inhaled corticosteroids 

Inhaled corticosteroids are available as metered-dose inhalers, dry powder inhalers, or nebulizer solutions. Inhalation of steroids allows the medication to go directly to the lungs, causing fewer adverse effects than steroids that are taken orally or by injection.

Metered-dose inhalers (MDI)

With a metered-dose aerosol inhaler, asthmatic patients inhale medication through one or more puffs. MDIs are portable and contain a dose counter, so the patient knows how many doses remain. Some examples of MDIs include Flovent HFA and Asmanex HFA. 

Dry powder inhalers

With a dry powder inhaler, when the medication is used, the inhaler releases the dry powder for inhalation. Like MDIs, dry powder inhalers are also portable and have a dose counter. Some examples of dry powder inhalers include Flovent Diskus and Asmanex Twisthaler. Patients with a severe milk protein allergy should not use dry powder inhalers that contain lactose, because they could have a severe allergic reaction. 

Nebulizer solution

With nebulizer solution, the inhaled corticosteroid is packaged into individual vials, or ampules. Each dose is placed into a nebulizer as directed. The patient wears a mask and a fine mist delivers the ICS over about 15 minutes. An example of an ICS nebulizer solution is Pulmicort respules.

Who can take inhaled corticosteroids?

The following information is general in nature. Because everyone has a unique medical history, talk to your healthcare professional before beginning inhaled corticosteroid therapy. Only your doctor can determine if a medication is safe and appropriate for you. Tell your doctor about all of your symptoms, medical conditions, and medical history. Also, tell your doctor about all of the medications you take, including prescription drugs, over-the-counter medicines, and vitamins or supplements. 

Men 

Men can take inhaled corticosteroids, provided that they qualify based on medical conditions and do not fall into one of the restricted categories listed below. 

Women 

Women who are not pregnant or breastfeeding can take inhaled corticosteroids, provided that they qualify based on medical conditions and do not fall into one of the restricted categories listed below 

Women who are pregnant, trying to become pregnant, or breastfeeding should consult their healthcare provider before using an ICS. There is not enough data in pregnant women to determine risk, and animal studies showed harm to the unborn baby. However, poor management of asthma during pregnancy can cause problems as well. The prescribing information recommends that pregnant women who take an ICS should be closely monitored. Breastfeeding women should consult their healthcare provider for medical advice. 

Children 

Inhaled corticosteroids can be used in children, however, with some caveats. Different ICS are approved in different age groups. For example, the Flovent Diskus is approved for children ages 4 years and older, while Asmanex HFA is approved for children 5 years and older, so the child’s age is a factor. Also, because ICS can affect a child’s growth, a low dose should be used if possible, for the shortest duration, and growth should be monitored. Check with your health care provider regarding age and growth issues before using an ICS. 

Seniors

Older adults can take inhaled corticosteroids, provided that they qualify based on medical conditions and do not fall into one of the restricted categories listed below. The prescribing information states that there may be some sensitivity in older adults, so if you are 65 years or older, check with your doctor before using an ICS.

Are inhaled corticosteroids safe?

Recalls

No recalls currently. You can check for recalls on the FDA website. 

Restrictions and warnings

Certain people should not take inhaled corticosteroids. ICS are contraindicated (should not be used in) people who are/have:

• An allergy to the drug or any ICS or part of the drug

• Severe hypersensitivity to milk proteins (in dry powder inhalers)

• Status asthmaticus/severe asthma

• Acute bronchospasm 

Inhaled corticosteroids should be used with caution in people who are/have:

• Children or adolescents

• Recent long-term steroid treatment

• Immunosuppression

• Active infection

• Tuberculosis infection

• Exposure to measles or varicella

• Osteoporosis or increased risk of osteoporosis

• Cataracts 

• Glaucoma or increased risk of glaucoma

• Ocular herpes simplex virus

An ICS should not be stopped abruptly.  When it is time to stop taking an ICS, consult your healthcare professional for a tapering schedule.

