Hanania N A, Chapman K R, Kesten S
Asthma Centre, Toronto Hospital, University of Toronto, Canada.
Am J Med. 1995 Feb;98(2):196-208. doi: 10.1016/S0002-9343(99)80404-5.
Inhaled corticosteroids are considered by many to be the anti-inflammatory therapy of choice in adult asthma, given their remarkable efficacy and apparent safety. They are presently being prescribed to more patients, at larger doses, and for longer periods of time than ever before. Oropharyngeal candidiasis and dysphonia are the most commonly recognized adverse effects of therapy, but these topical phenomena cause no significant morbidity and are easily managed. By contrast, there is now increasing concern about the potential systemic effects of inhaled corticosteroids. These putative effects may include adrenal suppression, bone loss, skin thinning, increased cataract formation, decreased linear growth in children, metabolic changes, and behavioral abnormalities. Changes in adrenal function have been noted in patients using medications such as beclomethasone dipropionate and budesonide in doses exceeding 1,500 micrograms/day. The clinical relevance of these changes has yet to be clarified. Several short-term and cross-sectional studies have also revealed changes in biochemical markers of bone turnover and retrospective studies have found reduced bone density in asthmatics treated regularly with inhaled steroids. Long-term prospective studies assessing bone density changes remain to be done. Although much controversy exists, there is no unequivocal evidence that conventional doses of inhaled steroids significantly retard bone growth in children. Reports on skin changes, increased cataract formation, and behavioral changes are difficult to interpret because of several confounding factors. Although inhaled steroids should, at the present time, continue to be a recommended therapeutic option to all patients with symptomatic asthma, they should always be used in the lowest dosage compatible with disease control.
鉴于吸入性糖皮质激素具有显著疗效和明显安全性，许多人认为其是成人哮喘抗炎治疗的首选药物。目前，使用吸入性糖皮质激素的患者比以往任何时候都更多，剂量更大，疗程更长。口咽念珠菌病和发音困难是最常见的治疗不良反应，但这些局部现象不会导致明显的发病率，且易于处理。相比之下，现在人们越来越关注吸入性糖皮质激素的潜在全身影响。这些假定的影响可能包括肾上腺抑制、骨质流失、皮肤变薄、白内障形成增加、儿童线性生长减缓、代谢变化和行为异常。使用丙酸倍氯米松和布地奈德等药物且剂量超过1500微克/天的患者已出现肾上腺功能变化。这些变化的临床相关性尚待阐明。几项短期和横断面研究也揭示了骨转换生化标志物的变化，回顾性研究发现，经常接受吸入性糖皮质激素治疗的哮喘患者骨密度降低。评估骨密度变化的长期前瞻性研究仍有待开展。尽管存在诸多争议，但尚无明确证据表明常规剂量的吸入性糖皮质激素会显著延缓儿童骨骼生长。由于存在几个混杂因素，关于皮肤变化、白内障形成增加和行为变化的报告难以解读。尽管目前吸入性糖皮质激素仍应继续作为所有有症状哮喘患者的推荐治疗选择，但应始终以与疾病控制相适应的最低剂量使用。
