Q.

Inhaled corticosteroids (ICS) are preferred to oral prednisolone in chronic bronchial

asthma.
Ans: Inhaled corticosteroids (ICS) are the treatment of choice in preventing asthma
exacerbations in patients with persistent asthma. Persistent asthma is classified by symptoms more
than two days a week, more than three nighttime awakenings per month, more than twice a week
use of short-acting beta-2 agonists for symptom control, or any limitation of normal activity due to
asthma. Regular use of these medications reduces the frequency of asthma symptoms,
bronchial hyperresponsiveness, risk of serious exacerbations, and improves quality of life.
These medications are initiated in a stepwise fashion based on the frequency and severity of the
asthma symptoms. Low-, medium-, and high-dose inhaled corticosteroids are available to treat
mild, moderate, and severe persistent asthma respectively. Inhaled corticosteroids have potent
glucocorticoid activity and work directly at the cellular level by reversing capillary permeability
and lysosomal stabilization to reduce inflammation. The onset of action is gradual and may take
anywhere from several days to several weeks for maximal benefit with consistent use. Metabolism
is through the hepatic route, with a half-life elimination of up to 24 hours. These drugs are
administered through the inhalation route directly to their sites of action. This decreases the
dose required for the desired effect as it bypasses the first-pass metabolism in drugs taken
orally. The reduced systemic bioavailability also minimizes side effects. Inhaled corticosteroids
come in liquid capsule formulations that are given through a nebulizer machine, metered dose
inhalers (MDI) administered through spacers, and dry powder inhalers (DPI). Advantages and
disadvantages of each are as follows:
Nebulizer
 Advantages: Coordination with the patient not required, high doses possible
 Disadvantages: Expensive, more time required (10 to 15 minutes per dose), contamination
of machine
Metered Dose Inhalers (MDI)
 Advantages: Less expensive than nebulizers, convenient, faster to use, dose counter
 Disadvantages: Coordination is essential if not using a mask, pharyngeal deposition,
difficult to deliver high doses
Dry Powder Inhaler (DPI)
 Advantages: Portable, dose counter, less coordination needed compared to MDI
 Disadvantages: Needs higher inspiratory flow to use effectively, pharyngeal deposition of
medication, cannot use in mechanically vented patients
Local adverse effects of inhaled corticosteroids include dysphonia, oral candidiasis, reflex cough,
and bronchospasm. These adverse effects are less common with low-dose inhaled corticosteroids
than with high-dose inhaled corticosteroids. These adverse effects are also mitigated by spacer use
when taking the medication via metered dose inhalers.