STEROID TREATMENT FOR ASTHMA

Most people know that steroids are widely used to treat asthma and they are often very worried about the side-effects. In some cases they are right to worry and in others they are not. Many people are confused by the difference between those that are breathed in (inhaled steroids) and those that are swallowed (steroid tablets), and the different effects they have. Here these differences are made clear and their side-effects are discussed.

What are steroids?

Steroids are a wide range of chemicals made both by the body and artificially. Only one group, the corticosteroids, is used to treat asthma; similar to those that the body produces naturally, corticosteroids are now made by pharmaceutical companies.

Corticosteroids are different from the anabolic steroids taken by some athletes. Anabolic steroids are not used to treat asthma.

How do corticosteroids treat asthma?

Corticosteroids work by reducing the amount of inflammation, swelling and mucus in the airways, all of which cause breathing difficulties. Unlike bronchodilator (reliever) inhalers which work quickly to relieve asthma, corticosteroids only begin to work over a period of time.

How are corticosteroids taken and what are the side-effects?

There are three ways in which the steroids can be used:

1. Inhaling them (breathing them into the lungs) to prevent asthma.
2. Swallowing them (steroid tablets) to relieve acute attacks or to control severe asthma.
3. Injecting them (always done by a doctor or nurse) for acute, severe asthma attacks.

Inhaled corticosteroids

Inhaled steroids are used to prevent asthma. They are quite different from reliever inhalers (such as Bricanyl, Ventolin or salbutamol) which only ease the symptoms of asthma and do not treat the cause.

For adults, the most common presenter is an inhaled steroid. Breathing in the steroid is the safest method because the drug goes straight to the lungs so that only a small dose (amount) is needed.

The first choice of presenter for children may not be a steroid. Intal or Cromogen (sodium cromoglycate) may be tried, and if this does not prevent the child's asthma then a small dose of inhaled steroid will be prescribed.

Inhaled steroids are breathed in using an aerosol inhaler (puffer), often with a spacer, or a dry-powder inhaler or occasionally a nebuliser.

The most widely used inhaled steroids are budesonide (Pulmicort), beclomethasone (eg Becotide, Beclazone, Aerobec, Becloforte) and fluticasone (Flixotide).

Inhaled steroids only prevent asthma: they do not relieve an asthma attack. Over a period of time they slowly reduce the inflammation, swelling and mucus in the airways. Steroid inhalers must be used as prescribed, every day, even if the person with asthma is feeling entirely well. It may take up to 14 days before inhaled steroids start to work properly.

If a cold develops some doctors will advise increasing the dose of inhaled steroid for a few days to give more protection to the lungs.

Providing that the inhaler is being used properly (a doctor or nurse should check this), if standard doses of the inhaled steroid are not preventing regular symptoms, then a higher dose may be prescribed.

The side-effects of inhaled corticosteroids

There are very few side-effects after using inhaled steroids and they should not be confused with the side-effects from long courses of steroid tablets.

People inhaling standard doses of steroid can sometimes experience a hoarseness of the voice and occasionally minor mouth and throat infections (thrush) can appear. Some people find that using a spacer, cleaning their teeth and rinsing their mouth out after inhaling helps to reduce these problems.

Adults inhaling standard doses of steroid absorb virtually none into their bodies because what little steroid there is goes straight to the lungs. It may be possible for a small child to absorb a little and the same could apply to an adult inhaling the maximum dose. However it is only those with the more troublesome or severe asthma that inhale these high doses for long periods of time and the benefits to their asthma outweigh any slight risk of side-effects.

Reducing the risk of side-effects

For all young children and people inhaling higher doses of steroid, we recommend that the aerosol inhaler is attached to a plastic 'spacer' device. Spacers reduce the risk of any steroid being absorbed into the body and the risk of side-effects. A mask for small children is available to add to some spacers.

Very occasionally, steroids may also be given by means of a nebuliser. Normally a mouthpiece rather than a mask is better for adults as it stops the fine mist from covering the skin. Young children, however, who cannot use a mouthpiece may need a mask. Some people suggest that rubbing a thin layer of Vaseline over the skin before putting the mask on and wiping the skin afterwards will reduce any possible harm the mist may cause to the skin.

Tablets

Prednisolone is the most widely used steroid tablet. Doctors prescribe the tablets in two ways:

• Short courses to relieve severe, acute asthma.
• Long courses to give daily control to severe, chronic asthma.

Short courses of tablets for acute, severe asthma

If the symptoms of asthma continue despite regular inhaled steroids and the lungs do not respond sufficiently well to reliever treatment, then a short course of steroid tablets may also be needed. Steroid tablets begin to work after several hours. A typical child's course may last three to four days, while adults may require about two weeks.

Some doctors agree to a management plan whereby the patient may keep a supply of steroid tablets (a short course) which can be used when their asthma worsens; increasing symptoms (especially at night) and falling peak flow readings are strong signs of worsening asthma.

The side-effects of short courses

A short course lasting a week or two will have few side-effects, even on high doses. It is possible that a slight weight gain and a temporary increase in appetite may be experienced. Some mood change may happen and children may become excitable during the course.

Short courses of steroid tablets may be taken two or three times a year without causing harmful side-effects; more than this may mean some risk.

It is important to keep inhaling higher doses of regular preventer treatment in between times of bad asthma to reduce the need for frequent courses of steroid tablets.

Long courses of tablets for severe, chronic asthma

A minority of people find that even inhaled steroids and short courses of steroid tablets are not enough to control their asthma. Because their symptoms continue to break through, a daily dose of steroid tablets may be necessary. However, the new higher dose inhaled steroid means that fewer people need to take long courses of steroid tablets.

The side-effects of long courses

Steroid tablets swallowed over a period of months can have serious side-effects. These can include: weight gain; thinning of the bones (osteoporosis); increased blood pressure; stomach ulceration; and a heightened risk of diabetes in those prone to it. Children may tend to grow more slowly.

It is for this reason that doctors try to prescribe the smallest possible dose. Beforehand the doctor will consider with the patient whether the suffering caused by chronic asthma together with the dangers of an acute attack outweigh the risks of the side-effects. It is not an easy decision to make, but it can be a life-saver.

Doctors also prescribe high-dose inhaled steroids as an alternative wherever possible. A long course of steroid tablets is rarely given to children and even then only every other day to reduce side-effects.

People with chronic asthma can often be kept in very good health on a dose of steroid tablets as low as 5mg per day; even after many years, side-effects are minimal and mostly not serious. Side-effects become more likely if the dose is above 5mg per day.

To reduce the risk of certain side-effects the total daily dose of steroid tablets is normally taken first thing in the morning.

Warning!
Long courses of steroid tablets can be stopped only by gradual reduction and under the guidance of a doctor. If they are stopped suddenly it can cause serious withdrawal symptoms. For this reason the doses should be reduced slowly over a period of weeks or months. Short courses of steroid tablets do not need to be reduced slowly. Everyone taking long courses of steroid tablets should be given a steroid card by their doctor to be shown in any emergency.

Injecting steroids

Steroids can be injected only by a doctor or nurse. They are usually only used to treat acute, severe asthma. Injections do not work any faster than the tablets, but they can be useful if the patient is too unwell to swallow or is vomiting.

For more information about asthma in general please see the 'Take control of asthma' booklet, produced by the National Asthma Campaign or call the Asthma Helpline on 0345 010203.