Inhaled Steroid Options for Treating Asthma

Inhaled corticosteroids, also called inhaled steroids, are medications used for long-term management of asthma. They typically are the preferred treatment for people with asthma who need more than a rescue inhaler can offer.

Inhaled steroids help prevent symptoms of asthma, including wheezing, shortness of breath, coughing, and tightness in the chest. These inhalers are not effective for treating an acute asthma attack. Instead, they are to be used daily—symptoms or not—to control asthma over time.

When used as prescribed, inhaled steroids can:

• Reduce the frequency and severity of attacks (exacerbations)
• Decrease the need for rescue inhalers
• Improve lung function
• Decrease hyper-responsiveness of the airways
• Prevent asthma-related ER visits, hospitalizations, and death
• Improve quality of life

Your healthcare provider may recommend an inhaled steroid for your asthma if any of these factors apply:

• You need a ß-agonist inhaler (e.g., albuterol) more than two days a week.
• Symptoms of asthma recur more than twice a week.
• Asthma interferes with daily activities.
• You've needed oral steroids (such as prednisone) more than once in the previous year.

Types of Inhaled Steroids

Healthcare providers prescribe steroids for individual patients based on factors such as the severity of their asthma and their overall health:

Some steroid inhalers contain only a corticosteroid, such as:

• Alvesco (ciclesonide)
• Asmanex HFA (mometasone) 
• Asmanex Twisthaler (mometasone)
• Flovent Diskus (fluticasone)
• Flovent HFA (fluticasone)
• Pulmicort Flexhaler (budesonide)
• Qvar (beclomethasone)

Others contain a steroid plus a long-term beta-agonist (LABA), a type of bronchodilator that is effective for up to 12 hours. Known as combination therapies, these inhalers typically are prescribed for people with poorly controlled asthma symptoms.

• Advair HFA (fluticasone, salmeterol)
• Advair Diskus (fluticasone, solmeterol inhalation powder)
• Arnuity Ellipta (fluticasone furoate inhalation powder)
• Dulera (mometasone furoate, formoterol)
• Symbicort (budesonide, formoterol)

How Inhaled Steroids Work

Asthma is essentially an overactive response of the immune system to something in the environment.

When you come in contact with an asthma trigger (an allergen such as pet dander, smoke, etc.), your immune system releases cells that cause inflammation in your bronchial tubes (airways). This narrows them and makes it hard to breathe.

Inhaled corticosteroids reduce this inflammation. They also reduce the amount of mucus in your bronchial tubes. The result is clear and open airways that allow you to breathe normally.

Corticosteroid drugs reduce inflammation in a couple of ways. The first is by getting the immune system to halt its attack.

Raising Hormone Levels

In asthma, inflammation of the airways can become chronic. Everyday levels are lower than those during an asthma attack, but that constant state of inflammation means it doesn't take much of a response to challenge your breathing.

Your body produces hormones that regulate the immune response and inflammation, and steroids are synthetic versions of those hormones. When you take a corticosteroid, your body detects high levels of the hormone and stops producing it, effectively "taking its foot off the accelerator."

Blocking Allergy Response

Another major contributor to inflammation is allergies, which are common in people with asthma and also are caused by a hyper-responsive immune system.

Steroids block the late-phase immune reaction to allergens, which lowers inflammation, decreases over-responsiveness of the bronchial tubes, and blocks the immune system's inflammatory cells.

The excess mucus associated with asthma comes directly from the bronchial tubes as part of the inflammatory response, so lowering inflammation can help lessen mucus as well.

This anti-inflammatory response is central to achieving long-term control of your asthma.

Choosing an Corticosteroid Inhaler

Inhaled steroids come in three different types of devices:

• Metered dose inhalers (MDIs): A small pressurized canister contains the medication and a propellant spray. You push down on the canister and the propellant delivers the medication through a plastic mouthpiece into your lungs. Examples include Asmanex HFA, Flovent HFA, and Alvesco.
• Dry powder inhalers (DPIs): The device may be similar to an MDI or be a disc or oval shape, but it doesn't contain a propellant. The medication is a dry powder, which you release by taking a deep, fast breath. DPIs prescribed for asthma include Flovent Diskus, Pulmicort Flexihaler, Qvar RediHaler, and Asmanex Twisthaler.
• Nebulizer: Nebulizers turn liquid medicine into a mist that you inhale. They come in electric or battery-run versions with either a mouthpiece or a mask.

When choosing an inhaler, one of the main considerations is how much of the drug exiting the inhaler is actually deposited in the air passages of the lungs. By and large, DPIs tend to deliver more active drug than MDIs.This doesn't necessarily mean the therapeutic effects of MDIs are any less than that of the DPIs; they generally aren't. It may only pose a problem if a spacer is used.

