Continuing Education Column

Inhaled Corticosteroids in Asthma

| | Jong Myung Lee, MD
Department of Internal Medicine, Kyungpook University School of Medicine
Email : jomlee@knu.ac.kr
J Korean Med Assoc 2007; 50(10): 894 - 902

Abstract
sthma is characterized by airway inflammation, hyperresponsiveness, and remodeling,
which are responsible for the variable airway obstruction and respiratory symptoms.
Although a number of anti-asthma drugs have been developed, none has succeeded in
managing symptoms and underlying airway inflammation as effectively as corticosteroids.
However, systemic effects of the drugs were a major obstacle to use them in asthma therapy. A
significant breakthrough in asthma therapy occurred when corticosteroids became available as
inhaled preparations, reducing the potential for systemic effects while achieving excellent
therapeutic efficacy. The first inhaled corticosteroid (ICS) having such characteristics was
beclomethasone-17, 21-dipropionate, which was introduced in the early 1970s. With growing
information on their efficacy and the recognition of chronic inflammation as a fundamental
component of asthma, ICSs have become the cornerstone of asthma therapy since the early
1990s. The potent anti-inflammatory effect of ICSs seems to be resulted mainly from the
reduction of the number and activation of inflammatory cells in the bronchial mucosa and through
their inhibitory effects on the synthesis of various mediators and cytokines. In addition, the airway
selectivity is thought to come from a high hepatic first-pass inactivation rate of the drugs. A
number of ICSs are currently on the market, and some drugs are available as the combination of
an ICS and a long-acting beta2 agonist in a single inhaler. The present paper comprises a short
background behind the development of ICSs, their pharmacologic and clinical profiles, and the
current positions in asthma treatment.

Keywords : Inhaled corticosteroid; Asthma

: ;

(1, 2).

(3).

894

Inhaled Corticosteroids in Asthma

.

.

. ,
-

Figure 1. The mechanism by which inhaled drug particles deposit

in the airway lumen

(6).

(diffusion gradient)

beclomethasone-17, 21-dipropio-

nate (BDP) 1970

(4).

(7). BDP /

(8),

(5).

. 0.5 ~ 5m

. 0.5m

90%

(Figure 1).

. 1960 dexa-

, , ,

methasone 21-phosphate ester

(9).

895

Lee JM

Table 1. Lipophilicity (log P), receptor-binding affinity (RBA), and

oral bioavailability (F%) of inhaled corticosteroids

Drug

Iog P

RBA

F%

Beclomethasone dipropionate
Triamcinolone acetonide
Flunisolide
Budesonide
Fluticasone propionate
Momethasone furoate

4.40
2.53
2.28
3.24
4.20

0.3
0.5
0.2
1.0
2.3
2.8

25 (?)
23
21
6~13
<1
<1

(Figure 2).
Figure 2. Schematic overview of pharmacokinetics of inhaled ste-

roid. Each steroid has a different rate of the hepatic

first-pass deactivation.

,

. (turbuhaler),

(diskhaler)

10%

30 L/min

steroid 16, 17-acetals (budesonide, triamcinolone,

flunisolide) steroid 17-esters (beclome-

thasone, fluticasone). 16 17 lipo-

philic substitution

(10).

10% 70%

(first-pass

metabolism)

896

Inhaled Corticosteroids in Asthma

Figure 3. Action mechanism of corticosteroid (Modified from Am J Respir Crit Care Med 1998; 157: 51- 53): Glucocorticoids enter the cell

and bind to a glucocorticoid receptor (GR), which is complexed with two molecules of the 90 kDa heat shock protein (hsp90) and
with p59 protein. Upon ligand binding, GR dissociates from hsp90 and translocates to the nucleus, where it binds as a dimer to a
glucocorticoid response element (GRE) located within the promoter of target genes. GR can also interact as a monomer, via direct
protein-protein interaction, with transcription factors such as NFkB and AP-1, activated by cytokines and other pro-inflammatory
stimuli. The resulting mutual repression prevents both GR and the other transcription factors from binding to theirrespective DNA
response elements (RE).

1/4 . 3/4

(11)

(lung bioavailability)

(oral

bioavailability) 6 ~ 11%,

1% .

1%

(12).

25%

897

Lee JM

Table 2. Estimated equipotent daily doses (g) of inhaled steroids for adults

(16).

Drug

Low dose

Medium dose

High dose

Beclomethasone dipropionate
Budesonide
Ciclesonide
Flunisolide
Fluticasone
Mometasone furoate
Triamcinolone acetonide

200~ 500
200~ 400
80 ~ 160
500 ~ 1,000
100 ~ 250
200 ~ 400
400 ~ 1,000

>500 ~ 1,000
>400 ~ 800
>160 ~ 320
>1,000 ~ 2,000
>250 ~ 500
>400 ~ 800
>1,000 ~ 2,000

>1,000 ~ 2,000
>800 ~ 1,600
>320 ~ 1,280
>2000
>500 ~ 1,000
>800 ~ 1,200
>2,000

, ,

(Figuer 4).

(13). ,
Table 1
.

1960

(17~20).

(14).

, 2 , ,

, ,

NF-kB

AP-1

(Figure 3).

(equipotent doses)

. CD4+

Table 2 .

T ,

CD4+ T IL-5 Th2

, ,

(15).

(21).

898

Inhaled Corticosteroids in Asthma

Figure 4. Biological effects of corticosteroids on inflammatory cells and structural cells in the airways.

(27).

(22~25).

(28).

1 2 .

, (26),

1 4

899

Lee JM

,
, , ,
, .
.

(systemic potency ratio) 3:1

. 2006 GINA

. 5
1
(32).
1) 1: 2

3 .

(2~5 )
2) 2:
3) 3: 2

1.5:1 1:1 (29).

4) 4: / 2

, ,

(3).

( )
5) 5: 4 IgE

, , ,
.

(30).

, .
5~10%
.

.


.

, .

nystatin
2, 3 ~ 4 .
30%

.


(31).

900

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Peer Reviewer Commentary

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