Inhaled corticosteroids may provoke oropharyngeal adverse events

Key Points

Inhaled corticosteroids (ICSs) are associated with a risk of oropharyngeal adverse events, according to a meta-analysis published in the journal Annals of Allergy, Asthma & Immunology.

The study was conducted via an electronic search of MEDLINE (January 1966–June 2004) and EMBASE (January 1974–June 2004). All randomized, placebo-controlled studies that emphasized oral ICSs for treating persistent asthma were eligible for inclusion, and 23 studies were included in the evaluation.

When not considering device, fluticasone yielded the highest risk of oral candidiasis (OR=5.41; P<.001) versus placebo; budesonide was linked to the greatest risk of dysphonia (OR=11.45; P=.02) and pharyngitis (OR=5.09; P=.04) versus placebo.

In comparing doses of various ICSs, at high doses (≥1,000 mcg), beclomethasone demonstrated the greatest risk of oral candidiasis versus placebo (OR=13.64; P=.08), followed by high-dose fluticasone (OR=4.51; P=.01). No data were available for high-dose budesonide, so medium-dose budesonide was used in the comparison for dysphonia and pharyngitis. Medium-dose budesonide (401–999 mcg) was associated with the greatest risk of dysphonia (OR=13.64; P=.08) and pharyngitis (OR=7.17; P=.19) versus placebo.

Comparison of various devices used to administer ICSs demonstrated that for the MDI device, budesonide was associated with the greatest risk of oral candidiasis (OR=19.29) versus placebo at all doses and combined for that group of devices. Fluticasone was associated with the greatest risk of oral candidiasis for the DPI device (OR=4.73). Budesonide MDI and fluticasone DPI were associated with the greatest risk of dysphonia (OR=11.45 and OR=5.70, respectively). The greatest risk of pharyngitis was associated with budesonide MDI (OR=5.08) and budesonide DPI (OR=5.11) versus placebo at all doses and combined in every group of devices.

The authors stated that mouth washing helps remove ICS deposits that remain after inhalation and may help reduce the incidence of oropharyngeal adverse events. However, they noted that mouth washing is not always practical and may lead to decreased adherence due to complicated dosing regimens. Additionally, spacers can help reduce oral deposits and subsequent oropharyngeal adverse events; however, there were insufficient data to assess this effect, according to the authors. Another way to help reduce oropharyngeal adverse events is through dose reduction, although the authors cautioned that this method requires patient monitoring to ensure adequate asthma control.

Rates of oropharyngeal adverse events associated with ICSs may be higher than expected, according to the authors. Furthermore, they stated that this study demonstrated that the risk of oral candidiasis, dysphonia, and pharyngitis increased with dose, no matter which ICS was employed. However, according to the authors, the benefits of using ICSs appeared to outweigh any risk of adverse events.

SOURCE

Rachelefsky GS, Liao Y, Faruqi R. Impact of inhaled corticosteroid-induced oropharyngeal adverse events: Results from a meta-analysis. Ann Allergy Asthma Immunol. 2007;98:225–238.