Asthma Practicum
Friday 3/9/07 Noon Conference
Station 4 Quiz
Dr. Grace Cheng, General Pediatrics Hospitalist
1. List 3 local side effects of inhaled corticosteroid use. Are any preventable, if so by what action?
2. List 5 systemic adverse effects of inhaled corticosteroid use.
3. What (if any) contraindications are there for inhaled corticosteroid use?
4. List 3 side effects of inhaled B-agonist use.
5. Why does B-agonist use sometimes precipitate worsened hypoxia in an asthmatic?
6. What (if any) contraindications exist for inhaled B-agonist use?
ANSWERS
1. List 3 local side effects of inhaled corticosteroid use. Are any preventable, if so by what action?
1. oral candidiasis
-positive Candida throat cx in 45-58% pts, clinical thrush in 0-34% pts
-low dose ICS = 5% candidiasis, more common in adults than children
-PREVENTION/Rx: spacer if CFC inhaler (no data yet if HFA + spacer decreases candidiasis), rinse
mouth with water after inhalation, administer less frequent dosing (bid instead of qid), treat infections
with topical or oral antifungal agents
2. dysphonia (difficulty with vocal cord function)
-in 5-50% pts, worse with higher doses ICS
-PREVENTION/Rx: use spacer/MDI which is NOT breath-activated (e.g. not diskus, not tube DPI),
temporarily reduce dosage
3. reflex cough/bronchospasm
-PREVENTION/Rx: slower rate of inspiration, possibly pre-treatment with SABA
2. List 5 systemic adverse effects of inhaled corticosteroid use (7 possible below)
1. Reduced linear growth
-higher doses of ICS have greater potential for growth suppression, but high doses of ICS have less
linear growth suppressive effect than oral systemic corticosteroid use.
-data for low-to-medium dose ICS therapy shows possible but not predictable adverse effect on linear
growth
-poorly controlled asthma may delay growth in children
2. Bone mineral density (in adults)
-dose-dependent reduction in BMD associated w/ ICS use in pts > 18 yrs, not observed in children
-PREVENTION: if pt has risk factor for osteoporosis or low BMD scores, consider bone-protecting Rx
(bisphosphonate), consider measuring BMD q 1-2 yrs, depending on ICS and h/o oral steroid dose /
prior BMD scores
3. Disseminated varicella
-case reports of children taking immunosuppressive doses of systemic corticosteroids developing fatal
disseminated dz from varicella infection (also Strongyloides, TB) --- high dose ICS has theoretical risk
-PREVENTION/Rx:
-children requiring episodic systemic corticosteroids without h/o clinical varicella should get
varicella vaccine—NOT if receiving immunosuppressive doses of systemic corticosteroids (2 mg/kg
or 20 mg/day of prednisone for > 1 month)
-children who completed short prednisone course can get varicella vaccine without delay
-if child receiving immunosuppressive doses of corticosteroids exposed to varicella, consider oral
antiviral Rx; if clinical varicella develops, IV antiviral agent required
4. Dermal thinning and increased skin bruisability
-dose-dependent
5. Ocular effects
-glaucoma and cataracts NOT increased in children on low-medium dose ICS
-adults with long-term ICS exposure do have increased prevalence of cataracts, and increased prevalence
of glaucoma if family history positive for glaucoma
-PREVENTION/Rx: periodic assessment and treatment for increased intraocular pressure in asthmatics,
esp if FH glaucoma or higher dose ICS use over time
6. hypothalamic-pituitary-adrenal axis
-rarely, an ICS can cause HPA suppression, which can be dangerous if a metabolic stressor occurs and
there is consequent adrenal insufficiency (symptoms indicating this include acute hypoglycemia, altered
consciousness, hemodynamic collapse, coma, convulsion. Symptoms suggesting adrenal insufficiency
are nonspecific: lethargy, weight loss, anorexia, hyperpigmentation, vomiting, hypoglycemia, electrolyte
imbalance)
-PREVENTION/Rx: (Effects of glucocorticoids on the hypothalamic-pituitary-adrenal axis in children and adults. Gulliver T Immunol Allergy Clin North Am - 01-AUG-2005; 25(3): 541-55, vii)
-consider assessing HPA axis if pt on > 500 mcg/day of inhaled fluticasone or equivalent (??John),
also assess axis if suddenly reducing doses of ICS
–inform families of pts on high-dose ICS for possible need for systemic steroids with significant
illnesses or surgery
7. glucose metabolism
-at > 1000 mcg/day of inhaled budesonide, significantly greater rise in serum fasting insulin levels and
glucose during gtt noted but results still within normal limits
3. What (if any) contraindications are there for inhaled corticosteroid use?
-serious adverse reaction to steroid use in the past
-consider carefully risks and benefits of use in pts with:
-active varicella
-glaucoma or cataracts
-history of adrenal insufficiency or concern for HPA axis function
4. List 3 side effects of inhaled B-agonist use.
(Beta-agonists. Dutta EJ - Med Clin North Am - 01-SEP-2002; 86(5): 991-1008)
1. Tremor: most common, from muscle B2-receptor stimulation
2. Tachycardia: from B1 and B2 receptor stimulation in heart; arrhythmia rarely reported prolongation of
QTc possible; possible increased risk of acute coronary events in adults
3. Hypokalemia: from B2-receptor mediated stimulation of the membrane-bound sodium-potassium pump,
dose-related effect
5. Why does B-agonist use sometimes precipitate worsened hypoxia in an asthmatic?
-reversal of potential hypoxemic vasoconstriction in pulmonary vasculature leads to changes in blood flow
distribution, causing an increase in ventilation – perfusion mismatch, should last < 10 min
6. What (if any) contraindications exist for inhaled B-agonist use?
-serious adverse reaction to beta-agonist use in the past (rare case reports of urticaria, angioedema, anaphylaxis
esp to levalbuterol) (?? John)
-congenital prolonged QT syndrome
-consider carefully risks and benefits of use in pts with:
-cardiovascular disorder, coronary insufficiency
-hyperthyroidism, pheochromocytoma (potentiate sympathomimetic effects on body)
-avoid concomitant use with MAO inhibitors, TCAs (potentiate B-agonist action on peripheral vasculature
causing severe hypotension), monitor if concomitant digoxin use (digoxin level increases with B-agonist use)