Corticosteroid Therapy in
AsthmaAttaran D, MD,Pulmonologist , Associate professor ,
Mashhad University of Medical Sciences
Attaran D, MD,Pulmonologist , Associate professor ,
Mashhad University of Medical Sciences
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
Steroids are the most effective therapy for asthma
Steroids are recommended as the first line therapy for all patients
Inhaled steroids have been a great advance in the management of asthma
Inhaled steroids control inflammation & symptoms without significant side effects
Anti inflammatory gene activation
Switching off inflammatory genes
Inflammatory cell inhibition ( lymph , Mast cell, Eos , Mac )
Increased B2 receptor effects
Steroids have no distinct effects on airway muscle
Molecular effects of corticosteroidsMolecular effects of corticosteroids
Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD
Asthma Inflammation: Cells and MediatorsAsthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD
AsthmaAsthma Inflammation: Cells and MediatorsInflammation: Cells and Mediators
A single dose of steroids has no effect on the early response to allergen But does inhibit the late response
The fraction of steroid that is inhaled acts locally on the airway mucosa Systemic absorption from airway, alveolar surface &
oropharyngeal swallowing Absorbed fraction metabolized in the liver ( first pass
metabolism ) Budesonide & Fluticasone have a greater first pass metabolism
Clinlcal useClinlcal use
Estimate Comparative Daily Dosages for Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeInhaled Glucocorticosteroids by Age
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200
600-1000 >200-400 >1000 >400
Budesonide-Neb Inhalation Suspension
250-500
>500-1000
>1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750
>1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200
>250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200
> 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800
>1000-2000 >800-1200 >2000 >1200
Use of spacer reduce oropharyngeal deposition and complications
Low dose inhaled steroid up to 400mcg BDP ( 250mcg Fluticasone )
Medium dose inhaled steroid up to 1000mcg BDP ( 500mcg F )
High dose inhaled steroid up to 2000mcg BDP (1000mcg F )
Usual maintenance dose is 10-15 mg
Oral steroids are usually given as a single dose in the morning
In acute severe asthma maximal beneficial effect is usually achieved with 30-40 mg Prednisolone daily
Steroid ComplicationsSteroid Complications
Suppression of HPA axis (dose dependent & duration)
Systemic effects
Localized effects
Steroid Insensitive AsthmaSteroid Insensitive Asthma
DiagnosisDiagnosis
Management of SR or SI AsthmaManagement of SR or SI Asthma
Evaluation for comorbid or masquerading conditions
VCD,GERD, ABPA,HP,Upper airway dis
Assessing of persistent tissue inflammation ( e NO , ECP ) Ensure adequate treatment adherence
Possible microbial infection ( MP , CP )
Combination therapy with LABA
Final step is use of alternative anti
inflammatory & immunomedulatory
( Omalizomab ,Cyclospurine ,IV Ig )
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