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Side Effects With Inhaled Corticosteroids: Control and Monitoring of Side Effects Local Side Effects

Published in Asthma

The only other systemic side effect with ICS mentioned in the NAEPP 1997 guidelines was disseminated varicella infection. While oral corticosteroid use, with or without immunosuppression, has been associated with a high risk of severe varicella infection compared with case-matched control sub-jects, no causal relationship has been shown with ICS, despite sporadic case reports of severe varicella infections in patients receiving ICS.
The 1997 NAEPP guidelines suggested the following clinical interventions to mitigate the risk of, or treat, local side effects:
• Oral candidiasis (thrush): use a spacer/holding chamber, rinse mouth with water after inhalation, and administer ICS less frequently (twice daily vs four times daily). Topical or oral antifungal agents should be used to treat active infections. •    Dysphonia: use a spacer/holding chamber, temporarily reduce dosage, or rest for vocal stress.
•    Reflex cough and bronchospasm: use a slower inspiration rate and/or a spacer/holding chamber or pretreat with an inhaled (32-agonist.

These recommendations were based on the evidence available at the time. However, subsequent investigation of some of these interventions has provided contrary results. For example, in a study in children, mouth rinsing or spacer use had no protective effect regarding the development of oral candidiasis. In a study designed to assess the effect of gargling after ICS inhalation, at least in a subgroup of asthmatics using steroid inhalers, gargling with water, or even weak concentrations of amphotericin B did not prevent colonization of the throat with Candida albicans. However, gargling with amphotericin B at concentrations 100 times dilution did prevent clinically detectable oral candidiasis. Moreover, two studies in children showed that dysphonia and cough were more frequent in patients using a spacer device. It is unclear whether patients in these studies were coughing because they were using a spacer device or whether, in line with the guidelines, patients with cough on inhalation were more likely to have been administered a spacer to attempt to reduce the occurrence of this side effect. However, in adults, the use of a large-volume spacing device did not appear to protect against dyspho-nia or cough.