Long Term Inhaled Steroids vs Intermittent Oral Steroids


Inhaled corticosteroids (ICS) have been the mainstay of asthma treatment for over 30 years.  The steroid molecules have improved considerably over time, with greater topical potency and less systemic side effects.  During that time, numerous studies have shown that ICS are effective at reducing symptoms, exacerbations, hospitalizations, and death due to asthma.  Likewise, there have been numerous studies examining the side effects of these medications which have shown that in low to medium doses, there are few if any systemic complications.  In the highest doses, there may be a slight increase in cataracts and loss of calcium from the bone.  But, and this is a very important point, these risks have to be weighed against the risks of the alternative: more symptoms, more exacerbations and more oral steroid use.

A common concern voiced by patients and parents is, “I don’t like taking medications” or “I don’t want my child to be on daily medications”.  It’s right to be thoughtfully critical of regular medication use, but, by the same token, if regular medications are helpful and are the better alternative, then they are a good choice.  In order to explain why regular ICS are a good choice, I’ve got to do a little math.  Let’s say you were just using a rescue inhaler for asthma control and that during the last year you only required one course of oral steroids, prednisone.  A usual prednisone “burst” is 40mg a day for 5 days for a total of 200mg or 200,000mcg.  By way of comparison, each dose of Advair 100/50 contains 100mcg of fluticasone, the steroid.  If you took Advair 100/50 twice a day, the usual dose, it would take you 1000 days of regular use to equal the amount of steroids in one burst of prednisone on a mcg-per-mcg basis.

But wait, there’s more.  When you swallow a predinisone pill, 100% of the drug makes it into your system.  Doctors call this bioavailability.  In contrast, the bioavailability of inhaled steroids, especially the newer molecules is very low, from 1-6%.  Why is this? When you use an ICS, you swallow a significant amount of the drug.  When the swallowed portion is absorbed in the stomach, it travels directly to the liver where it is broken down and inactivated.  This is called first pass metabolism.  A part of the inhaled portion of the drug  can still make it into the blood stream.  This part is not immediately inactivated by the liver and, therefore, is the portion which can lead to systemic side effects.  So, back to the math: if only 1% of the inhaled steroid dose in Advair is bioavailable, then you multiply 1000 days by 100 to get 100,000 days of regular use to equal one burst of prednisone on a bioavailable mcg-per-mcg basis.

To be completely honest, the newer inhaled steroids are more potent than prednisone on a mcg-per-mcg basis which means the 100,000 day number is inflated.  Also, the amount of steroid that is absorbed and the subsequent systemic side effects vary based on delivery device, inhaler technique, and timing of administration.  Nevertheless, the underlying point holds true:  one round of oral steroids is worth a whole lot of inhaled steroids.  Given this and the quality of life improvements afforded by regular inhaled steroids, in all but the mildest asthmatics the tradeoff is a no-brainer.


  1. Oral steroids?

    I am a 75 yr old male in good health-no significant health issues- except ongoing allergies.
    Skin tests and countless exams have not revealed reason for my allergic reactions. These include congestion, sneezing, mucous…just overall lousy feelings. All allergy meds I have used DO CONTROL the allergy problem but with a serious side effect—urination problems. My sleep is often interupted 5x a night. I do take meds for enlarged prostate in an effort to control my problem.

    Recently I had a shoulder pain and my Dr prescribed a 5day round of prednissohlone in the METHYLPRED 4MG Pak. Not only did this med help my shoulder pain but my allergy and urination problems totally stopped (for 8 days as this is written).

    I previously had taken some of the steriodal sprays which stopped the allergy but aggravated the urination problem.

    Should I now consider oral steroids for my ongoing allergies?

    I am a TN resident and could travel to one of your middle Tn locations if you recommend.

    Thank you.

  2. Oral steroids’ beneficial effects can be pretty non-specific, they help a wide range of problems including, but not limited to, allergies. As an occasional, short-term treatment they are ok to use for severe symptoms, but long term use will certainly cause complications. They are not a long-term answer.

    Nasal steroids shouldn’t cause the urinary symptoms you describe, especially if oral steroids didn’t. Decongestant pills can cause urinary frequency as do some older antihistamines.

    The incidence of allergies declines as one ages, so a 75 year-old’s nasal symptoms are less likely to be due to allergies. In my experience, allergy blood tests are a better option for your age group, though statistically, they are likely to be negative in a 75 year-old. Nevertheless, it is still important to rule out allergies and some other potential causes as well. If you haven’t seen a board-certified allergist, that would be a good next step.

  3. The long term inhaled steroid is more addictive compared to the other one. The user will be dependent with the drug as time pass by.

  4. One of the long term side effects of the inhaled steriod in children is growth suppression.

    This summer my daughter got pneumonia and was put on 2 rounds of oral steriod prednisone.

    Although she would be getting the same or more amount of steriod in her system from the oral, would it have any effect on her growth velocity with it being a short term dose?

  5. I have copd and have been on symbicort for about 6 years..what are the long term dangers.

    • The short answer is very little. At high doses, long term use of older inhaled steroids has been associated with cataracts. I’m not aware that this has been shown with newer drugs like the budesonide in Symbicort. In emphysema patients, high dose ICS led to a slight increased risk of pneumonmia. However, the benefits of these medications generally outweigh the risks. You also have to consider the quality of life improvements and the risk of not taking the medications.

  6. I’m a male in my 50’s. At a point in my life in my 40’s, I was on Advair 100/50 2X daily for about 9 months for asthma. Within a week after I had stopped, I experienced no adverse reaction other than I noticed considerable amount of facial acne and my sex drive shot up a little. This was going on for about a month, then it seemed to settle down back to normal. About 2 months after that, I noticed my hair had thinned out on top. Believe me, there is a systemic effect with ICS. Quick question – is 9 months on Advair considered long term or short term? Thanks.

    • You describe side effects of anabolic steroids, like testosterone. They are totally different from the glucocorticoids found in many asthma inhalers. Inhaled corticosteroids have never been associated with acne, libido, or hair loss.

  7. As a Respiratory Therapist and Asthma educator I greatly appreciate how you have broke this down. Daily I talk to parents and educate them the importance of daily inhalers vs oral steroids every 2-3 months. I had my own break down to it but yours is very clear cut and takes into account the first pass. Thank you! I have referred a couple parents here already to read your article.

  8. My son is 3 years old. Since his 3rd (04/2012) birthday he has been prescribed oral prednisolone 6 times (2tsp daily for 5 days). He has not been officially diagnosed with Asthma as the symptoms only hit him when he gets a virus. They conclude it to be viral or intermittent as he has no allergies that we can detect. My doctor is talking about putting him on an inhaled steroid through the sick months. October-April. Is this beneficial for his little growing body? any full time medication scares me. I just want what is best with the least effects on his growth and well being.
    Thank you.

  9. Can you take inhaled steroids at the same time that your taking oral steroids,prednisone, 20mg. per day?

  10. I’ve got, Copd, and been on long-term oral prednisone steroids more on then off now for a year and eight months, now my doctor is trying to take me off prednisone and put me on inhaled steroids, but I see all these worse side effects that state on the packaging’s of those inhaled steroids, and it’s alot of them, compared to the side effects of the oral prednisone steroid, so how can they say inhaled steroids are better and lesser side effects, when the inhaled steroids say more side effect possibilities, and more dangerous one’s then the prednisone?

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