Are inhaled steroids safe? The honest answer

"Doctor, is this a steroid?" — asked in a particular tone, usually a few seconds after the prescription is handed over. It is one of the most common questions in a chest clinic, and one of the most reasonable. The word carries a great deal of baggage, most of it earned by a completely different class of drug.

Here is the honest answer, including the parts that are not reassuring.

They are not the steroids you are thinking of

Two different things share the name.

Anabolic steroids are synthetic testosterone, misused for muscle. They cause the harm people have heard about — heart disease, liver damage, infertility, mood disturbance. These have nothing whatever to do with asthma treatment.

Corticosteroids are versions of cortisol, a hormone your adrenal glands make every day of your life. They reduce inflammation. These are what asthma treatment uses.

Within corticosteroids, the route matters enormously:

• Tablets (prednisolone, and the ones often given as a "steroid course") go through the bloodstream to every tissue. Taken repeatedly or long term they cause the serious effects: weight gain, raised blood sugar, thinning bones, cataracts, skin changes, raised blood pressure.
• Inhaled steroids are delivered directly to the airway lining in microgram doses. Very little is absorbed into the body, and most of what is swallowed is broken down by the liver before it reaches general circulation.

The difference in dose is not marginal. A typical daily inhaled preventer dose is measured in a few hundred micrograms; a short course of steroid tablets is measured in tens of milligrams — hundreds of times more, and distributed everywhere rather than to the airway.

The real side effects

These exist, and nobody should pretend otherwise.

Oral thrush — white patches in the mouth, soreness. Caused by steroid left in the mouth rather than reaching the lungs. Prevented almost entirely by rinsing and spitting after each dose, and by using a spacer.

A hoarse voice — from the effect on the vocal cords. Same prevention; it settles if the dose is reduced or the device changed.

Bruising more easily — seen with higher doses used over years.

Growth in children. This is the one parents ask about, and it deserves a straight answer rather than reassurance. Low-dose inhaled steroids have a small effect on growth rate, mostly in the first year of treatment, amounting to a reduction in final adult height of roughly a centimetre in the studies that followed children to adulthood. That is real. Set against it: poorly controlled asthma itself suppresses growth, and repeated courses of steroid tablets for attacks carry far more risk than the daily inhaler that prevents them.

At high doses, long term, the effects of tablets can begin to appear — adrenal suppression, bone thinning, cataracts. This is why the aim is always the lowest dose that keeps you well, reviewed regularly, rather than the highest dose that seems safe.

Where the fear comes from

It is worth saying that this anxiety is not irrational. It was earned, by a real pattern — just not by inhalers.

Steroid tablets and injections have been handed out freely in India for decades, for fever, for body ache, for "weakness", often without the person knowing what they were taking. People have seen a relative gain weight, swell in the face, develop diabetes or lose bone strength after months on something collected from a shop. Steroids also turn up undeclared in skin-lightening creams and in weight-gain tonics, where they do real harm.

So when a doctor says "steroid", the listener is thinking of that — a systemic drug, taken by mouth, at a dose nobody measured, for a reason nobody explained. The caution is sound. It is simply aimed at the wrong target.

The distinction worth holding on to is route and dose. The harm came from large doses reaching the whole body for a long time. A preventer inhaler delivers micrograms to the surface of the airway, and the dose is written on the canister. These are the same family of molecule used in two almost unrelated ways, and conflating them is how people end up avoiding the version that would have kept them well.

What stopping costs

The question is never "steroid or no drug". It is "steroid, or untreated airway inflammation". That second option has its own side effects, and they are worse.

Uncontrolled asthma means attacks. Attacks mean courses of steroid tablets — the ones with the real risks — several times a year. It means nights without sleep, school and work missed, emergency visits, and in a proportion of people, airway remodelling: scarring that makes the narrowing progressively less reversible. Asthma still kills people, and a large share of asthma deaths occur in people who were not taking a preventer.

Put plainly: the most reliable way to end up taking the dangerous kind of steroid is to avoid the safe kind.

How to reduce the risk that does exist

Use a spacer. It delivers far more of the dose to the lungs and far less to your mouth and throat — which both improves the effect and reduces the local side effects.

Rinse and spit after every dose. Five seconds, and it prevents thrush and hoarseness.

Check your technique. A badly used inhaler deposits the drug in your mouth, which is the worst of both worlds. Five reasons your inhaler has stopped working covers the specific errors.

Be on the right dose. Control should be reviewed at least yearly, and the dose stepped down when you have been stable. A preventer dose set during a bad winter three years ago may be higher than you now need.

Treat what is driving it. If allergy is the trigger, identifying it means less medicine, not more. Allergy testing often changes what a household does more usefully than any prescription.

The reliever-only trap

There is a particular version of this that deserves its own warning, because it feels like the safe choice.

Many people with asthma use only the blue reliever inhaler. It works within minutes, it contains no steroid, and it is easy to obtain without a prescription. Breathing improves, so it appears to be treating the problem.

It is not. The reliever relaxes the muscle around the airway. The inflammation underneath — the swelling and mucus that caused the narrowing — is untouched, and goes on worsening while the symptoms are being erased several times a day. Guidance worldwide now advises against treating asthma with a reliever alone, in large part because of what happens to people who do.

Two numbers to know about your own treatment. Needing a reliever more than twice a week means the asthma is not controlled. Getting through more than two or three reliever canisters a year is associated with a markedly higher risk of a severe attack, and it is one of the few warning signs that can be read off a pharmacy record.

The current approach for many people is a single inhaler combining a low-dose steroid with a fast-acting reliever, so that the anti-inflammatory arrives with every rescue dose — you cannot take the relief without the treatment. Whether that suits you depends on your pattern, but the principle holds: the blue inhaler alone is not asthma treatment.

What a good conversation looks like

If you are worried, these are fair questions to ask, and any doctor should welcome them:

• Which of my inhalers contains a steroid, and at what dose?
• Is that a low, medium or high dose?
• When will we review whether it can be reduced?
• What should I do if I get a hoarse voice or mouth soreness?
• What is my plan for a bad day, so I need fewer tablet courses?

What is not a good plan is stopping quietly and not mentioning it. It is extremely common, entirely understandable, and the usual route to an attack — because a preventer works invisibly, and nothing appears to happen for the first week or two after it is stopped.

The summary

Inhaled steroids at asthma doses are among the better-studied medicines in use, and the balance of risk is not close: small, mostly local, mostly preventable effects, against a condition that causes attacks and occasionally deaths when it is left untreated.

The fear is understandable. It is aimed at the wrong drug.

If you have stopped your preventer, or you are not sure which inhaler is which, bring them all in — the actual devices, not a list — and we will go through them. Book a consultation or call 8563816000.