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Corticosteroids - inhaled
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Exam Tips
- ICS are preventers, not rapid relievers; explain delayed anti-inflammatory onset in OSCE counselling.
- State clearly that potency differs by formulation: extrafine beclometasone products are not dose-equivalent to standard beclometasone inhalers.
- Always mention safety checks: mouth rinse, spacer use, growth monitoring in children, and adrenal suppression risk at high cumulative steroid exposure.
- Name key interaction: strong CYP3A4 inhibitors (ritonavir, itraconazole, ketoconazole) can increase systemic steroid effects.
- For prescribing stations, include brand prescribing where non-interchangeability is clinically relevant and consider steroid treatment card when exposure risk is high.
Definition
Inhaled corticosteroids (ICS) are glucocorticoid medicines delivered directly to the airways to control chronic airway inflammation, mainly in asthma and selected people with COPD. They reduce exacerbation risk and improve symptom control by suppressing inflammatory signalling in bronchial mucosa while aiming to minimise systemic steroid exposure compared with oral corticosteroids.
Pathophysiology
ICS bind intracellular glucocorticoid receptors in airway epithelial and immune cells, then alter gene transcription to reduce pro-inflammatory cytokines, eosinophilic inflammation, mucosal oedema, and microvascular leak. This lowers airway hyper-responsiveness over days to weeks and improves lung function/exacerbation frequency; benefit is preventive rather than immediate bronchodilation. Systemic effects can still occur (for example adrenal suppression, reduced growth velocity in children, bone and ocular effects) when dose, potency, duration, lung deposition, or drug interactions increase bioavailability. See Figure from core respiratory pharmacology text (airway inflammation and glucocorticoid receptor signalling).
Risk Factors
- High-dose or prolonged ICS use
- Young/small children (higher dose per kg exposure)
- Use of more potent or extrafine formulations (for example Qvar/Kelhale compared with some standard beclometasone products)
- Concomitant corticosteroids (oral, intranasal, topical) increasing cumulative steroid burden
- Concomitant CYP3A4 inhibitors (for example ritonavir, itraconazole, ketoconazole)
- Poor inhaler technique leading to high oropharyngeal deposition and local adverse effects
- Active or previous tuberculosis, untreated fungal/bacterial/systemic viral infection, or ocular herpes simplex
Clinical Features
Symptoms
- Indication context: recurrent wheeze, chest tightness, cough, variable breathlessness (asthma) or frequent COPD exacerbations in selected patients
- Local adverse effects: hoarse voice, sore throat, oral discomfort, dry mouth, dysphonia
- Oral candidiasis symptoms: sore white patches, altered taste
- Possible systemic steroid effects at higher exposure: fatigue, weight change, easy bruising, mood/sleep disturbance
Signs
- Expiratory wheeze or prolonged expiratory phase during uncontrolled airway disease
- Oral thrush on examination (white plaques that may scrape off)
- Dysphonia without upper respiratory infection signs
- In children on long-term/high-dose treatment: reduced growth velocity on serial height centiles
- Rarely Cushingoid features or signs of adrenal suppression in significant systemic exposure
Investigations
Spirometry with bronchodilator reversibility (or peak flow variability):Obstructive pattern with significant reversibility/variability supports asthma phenotype likely to benefit from ICS
Blood eosinophils (especially in COPD phenotyping):Higher eosinophil count suggests greater likely exacerbation reduction from ICS-containing regimens
Inhaler technique and adherence review:Common errors (poor actuation-inhalation coordination, inadequate inspiratory flow, missed doses) explain poor control
Oral examination:Thrush or mucosal irritation indicates local steroid deposition and need for spacer/rinsing technique optimisation
Growth monitoring in children and adolescents:Downward centile crossing suggests clinically relevant systemic exposure
Morning serum cortisol (if adrenal suppression suspected):Low cortisol supports hypothalamic-pituitary-adrenal axis suppression from cumulative steroid exposure
Management
Lifestyle Modifications
- Teach and re-check inhaler technique at every review; match device to age, dexterity, cognition, and preference
- Use spacer with pressurised metered-dose inhalers where appropriate to reduce oropharyngeal deposition
- Rinse mouth and spit (and brush teeth if possible) after each ICS dose to reduce candidiasis/dysphonia
- Smoking cessation and trigger minimisation to improve asthma/COPD control
- Provide written personalised action plan and adherence counselling
Pharmacological Treatment
ICS monotherapy (typical asthma preventer dosing)
- Beclometasone dipropionate 100-200 micrograms twice daily via inhaler (adult typical start; adjust to lowest effective dose)
- Budesonide 200-400 micrograms twice daily (adult typical start range)
- Fluticasone propionate 100-250 micrograms twice daily (adult common range)
- Ciclesonide 80-160 micrograms once daily (adult licensed options vary by product)
No absolute contraindications, but use caution in active/quiescent TB, untreated infections (including ocular herpes simplex), and pregnancy/breastfeeding. Prescribe by brand because potency/device are not interchangeable (for example Qvar vs Clenil; fluticasone furoate vs fluticasone propionate). Use the minimum effective dose and step down when stable.
ICS/LABA combinations
- Beclometasone/formoterol (for example 100/6 micrograms per actuation, commonly 1-2 puffs twice daily depending on product/licence)
- Budesonide/formoterol (for example 200/6 micrograms 1-2 inhalations twice daily; some regimens use MART per licence)
- Fluticasone propionate/salmeterol (for example 125/25 or 250/25 micrograms twice daily)
- Fluticasone furoate/vilanterol (once-daily strength depends on indication/product)
Use when control is inadequate on ICS alone or per guideline step. Confirm age-specific licensing and regimen (maintenance vs maintenance-and-reliever) in the product information.
ICS/LABA/LAMA triple therapy (usually COPD or severe asthma pathways)
- Beclometasone/formoterol/glycopyrronium
- Budesonide/formoterol/glycopyrronium
- Fluticasone furoate/vilanterol/umeclidinium
- Mometasone/indacaterol/glycopyrronium
Consider in patients with persistent symptoms/exacerbations despite dual therapy and phenotype-appropriate indication. Reassess pneumonia risk in COPD and continue only with clear clinical benefit.
Complications
- Oral candidiasis and dysphonia
- Adrenal suppression (rare but serious, especially with high dose/cumulative steroids)
- Reduced growth velocity in children
- Skin thinning/easy bruising
- Reduced bone mineral density/osteoporotic fracture risk with prolonged high exposure
- Cataract or glaucoma risk with chronic higher-dose use
- Increased pneumonia risk in COPD populations on ICS-containing regimens
Prognosis
When matched to the right indication and delivered with good technique, ICS substantially reduce asthma exacerbations and improve day-to-day control. Prognosis is best with regular review, dose minimisation to the lowest effective level, and prompt management of local or systemic adverse effects.
Sources & References
✅NICE Guidelines(1)
- Corticosteroids - inhaled[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 616, 617)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 586)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 585)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 584)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1743)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 563, 564)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 588, 589)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 564, 565)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 585, 586)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 585, 586)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 588, 589)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 584)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1743)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 584, 585)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 616, 617)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 589)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 583, 584)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 871, 872)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 871, 872)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 196, 197)[context]