Question
What is the first inhaled corticosteroid of choice for young children? Is there any evidence that inhaled corticosteroids have an effect on the oral mucosa?
Sergio Manuel Bernal Granillo, MD
Response From the Expert
Mark T. O'Hollaren, MD
Director, Allergy Clinic, LLC, Clinical Professor of Medicine, Oregon Health & Science University, Portland, Oregon
The choice of an inhaled corticosteroid is often an individualized one. Often, the delivery system for the medication is taken into account when making that choice. In the United States, budesonide is the only inhaled corticosteroid available in nebulized form for administration to children who are unable to use a metered-dose inhaler. Spacer devices, with a mask attachment if necessary, are also available to help with the administration of metered-dose inhaled corticosteroids.
Budesonide has been carefully studied in the Childhood Asthma Management Program research study involving over 1000 children (aged 5-12 years). In this study, children were given placebo, budesonide, or nedocromil. After treatment, the children who had received budesonide had lower airway responsiveness to methacholine, fewer hospitalizations, fewer urgent visits to a caregiver, and a greater reduction in the need for albuterol for symptom control. They also required fewer courses of prednisone and had a smaller percentage of days in which additional asthma medication was needed. During the course of this study, the mean increase in height in the budesonide group was 1.1 cm less than in the placebo group; this difference was evident mostly within the first year. It appears that this small suppression in growth velocity was transient. It should also be pointed out that untreated asthma can result in suppression of growth. There were no significant ocular, psychiatric, bone density, or other side effects from treatment with inhaled budesonide.
Treatment with inhaled corticosteroids can result in some transient oral and oropharyngeal side effects, such as sore throat, hoarseness, and oropharyngeal candidiasis. These side effects are usually prevented by good mouth rinsing and use of a spacer device (in the case of metered-dose inhalers). Local oropharyngeal candidiasis may need specific treatment. Rarely, side effects may be significant enough to warrant discontinuation of the drug. I am not aware of any long-term, significant, local oral mucosal side effects from the use of inhaled corticosteroids.