Other patient information

• ICS can cause local infections with Candida albicans (a fungus) in the mouth and throat, called oral thrush. After using an Inhaled corticosteroid, rinse your mouth with water and spit (do not swallow) to help lower the risk of oral thrush. If symptoms occur, consult your healthcare professional.

• ICS medications are not to be used as a rescue medicine for acute exacerbations of asthma. Acute asthma symptoms should be treated with your rescue inhaler, such as albuterol. Contact your doctor if your asthma worsens. 

• Avoid exposure to chickenpox or measles. If you are exposed, consult your doctor. Steroids may cause immunosuppression and worsen infections. If you are taking an ICS and you have any type of infection, notify your doctor. 

• In rare cases, inhaled corticosteroids may cause adrenal suppression. Deaths due to adrenal insufficiency have occurred during and after transfer from systemic corticosteroids. When switching from a systemic steroid to an ICS, your healthcare professional will have you taper the medication slowly. 

• Immediate hypersensitivity reactions, which can be severe, may occur. If you have symptoms of rash, hives, low blood pressure, wheezing, or swelling of the lips, face, tongue, or throat, get emergency medical help right away. Patients with a severe milk protein allergy should not take ICS that contain lactose. Ask your pharmacist if you are unsure if your ICS contains lactose. 

• Some inhaled medications, including ICS, can cause paradoxical bronchospasm. This is when you have an immediate increase in wheezing after using the medicine. If this occurs, treat with your rescue inhaler, stop using your ICS, and tell your doctor right away. Seek emergency medical help if needed.

• Talk to your doctor about your risk of osteoporosis, as inhaled corticosteroids may cause systemic effects, increasing the risk of fractures and decreased bone mineral density.

• ICS may affect growth in children. Children and teenagers who use an ICS should be closely monitored for growth with follow-up appointments. 

• Because long-term inhaled corticosteroid use may increase the risk of eye problems

  such as cataracts and glaucoma, ask your doctor about regular eye exams.

• Inhaled corticosteroids should be used daily as directed. It may take a few weeks or longer to see the full benefit of the medicine. Do not change the dosage of your ICS without talking to your doctor. An ICS should not be stopped abruptly—your doctor can provide you with a tapering schedule. If you must stop taking your ICS suddenly, for example, due to a severe allergic reaction, notify your doctor right away. 

• As inhalers work differently, follow instructions on usage and cleaning of your ICS.

Are inhaled corticosteroids controlled substances?

No, inhaled corticosteroids are not controlled substances.

Common inhaled corticosteroids side effects

As with any medication, inhaled corticosteroids can have side effects. Side effects may vary based on each drug. The most common side effects of medications in the ICS class include:

• Throat irritation

• Hoarseness or abnormal voice

• Altered taste

• Fungal infection of the mouth

• Dry mouth

• Upper respiratory infection symptoms/nasal congestion/cough/sore throat

• Headache 

• Nausea and vomiting

• Muscle, joint, back, or neck pain

• Weakness 

• Rash

• Bruising  

Serious side effects may include: 

• Serious allergic reaction

• Bronchospasm

• High blood sugar

• A high number of eosinophils

• Long-term use: adrenal suppression, immunosuppression, glaucoma, cataracts, osteoporosis

• Long-term use in children: growth suppression

This is not a full list of side effects. Other side effects may occur. Consult your healthcare provider for a full list of side effects. Before using an ICS, talk to your doctor about what side effects to expect and how to address them. While taking inhaled corticosteroids, report side effects to your doctor. If rare but serious side effects occur, seek medical help or emergency care if necessary.

How much do inhaled corticosteroids cost?

Inhaled corticosteroids vary in cost. Generally, choosing a generic, when available, will save a considerable amount of money. However, the only ICS currently available in generic form is Pulmicort respules (budesonide) for the nebulizer. Most insurance plans and Medicare prescription plans cover inhaled corticosteroids, however, the amount you owe will vary by your specific plan. Contact your insurance provider for up-to-date coverage information. You can always use a free SingleCare card on your ICS prescription and refills. You can save up to 80% on prescription drug costs. Ask your pharmacist to compare prices to start saving today.