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 )

خدايا به من آرامشي عطا فرماتا بپذيرم آنچه را نمي توانم تغيير دهمو شهامتي تا تغيير دهم آنچه را

مي توانم و دركي تا بفهم تفاوت اين دو را