Drippy nose? Allergies? Asthma? How often do these symptoms/conditions have you reaching for your prescription pad and scribbling a script for an inhaled or intranasal corticosteroid?
If you’re like most primary care physicians, a lot. Today, just as inhaled corticosteroids (ICSs) are the first-line treatment for asthma, intranasal corticosteroids (INC) serve that role for allergic rhinitis. Even 10 years ago, the authors of a review article on the safety of INCs wrote that their efficacy and convenience “established these agents as indispensable in controlling the symptoms of perennial and seasonal allergic rhinitis.”1 Meanwhile, the underuse of ICSs is a leading cause of uncontrolled disease in patients with asthma.2
Yet say the word “steroid” to patients, particularly parents of young children, and watch the questions fly. One study of 389 parents of children with asthma found that 76% worried about side effects from ICSs even though just 24% of their children were actually using the drugs. Nearly half thought inhalers caused addiction.3 Other studies find that parental and physician concerns about the safety of INCs relegates them to use as a second-line agent rather than the first-line therapy for which they are most suited.4
For both classes of drugs, concerns typically stem from the significant adverse effects associated with long-term use of oral or high-dose inhaled corticosteroids, including growth inhibition, osteoporosis, cataracts, glaucoma, hypertension, diabetes, and myopathy. None of these is typically observed with ICS or INS when used at recommended dosages.5,6
Thus, it is incumbent on primary care clinicians to be comfortable about discussing the safety and efficacy of these drugs with their patients.
Safety of Inhaled Corticosteroids
Several recent reports provide good overviews of the safety and efficacy of ICSs. A drug class review of controller medications for persistent asthma published in April 2011 found no differences between equipotent doses of ICSs in their ability to control asthma symptoms, prevent exacerbations, or reduce the need for rescue medication, or in their overall incidence of adverse effects.7 The report also found significantly greater benefits with ICS monotherapy than with leukotriene modifier (LM) monotherapy.
Although there is some evidence of growth rate retardation among children who use ICSs, the effect is tiny, the report found: a mere 1.1-cm difference between placebo and ICS-treated patients over an average of 4.3 years. In addition, the reduction occurs only in the first year of treatment, suggesting the effect is not progressive.
When ICSs are used for COPD, one concern is the increased risk of pneumonia. A 2012 review article found no such increased risk in patients with asthma, provided the drugs are used at the low doses recommended for that disease.7
Safety of Intranasal Corticosteroids
A recently published review on the local and systemic safety of INCs in allergic rhinitis, rhinosinusitis, and nasal polyps found no significant adverse effects.6 One key point: Today’s INC agents, including fluticasone propionate, ciclesonide, and fluticasone furoate, are specifically formulated to reduce systemic bioavailability compared to first-generation INCs (triamcinolone acetonide, flunisolide, beclomethasone, and dexamethasone).
The most common adverse events associated with INCs are nosebleed, throat irritation, and nasal dryness, burning, and stinging, all of which are self-limited and, in most clinical trials, occur at rates similar to those observed with placebo. Providing clear instructions on how to use the nasal applicator is important, since nosebleeds (epistaxis) may be related to pressing the tip against parts of the nose. Appropriate administration technique also reduces the risk of dryness, crusting, and septal bleeding. Although there have been rare reports of septal perforation associated with INCs, the incidence is miniscule given the wide use of these compounds and is unlikely to be related to the medication.
There also appears to be little to no effect of the newer INCs on the hypothalamic-pituitary-adrenal (HPA) axis, growth rates (as long as the drugs are used at recommended dosages), bone density, or ocular changes.
The evidence simply does not support concern about systemic adverse effects with these drugs, conclude the authors of the review. “Rather, robust clinical evidence demonstrates the safety and efficacy of the newer INCs for management of allergic rhinitis, rhinosinusitis, and nasal polyps.”