GPAtlas🧭 When to suspect
Inhaled corticosteroids (ICS) are the cornerstone anti-inflammatory treatment in asthma and are used selectively in chronic obstructive pulmonary disease (COPD). At the low-to-medium doses taken by most patients they are safe and highly effective, and their benefits – fewer exacerbations and fewer asthma deaths – far outweigh their risks. Suspect an ICS-related problem when a patient develops local side effects (hoarseness, oral thrush) or features of systemic absorption, particularly on high doses long-term, on a potent agent (fluticasone), or when an interacting drug has been started.
Two practical skills matter in primary care: recognise and treat the common, benign local effects (largely prevented by a spacer and mouth-rinsing), and stay alert to the uncommon but serious systemic effects of high-dose therapy – chiefly hypothalamic–pituitary–adrenal (HPA) axis suppression. The unifying principle throughout is to prescribe the lowest effective dose.
| Local effects (common, dose-related) | Systemic effects (uncommon, high-dose / long-term) |
|---|---|
|
• Oral candidiasis (thrush) – the commonest, affecting roughly 1 in 30 users • Dysphonia / hoarseness – often a laryngeal myopathy rather than thrush • Throat irritation, cough, reflex bronchospasm on inhalation • Paradoxical bronchospasm – rare but potentially severe |
• Adrenal (HPA-axis) suppression → risk of adrenal crisis under stress • Reduced bone mineral density / fracture – modest and dose-dependent • Cataract and glaucoma; rarely central serous chorioretinopathy • Skin thinning, easy bruising, purpura • Reduced growth velocity in children (small, largely non-progressive) • Increased pneumonia risk in COPD; rarely Cushingoid features, hyperglycaemia, mood change |
Risk rises with dose and duration, and is greatest with fluticasone, in children, in the elderly, and when an ICS is combined with a potent CYP3A4 inhibitor. Systemic effects are unusual below a beclometasone-equivalent dose of around 800–1000 micrograms/day.
Source: NICE NG245 · NICE NG115 · MHRA
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