Barnes Neil C
The London NHS Trust School of Medicine and Dentistry, London, UK.
Prim Care Respir J. 2007 Jun;16(3):149-54. doi: 10.3132/pcrj.2007.00038.
Inhaled corticosteroids remain the most important therapy for chronic asthma in both adults and children. As all inhaled corticosteroids act by binding to a common glucocorticoid receptor there is little evidence of any real difference in clinical efficacy between the different inhaled corticosteroids. The main potential differences are in their propensity to cause side effects. Local side effects such as a hoarse voice do occur in a proportion of adults and there is some limited evidence that ciclesonide may cause less local side effects. In adults there is little evidence for clinically important systemic side effects from doses of inhaled steroids below 800 mcg/day (beclomethasone equivalent). Above this dose a proportion of patients may show some adrenocortical suppression, though it is unlikely to be of clinical importance. Data on bone mineral density and fracture rates is discrepant, but an overview would suggest that below 800 mcg/day there is no increase in fracture risk whereas above this dose there might be an increased fracture risk. The properties of ciclesonide would suggest that it has less propensity for systemic side effects, but large long term studies are needed to confirm this. In children using inhaled steroids at above-licensed doses reductions in short-term growth can occur, but there is little evidence for reductions in long-term growth at normal doses. At above-licensed doses, biochemical adrenocortical suppression can occur with some unusual but documented cases of clinical Addisonian crisis. Limited evidence in paediatric age groups would suggest that ciclesonide may have some advantage although it is not as yet licensed in all countries for paediatric use. Data on differences in side effects between normal and asthmatic patients, and between asthmatic patients with near-normal lung function compared to those with impaired lung function, indicate that inhaled corticosteroids (particularly fluticasone) are absorbed more in those with normal lung function; this strongly supports stepping down the inhaled steroid dose when asthma is controlled - as is recommended in asthma guidelines.
吸入性糖皮质激素仍然是成人和儿童慢性哮喘最重要的治疗方法。由于所有吸入性糖皮质激素都是通过与共同的糖皮质激素受体结合发挥作用，几乎没有证据表明不同吸入性糖皮质激素在临床疗效上存在真正差异。主要的潜在差异在于它们引起副作用的倾向。局部副作用如声音嘶哑在一部分成人中确实会出现，并且有一些有限的证据表明环索奈德可能引起较少的局部副作用。在成人中，几乎没有证据表明低于800微克/天（相当于倍氯米松）的吸入性类固醇剂量会产生具有临床重要性的全身性副作用。高于此剂量，一部分患者可能会出现一定程度的肾上腺皮质抑制，尽管这在临床上不太可能具有重要意义。关于骨密度和骨折发生率的数据存在差异，但总体情况表明，低于800微克/天骨折风险不会增加，而高于此剂量骨折风险可能会增加。环索奈德的特性表明它产生全身性副作用的倾向较小，但需要大型长期研究来证实这一点。在使用高于许可剂量吸入性类固醇的儿童中，短期生长可能会减缓，但几乎没有证据表明正常剂量会导致长期生长减缓。在高于许可剂量时，可能会出现生化性肾上腺皮质抑制，并有一些不寻常但有记录的临床肾上腺皮质危象病例。儿科年龄组的有限证据表明环索奈德可能有一些优势，尽管它尚未在所有国家获得儿科使用许可。关于正常患者与哮喘患者之间以及肺功能接近正常的哮喘患者与肺功能受损的哮喘患者之间副作用差异的数据表明，吸入性糖皮质激素（特别是氟替卡松）在肺功能正常的患者中吸收更多；这有力地支持了在哮喘得到控制时降低吸入性类固醇剂量，这也是哮喘指南中所推荐的。
