Letters Guidance on inhaled corticosteroids

Inhaled corticosteroids: first do no harm

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8204 (Published 20 December 2012) Cite this as: BMJ 2012;345:e8204
  1. Vincent H F Mak, consultant physician1
  2. On behalf of the NHS London Respiratory Team Programme Board
  1. 1Central Middlesex Hospital, London NW10 7NS, UK
  1. v.mak{at}nhs.net

Mackenzie highlights the lack of guidance on use of inhaled corticosteroids (ICS) and risk of adrenal suppression.1 The Medicines and Healthcare Products Regulatory Agency recommends issuing a steroid treatment card,2 but there is concern that this may alarm patients and reduce adherence. There is also no consensus on what constitutes a high dose.

High potency combination inhalers (ICS and long acting β agonist; daily dose ≥1000 µg beclometasone equivalent a day) are costly and the most commonly prescribed combination inhalers (www.drugtariff.co.uk). This suggests that a disproportionate number of people with asthma in England are at step 4 or above of the guidelines of the British Thoracic Society/Scottish Intercollegiate Guidelines Network. High dose ICS at step 4 is supported by grade D evidence only. Such inhalers are also commonly used in chronic obstructive pulmonary disease (COPD), but their role in the management of COPD is not clear.3 Use of high dose ICS exposes patients to the risk of adrenal suppression, increased risk of non-fatal pneumonia in COPD, and other well known side effects.4

The London Respiratory Team has developed a specific high dose ICS patient safety card and prescribing notes that are currently being evaluated by prescribers and patients. The prescribing notes outline the risks of high dose ICS, the limited evidence for use of high doses in asthma, and lower doses that can be used in COPD. They also explain that ensuring proper inhaler technique and adherence is often more cost effective and safer than stepping up the dose. The information aims to make prescribers more aware that, to avoid issuing a card, lower doses of ICS can be equally effective when used correctly and that more cost effective evidenced based interventions can be used.


Cite this as: BMJ 2012;345:e8204


  • Competing interests: None declared.