Bronchial asthma is one of the major diseases all over the world. Not only prevalent in developed countries, but it is also a major problem in the developing countries and the incidence varies in different countries. And among 5-11 year old children, the prevalence is roughly estimated to be 10-15%. Also with increasing pollution there are more number of attacks and increased incidence of asthma.
ASTHMA management, today’s era we use different types of inhalers either as single dose i.e as required medications and/or in combination with other drugs for long-term control and prophylaxis. Their usage and dosing vary according to severity and response of patients. Nonetheless, each of them carries long-term side effects and must be used in proper dosage and frequency within the prescribed limits.
Salbutamol is the short acting b2 agonist (SABA) and is the most frequently used inhaler as rescue treatment for all asthma patients. Long-term and repeated use without consulting a doctor and without controller and prophylaxis medication can increase asthma-related complications with increased severity of asthma exacerbations, cardiac arrhythmias and hypertension. With frequent usage for a long period, it becomes ineffective and may lead to hyperinflation of lung. Therefore, it is very necessary to use it with controller medications rather than taking it in increased frequency.
Formoterol and Salmeterol are the long acting b2 agonist (LABA) used for moderate and severe asthma control. Again, excessive and improper use of them without supervision of a doctor can lead to worsening bronchospasm, hypertensive crisis, cardiac arrhythmias and increased asthma-related deaths. Therefore, it is necessary to use them with inhaled steroids i.e other controller medication and isolated use should be avoided in patients.
Inhaled steroids are an important and the main component of asthma therapy. They not only give relief from symptoms of asthma but also prevent asthma attacks and repeated visits to the hospital. Since its discovery, asthma care has improved and has resulted in better management and control of asthma. It is important to understand that here steroid is taken in inhaled form and not in tablet (oral) form. Oral steroid tablets, when taken as a short course of 7-10 days or more, does not have any major side effects. But on the other hand when taken for many months or years, harmful side effects are likely and almost inevitable. The list of possible effects is long; it includes mood changes, forgetfulness, hair loss, easy bruising, a tendency toward high blood pressure and diabetes, thinning of the bones (osteoporosis), suppression of the adrenal glands, muscle weakness, weight gain, cataracts and glaucoma. After being swallowed, these tablets are absorbed from the stomach into the bloodstrestream and taken not only to the bronchial tubes (to treat asthma) but also to every other part of the body. Their effects are widespread.
On the other hand, only minuscule amounts of steroid medication enter the bloodstream after inhalation. The reasons for this difference are many. First, steroids used for inhalational treatment of asthma are designed not to cross well from the surface of the bronchial tubes into the bloodstream. Second, only very small amounts of steroid medication are delivered from the inhalers with each dose or “puff ”. It is important to note that the amount of steroid inhaled is in micrograms, which are unihaled is in micrograms, which are units one thousand times smaller than the milligrams!!
Nevertheless, there are some side effects of long-term use of inhaled steroids when used in high doses. Risk of fungal infection in the oral cavity increases because of local deposition of the drug. But this can be minimised with rinsing mouth with water after inhaling the steroid spray. Rinsing removes any medicine residue from your mouth. Also using spacer tube with the inhalers can result in increased delivery in the airway and less is deposited in the oral cavity.
It is important to understand that so far no serious long-term adverse effects have emerged in adults when given in the usual doses. They do not cause degeneration (atrophy) of the normal tissues of the respiratory passageway. They do not predispose the patients to lung infections. They do not cause cancer, diabetes or high blood pressure. These are myths which should be ignored.
But when used in high doses in adults, they are associated with certain side effects and also in children with usual doses it can have some side effects. Children’s bones may be sensitive to the very small amounts of steroids that can enter the bloodstream after inhalation. There is currently debate and considerable ongoing research to determine whether in children inhaled steroids might slow bone growth and reduce a child’s ultimate height. The reason for the side effects for high doses is because of the fact that there is increased spillover of the medication. Although the effect is small, like a very small dose of prednisone (oral steroid), over the years this small effect can potentially add up to serious harmful effects. High doses of inhaled steroids taken for a long time can probably predispose patients to cataracts, glaucoma, weakened immune system, increased incidence of infections and thinning of the skin and bones.
It is increasingly important to take the medications under the supervision of a doctor as sometimes, increased dose of inhaled steroid is required as a means to avoid steroid tablets. And the doctor will constantly work with the patient in an attempt to reduce the dose of inhaled steroids to a more conventional and safer range.
In general, patients should minimise use of rescue inhalers. And it is important to remember that not taking inhaled steroids for fear of side effects may have real consequences that are far worse than potential effects in the future; namely, asthma symptoms and risk of asthma attacks. Severe asthma attacks are usually treated with steroid tablets, which all agree have the worst side effects.