In such case, a DPI such as Qvar RediHaler, which delivers 50% of the active drug to the lungs, may be less impacted by a spacer than an MDI like Asmanex HFA, which delivers only 11%.

By comparison, nebulizers can sometimes deliver results that are superior to either type of inhaler. However, their use is limited by the fact that the machine is costly and not portable.

Moreover, some corticosteroids, including Alvesco and Asmanex cannot be delivered by nebulizer. Even so, nebulizers may be a better option for children, people who are unable to operate inhalers comfortably or reliably, and those who require large doses.

Dosages and Use

Dosages of inhaled corticosteroids varies widely depending on the specific drug, age, and the severity of asthma symptoms.

People with asthma who use an inhaled steroid to control symptoms routinely have been instructed to take one to two puffs once or twice a day—sometimes more.

It's important to follow the instructions provided to you precisely, as the doses need to be spaced just right for the medication to be effective. Also, taking more medication than directed can cause you to have unpleasant side effects.

Duration

It's worth repeating: These are long-term medications for daily use, not rescue inhalers that you used to end an asthma attack. Inhaled corticosteroids are intended to be used regularly, likely over the course of many years.

Talk to your healthcare provider before stopping your medication for any reason.

Side Effects

Generally speaking, inhaled corticosteroids have a relatively low risk of side effects, particularly when compared to oral corticosteroids. The most common ones affect fewer than 5% of people who use them.

Some side effects result when the medication and/or propellant comes in contact with tissues in the mouth and throat. Others are systemic, meaning they stem from the medication circulating through your body.

Mouth and Throat

These common side effects of oral corticosteroids often are easy to manage or even eliminate altogether.

• Thrush (oral candidiasis): This fungal infection of the mouth can be prevented by using a spacer, rinsing your mouth after use, or using a lower dosage (with your healthcare provider's OK). Thrush can be treated with antifungal medications.
• Hoarseness/dysphonia: Potential effects on the voice can be prevented by using a spacer or a temporarily lowered dosage to give the vocal cords a chance to rest.
• Reflex cough and bronchospasm: Using a spacer or inhaling more slowly can help prevent this. If you are having an attack, using a rescue inhaler first can reduce the risk as well.

Systemic

Systemic side effects are possible but uncommon with inhaled steroids. The risk generally is higher with a higher dose.

Poor growth is a concern for children with asthma who use inhaled corticosteroids. When growth is impaired, it's usually by less than half an inch. While noteworthy, this is especially rare at normal doses. Children who go off of the drug generally catch up in height.

Talk to your pediatrician if you have concerns about your child's growth. It's also important to consider, though, that poorly controlled asthma can also impair growth.

Other systemic side effects can include:

• Osteoporosis
• Easy bruising
• Cataracts and glaucoma

Again, these are less common at typical dosages. If you already have a high risk of any of these things, are concerned about them, or suspect you're experiencing one, talk to your healthcare provider.

Serious systemic symptoms may arise when the daily dosage is high—1,000 to 1,500 micrograms (mcg) per day—increasing the risk of the above side effects, plus:

• Weight gain
• Insomnia
• Mood swings
• Thinning of the skin

Most inhaled corticosteroids fall beneath this threshold. Comparatively speaking, a high corticosteroid dose without a spacer is defined as:

• Alvesco: 320 mcg/day
• Asmanex: 440 mcg/day
• Pulmicort Flexihaler: 400 mcg/day
• Flovent HFA: 440 mcg/day
• Flovent Diskus: 440 mcg/day
• QVAR RediHaler: 672 mcg/day

Pregnancy and Breastfeeding

Research suggests inhaled corticosteroids do not increase the risk of birth defects and that they're safe to use in low doses throughout pregnancy.

Healthcare provider generally believe the amount of inhaled steroids excreted into breastmilk is likely too small to have any impact on a nursing baby, so it's also considered safe to use these medications when you're breastfeeding.

Your practitioner may recommend one drug over another based on absorption levels.

A Word From Verywell

You have a lot of factors to weigh when selecting the right inhaled corticosteroid for your asthma. Some may be based on the known differences between the drugs; others may be based on personal preference or other considerations (such as health coverage and available patient assistance programs).

The right inhaler is the one that works for you. It's often necessary to try several to see how they work or if you experience any side effects.

While your first instinct may be to choose the latest drug, remember new doesn't always mean best. Opt for the drug that controls your symptoms with the lowest dose and fewest side effects.