The Steroid Question

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Now that I’ve written yet another disclaimer so you never, ever mistake my words for a doctor’s, nurse’s, or therapist’s, I’m finally tackling asthma treatment. This post will remain a static page you can access through the tab above.

Let’s talk steroids.

But first, let’s talk preventative medicine. Persistent asthma–that’s any case of asthma that generates weekly symptoms without treatment, even if the symptoms are mild and infrequent–usually motivates a doctor to prescribe maintenance meds. Flares are a whole lot easier to prevent than to treat because they can spiral out of control very fast. And spending all your time chasing down flares, worrying they’ll turn severe enough to require an ER visit, is no way to live.

Believe me, AG’s been there. It’s scary and it’s dangerous and the best part? It’s usually avoidable, since most asthma usually responds well to treatment.

Part of that treatment means avoiding asthma triggers, part of it can include taking antihistamines if allergies are the main trigger, part of it involves carrying a quick-relief inhaler, and part of it usually includes preventative inhaled steroids.

No parent likes the idea of giving steroids to children.
And I imagine no adult asthmatics like the thought of taking steroids, either. Who wouldn’t prefer good health without medication? But that’s just it — the idea of making my kid take steroids for asthma maintenance was far different from the reality of the benefits on her health and the real–as opposed to what I imagined–side effects.

Because:

Inhaled maintenance corticosteroids are NOT the same thing as anabolic steroids.
Let’s get that idea out of the way, too, because it formed a large portion of my mental block when AG was younger. Anabolic steroids are the ones you read about in the papers during pro-athlete scandals, the ones with horrible side effects like sterility, aggression, liver damage, masculinization of women, and even death. They are a synthetic version of the male sex hormone, and they work on protein and muscle.

Corticosteroids are synthetic versions of natural hormones that regulate things like the body’s stress and inflammation responses. Unlike anabolic steroids, these have nothing to do with sex and don’t affect the liver. The other difference here is that athletes who abuse anabolic steroids inject them or take them orally, and maintenance corticosteroids for asthma are inhaled directly into the lungs. (Except when severe flares warrant a oral dosage, but we’ll get to that.)

Inhaling the corticosteroids sends them directly to the bronchial and lung tissue where they need to go, and very little enters the bloodstream. So inhaled steroids don’t affect other organs to the extent that oral ones do.

But Why Steroids?
Remember how all asthma patients have swollen, inflamed airways and no one knows why? I always picture this part as a light switch when I’m thinking about my daughter. Somehow, her hyper-reactive switch got turned *on,* and there’s no way I can turn it *off.* Figuring out how to flip that switch would be the cure.

If I can’t turn the switch off, what I can do is beat down that bronchial inflammation that results. As I understand the process, inhaling corticosteroids can do this because that’s what the natural ones in her body do–they help balance out and regulate the healthy inflammatory response.

I think of it this way: if AG has problems with extra inflammation, then she needs extra amounts of the corticosteroids that reduce it. Bombarding the exact location–her airways–with a low level of steroids does the trick and minimizes the side effects. Then when she does encounter triggers, her flares aren’t made worse by swollen and irritated tissue.

Another reason why inhaled steroids aren’t as bad as they first sound? Doctors prescribe the lowest possible dose to maintain asthma control and can tailor the frequency of use for each patient. My daughter, for example, is lucky enough to use the lowest dosage (44 mcg) controller inhaler and doesn’t use it all during the summer.

What About the Side Effects?
Even inhaled corticosteroids have some, of course, but they’re minimal. The main one is throat irritation or thrush, which are avoidable by rinsing after using the inhaler. While not definitive, a few studies seem to indicate a slightly higher risk for cataracts in patients over 40 who use steroid inhalers and the risk of some bone loss in adults after long-term use.

Here’s the irony, though. Sometimes a parent (read: me) is terrified of inhaled corticosteroids without really knowing much about them, keeps her young child from using them despite moderate to severe persistent asthma not responding well to bronchodilators alone, and her kid (read: AG) ends up on oral corticosteroids instead. Those side effects are far, far more severe if used frequently because they enter the bloodstream.

Just about every asthma patient will end up needing a short burst of oral steroids to get over a particularly severe flare at least once, and these 5-day, infrequent courses mainly just result in a stomachache, weight gain from fluid, and mood swings. But using oral steroids often, like with severe asthma or with under-treated persistent asthma, can cause side effects from glaucoma and cataracts to osteoporosis and adrenal gland problems.

For me, the trade-off is clear. I can keep AG on daily inhaled steroids, or I can watch her flare constantly and end up on the more severe oral steroids several times every fall, winter, and spring. Because she will, no question.

Don’t be afraid of steroid inhalers if your child’s doctor prescribes one.
They don’t guarantee an existence free of life-threatening flares, but they sure can decrease the possibility. They changed my child’s life, and mine.

Common Inhaled Steroids
(Brand names in parentheses)

Beclomethasone (Beclovent, Qvar, Vanceril)
Budesonide (Pulmicort)
Fluticasone (Flovent)
Flunisolide (Aerobid, Aerobid-M)
Mometasone furoate (Asmanex)
Triamcinolone (Azmacort)

More on asthma and steroids:

National Jewish: Steroid Pills & Syrups
Asthma Society of Canada: All About Inhaled Steroids
Partners Asthma Center: Asthma & Inhaled Steroids

62 responses to “The Steroid Question”

  1. Asthmagirl says:

    Worth mentioning… I’ve read some info on airway remodeling… the concept being that untreated asthma makes permenant changes to the airway that makes treatment later on more difficult. I don’t know how valid it is… but I would probably tend to come down on the side of inhaled steroids rather than risk such a thing. And I’d really rather come down on the side of inhaled steroids as opposed to oral.

