Asthma: medicines safety priorities | Guidance and guidelines | NICE
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Inhaled corticosteroids ICSs are indicated in the management of asthma and chronic obstructive pulmonary disease COPD , which affects the alveoli and pulmonary blood vessels. Inhaled corticosteroids ICSs are indicated in the management of most patients with asthma and some patients with chronic obstructive pulmonary disease COPD  , .
However, dose equivalents are approximate, and the dose delivered will depend on other factors such as inhaler technique. Patients with asthma who do not use an ICS regularly have poorer outcomes. A national review of asthma deaths in the UK in found that patients with asthma who did not use an ICS were at significantly greater risk of death . The reason for this difference in efficacy may be related to the mechanism of action of ICS.
In asthma, inflammation is primarily caused by eosinophils, while in stable COPD neutrophils are predominant . Corticosteroids are more effective in reducing eosinophilic inflammation, which may explain this difference in clinical response. An ICS-specific card for patients, alongside guidance on counselling points for health professionals, has been developed by the London Respiratory Network and is available to download at www.
Patients who are using high-dose ICS should be advised to inform the healthcare team responsible for their treatment if they fall ill for any reason, as this may affect the dose required. All patients taking ICS who have never had chickenpox should be advised to avoid people with chickenpox or shingles, and to see a doctor if they come in contact with someone with either illness and then feel unwell.
Inhaled corticosteroids do not usually interact with other medicines. Patients who smoke may require higher doses of ICS compared with non-smokers for the same therapeutic effect . It is therefore important that all smokers using an ICS should be offered help to stop smoking, as this may reduce the dose required by the patient and minimise the risk of side effects. Treatment with high-dose ICS can result in clinically significant suppression of endogenous cortisol.
The analysis suggested 1,mcg of inhaled fluticasone propionate was approximately equivalent to 10mg oral prednisolone and at this dose, half of the patients were sufficiently suppressed to be unable to mount the necessary adrenal response to stress. This could be interpreted as being equivalent to 1,mcg of beclomethasone dipropionate, but caution is advised as direct comparator studies have not been published. Local ICS side effects can be distressing and may affect adherence to treatment.
They include a sore throat, hoarse voice and opportunistic oral candidiasis infection. All patients using ICS should be advised to rinse out their mouth with water spitting out the rinse and brush their teeth after using their device, which will reduce the risk of developing a sore throat or hoarseness.
Spacer devices can also be used to reduce oropharyngeal deposition of drug particles, and should be recommended for all ICS multi-dose inhalers . Patients using ICS who present with white patches plaques in their mouth should be referred to their GP, as this could be oral candidiasis and will require treatment with a topical antifungal e.
Systemic side effects may be dose-related, or more pronounced in patients with co-morbidities e. A dose-related increase in the risk of developing type 2 diabetes and its subsequent complications has been reported  , and data have shown an association between high-dose ICS and tuberculosis . Patients with COPD are at a higher risk of developing pneumonia than people who do not have COPD  , and this risk appears to be further amplified in patients using ICS  , particularly at high doses.
A Cochrane review was unable to determine a statistically significant difference in incidence of pneumonia, mortality or serious adverse events between patients prescribed fluticasone propionate, budesonide or BDP . All patients with COPD should be offered a pneumococcal vaccination and the annual influenza vaccination. The main strategy to minimise the risk of ICS-induced side effects is dose optimisation.
In most patients with asthma, there is limited evidence that increasing the dose of ICS above mcg BDP equivalent per day improves asthma control, although high doses are associated with an increased risk of adverse events .
It is unlikely a patient with asthma would have their ICS completely withdrawn. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. British Guideline on the Management of Asthma: A national clinical guideline. Global Strategy for Asthma Management and Prevention National Review of Asthma Deaths Inhaled corticosteroids for stable chronic obstructive pulmonary disease Review.
Cochrane Datab Sys Rev Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Resp J. Combined corticosteroid and long-acting beta 2 -agonist in one inhaler versus long-acting beta 2 -agonists for chronic obstructive pulmonary disease.
Similarities and differences in inflammatory mechanisms of asthma and COPD. Current Problems in Pharmacovigilance Volume Efficacy of low and high dose inhaled corticosteroid in smokers versus non-smokers with mild asthma. Systemic adverse effects of inhaled corticosteroid therapy: A systematic review and meta-analysis.
Br J Clin Pharmacol ;72 6: Risk factors for community-acquired pneumonia diagnosed by general practitioners in the community. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. Do inhaled steroids increase the risk of pneumonia in people with chronic obstructive pulmonary disease COPD? Risk of fractures with inhaled corticosteroids in COPD: The dose-response relationship of inhaled corticosteroids in asthma. John Baker 9 MAR Mahmood Poonja 11 MAR 9: Thank you John and Mahmood for the positive feed back, I'm glad it was useful!
I didn't mention ICS use in bronchiectasis as there is a paucity of evidence to support this. For commenting, please login or register as a user and agree to our Community Guidelines. You will be re-directed back to this page where you will have the ability to comment. Essential reference for Community Practitioner Nurse Prescribers.
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With numerous illustrations and case studies. BNF 75 March is your essential reference book for prescribing, dispensing, and administering medicines. The BNFC contains essential practical information for all healthcare professionals involved in prescribing, dispensing, monitoring and administration of medicines to children.
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