To Inhale or Not to Inhale Steroids

We've all seen the ads from Partnership for a Drug Free America that warn us and our children not to take steroids -- a piece of sound medical and moral advice. But this public campaign could be harming our children's health.

What if the poster warned against taking cough syrup lest one develop an addiction. Would we think twice?

Even though the government has recently announced that more and more teens have started abusing over-the-counter cough and cold medications, we're probably not all ready to give up an appropriate dose of cough syrup. Most of us grasp the difference between taking medications responsibly and potentially addictive abuse.

The same can be said for steroids. The drugs can cause problems, but they aren't entirely evil.

Steroids are not all alike, and different kinds of steroids have diverse effects -- both good and bad -- on the mind and body, depending on why and how much you use them.

Steroids are arguably the most effective medication available to control asthma. No steroids? No controlled asthma and no fun kid playtimes.

If you have seen the "avoid steroids" ads, you may have also seen the ad in which the child sadly walks off the gridiron because he cannot keep up with his peers. Fortunately, he is greeted by a celebrity football star, himself an asthmatic, who tells the tike he can play with others as long as he takes his asthma medication -- an inhaled steroid.

Different Steroids Control Airways, Muscles and Sex Appeal

The body manufactures many different kinds of steroid hormones: sex steroids, anabolic steroids (used by athletes of notoriety), steroids that maintain salt and water balance in the body, and steroids that help regulate the body's immune system.

They are all potentially dangerous if used inappropriately, but they are lifesaving if used judiciously.

The steroids used to treat asthma fall into the latter category. They regulate the body's immune response and act on the lower airways that become inflamed during and between asthma attacks -- this inflammation can happen even without a serious attack, so it's important to take a prescription as directed by a doctor.

As steroids reduce inflammation, the airways over time become less sensitive or twitchy, and flare-ups occur less often, as the usual triggers of attacks become less likely to irritate the airways and symptoms are controlled.

The best part is that very low doses of steroids bring great benefit. There is no question that some patients with asthma require higher doses to control symptoms, but this is the exception rather than the rule.

Steroid Medicines Also Risk Overuse

As with any drug, if some is good, more is not necessarily better -- and medical steroid use isn't entirely risk-free.

High doses of steroid medications, even those that are inhaled, can be harmful. The most serious problems occur when the administered steroids fool the body's own adrenal glands, which normally produce steroids. The adrenal glands may then fail to react when the body actually needs them. This little biological foolery can cause dehydration, a drop in blood pressure and low blood sugar.

Sometimes steroid medications are administered in doses that cause the cheeks to become puffy, called a moon-face reaction. The moon face usually doesn't occur when steroids are inhaled, and is almost unheard of if the steroids are taken in appropriate doses.

Another warning -- inhaled steroids can sometimes affect growth in children. Studies in the early 1990s showed that when children begin taking these medications their growth velocity (the rate of growth in millimeters per week) drops just a bit.

Year-long studies have repeatedly shown that over this time frame, a child with asthma who does take steroids will grow on average about one centimeter (1 inch = 2.5 cm) less than a child with asthma who does not take steroids. However, a child with poorly controlled asthma has an even greater risk of suppressed growth. But before we get all bent out of shape over this, science's best estimate is that a child's final adult height may -- and I emphasize may -- be reduced by about half an inch after steroid therapy. This has not been proved, but is understood to be a reasonable estimate of risk. So life-saving steroids may knock off a half inch of final height.

Incidentally, researchers believe that despite this initial slowdown in growth, children with asthma will catch up to their taller peers -- more likely because they receive appropriate treatment with inhaled steroids, not in spite of it.

Weigh Risks, Benefits of Treatment

Ultimately, the decision -- to inhale or not to inhale, so to speak -- boils down to a risk versus benefit analysis, and (conveniently enough) a summarized analysis has come down from the top asthma brass -- a collaboration of the American College of Chest Physicians, the American Academy of Allergy, Asthma, and Immunology, and the American College of Allergy, Asthma, and Immunology.

The preponderance of evidence concludes that the proven clinical effectiveness of inhaled steroid treatment for asthma decidedly outweighs the proven risks. Do not let steroid phobia interfere with your child's well-being.

You want your child to be out there with his or her playmates and not standing dejected at the sidelines.

Dr. Paul Pianosi is a consultant of pediatric pulmonology in the department of pediatric and adolescent medicine at the Mayo Clinic in Rochester, Minn.