    Do you have any scoop on schools of though behind airway remodeling?

  2. Amy says:

    Funny you mention it–I was going to write about that subject some, but this thing got long enough without it. (I should probably post something about airway remodeling and link it to here, actually, although it probably won’t get done until next week.)

    Plus, I don’t know too much about it. I DO know that scar tissue buildup is also a problem–if asthma patients have flares over and over again and just treat them with albuterol, they can build scar tissue up and then when they’re older the meds STOP working, and that’s a really scary thought.

    There’s a member of the BellaOnline messageboard who has this problem. She’s in her fifties I think, and grew up with a persistent case of asthma during a time without maintenance steroids. Now she’s on all kinds of meds, has cataracts, and ends up on prednisone constantly. It’s pretty sad, actually. As much as I complain about the inhaler co-pays going up, I’m so very glad AG has one that will treat her flares AND prevent them.

  3. Peg says:

    Feels like finding water in the desert. I am about the worst researcher on the web and able to find any number of useless links when I really need info-I usually just stop looking. I am dealing with a 14month old whose symptoms are not that drastic, who may well outgrow this. But wrapping my head around the fact that my youngest needs maintainance meds- I mean, that is for “sick” people, he is so healthy and cute, all I need is a script for something like cough syrup or decongestant, right? months? how long do I have to do this? And this wasn’t even selfish me speaking-it was just, “what?” I thank God for friends I know who have showed me their nebulizer and other stuff before I needed it. I read almost all your archives and gleaned so much- truthfully, I am so flighty lately the best was to ask questions until you understand.
    I also like your insight for its reality not to mention the fact that I am not going to accidentally hit some link to a drug company to “ask your doctor about” I was not able to find any nonbiased site that would list types of drugs or names like the list you put in one of your blogs, simple and to the point these are your drugs, the names, what they do.
    I was through my second bout of croup brought on by leaving the humidifier off by accident 1 night and more than half way thru a bottle of albuterol syrup before I realized that the sometimes and the in case of had become every day or 2x day and I could now hear wheezing-he doesn’t cough. I just didn’t trust myself that I wasn’t over reacting to a cold, something that he should be able to kick. By the time the motherly gut reaction intuition kicked in, he was getting serious, so I am waiting for the steroids to kick in now and rearranging cupboards for medicine, counters for the nebulizer… Throw the roast in the oven, change the trash, give the kid a treatment, pick up some toys… Redefine normal and pay attention as it may change, but you don’t have to be blindsided each time it changes hopefully.
    I use too many words, but I am grateful you take the time to do this blog.

  4. Amy says:

    Hi Peg,
    Thanks so much for stopping by and for your input. I’m sorry you have to join the asthma club, but grateful this blog is helping.

    Reading your comment reminds me so much how I felt when my daughter was diagnosed. I felt the same way–how could such a normal, active child need daily meds? Or have something that will likely affect her for the rest of her life? I think that adjustment to the idea that you have a “sick” kid is one of the hardest parts about asthma.

    And I also went through the same bit about not trusting myself–it’s so hard, even after you recognize the seriousness of your child’s condition, to get into that habit of recognizing the asthma symptoms, to just get used to giving those meds all the time.

    I hope you stick around, and please do keep asking questions whenever you need to. I don’t always have the answers, but sometimes another regular reader will, or I can direct you to another site that does.

    Other, more experienced asthma parents truly saved my sanity when my daughter was newly diagnosed, and even after all this time, I’m still learning new things to help her.

  5. Rachael says:

    Most of you have a child with asthma on here and don’t know the disease personally. I have had asthma since I was a young girl, about 8, I’m now 26. Inhaled corticosteriods may seem safe when the doctor tells you they are, and no doubt they work. However what they don’t tell you are the true side effects. I have been researching online about these drugs, they are dangerous and should not be used long term. I was on Advair about a year, over that course of time the steroid built up in my body and began causing all sorts of problems I never had before. From intense headaches in the afternoon, to my heart racing, feeling of anxiety all the time, extreme thirst, muscle and joint pains, extreme fatigue that hits in the afternoon, tingling in my fingers and legs, slight insomnia, to the apex of my inhaled steroid use: waking up in the morning with chest pain, passing out in the shower, and feeling like I was having a heart attack. All to be told by the ER and doctors that it must be something else because we can’t find anything wrong with you. I had thyroid, diabetes, anemia, all those blood tests done and all came back negative. And yet I continued to feel not like myself, I couldn’t concentrate, my brain felt disattached from the rest of the body. I knew that there was something wrong, and yet not one doctor questioned the Advair.

    If your child is on this drug, think twice. They most likely can’t tell you what they’re experiencing. And I would hate to think of a child going through what I did.

  6. Anne says:

    Rachael,
    So what did you do instead? Was there an alternative? Or did you have to accept what the Advair was doing, in order to control your asthma? Or did you find a different inhaled steroid that was less of a problem?
    Thank you.

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