Pediatric Drugs

, Volume 5, Issue 7, pp 481–504 | Cite as

Safety of the Newer Inhaled Corticosteroids in Childhood Asthma

  • Tabitha L. Randell
  • Kim C. Donaghue
  • Geoffrey R. Ambler
  • Christopher T. Cowell
  • Dominic A. Fitzgerald
  • Peter P. Van Asperen
Review Article

Abstract

Inhaled corticosteroids (ICS) remain a vital part of the management of persistent asthma, but concerns have been raised about their potential adverse effects in children. This review examines the safety data on three new ICS — fluticasone propionate, mometasone, and extrafine beclomethasone in hydrofluoroalkane (HFA-134a) propellant (QVAR®1 formulation) in relation to the older corticosteroids.

Topical adverse effects such as thrush and dysphonia are rare, but dental erosion is a possibility with powder forms of ICS because of their low pH. Thus, it is important to stress mouth rinsing after administration and maintaining good dental hygiene to minimize this risk.

Biochemical adrenal suppression can be readily demonstrated, particularly with high doses of all ICS. The clinical relevance of this was uncertain in the past, but there have now been >50 reported cases of acute adrenal crises in children receiving ICS, most of whom were on fluticasone propionate. In order to minimize the risk of symptomatic adrenal suppression, it is important to back-titrate the ICS dose and alert families of children receiving high-dose ICS of this potential adverse effect. A pediatric endocrine opinion should be sought if adrenal suppression is suspected. The older ICS cause temporary slowing of growth velocity, but the limited data available do not show any significant compromise of final adult height. The effect on growth of fluticasone propionate may not be as great as with the older ICS, but the studies have been short term and only used low doses of fluticasone propionate. There have been case reports of growth suppression in children receiving high doses of fluticasone propionate. The limited studies performed on the effect of ICS on bone mineral density in children did not show any adverse effects, but there may be an increased risk of fractures.

Hydrofluoroalkane beclomethasone (QVAR) is essentially the same drug as chlorofluorocarbon beclomethasone, but with double the lung deposition owing to the smaller particle size. Thus, it could be expected that any adverse effects seen with chlorofluorocarbon beclomethasone would be the same with hydrofluoroalkane beclomethasone. However, some of the published data, particularly in adults, suggest that hydrofluoroalkane beclomethasone may be less systemically active than chlorofluorocarbon beclomethasone, even at equipotent doses. As yet, there are no long-term data on mometasone, but initial studies in adults suggest there may be less suppression of the hypothalamic-pituitary-adrenal axis, although further studies are required, particularly in children.

ICS will remain a cornerstone in the management of persistent pediatric asthma, provided that the diagnosis of asthma is secure. It is very important to use ICS appropriately and to ensure the lowest possible doses are used to achieve symptom control, thus minimizing the risk of serious adverse effects.

Notes

Acknowledgements

The authors wish to thank Dr Amabel Clavano for allowing us to reproduce her data on bone mineral density.

References of relevant studies were sought from the manufacturers of the ICS. No sources of funding were used to assist in the preparation of this manuscript. The authors believe that there are no potential conflicts of interest that are directly relevant to the content of this manuscript.

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Copyright information

© Adis Data Information BV 2003

Authors and Affiliations

  • Tabitha L. Randell
    • 1
  • Kim C. Donaghue
    • 1
    • 2
  • Geoffrey R. Ambler
    • 1
  • Christopher T. Cowell
    • 1
    • 2
  • Dominic A. Fitzgerald
    • 2
    • 3
    • 4
  • Peter P. Van Asperen
    • 2
    • 3
  1. 1.Institute of Endocrinology and DiabetesThe Children’s Hospital at WestmeadSydneyAustralia
  2. 2.Discipline of Paediatrics and Child HealthUniversity of SydneySydneyAustralia
  3. 3.Department of Respiratory MedicineThe Children’s Hospital at WestmeadWestmead, SydneyAustralia
  4. 4.Division of Academic and General MedicineThe Children’s Hospital at WestmeadSydneyAustralia

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