Daniel More, MD, is a board-certified allergist and clinical immunologist. He is an assistant clinical professor at the University of California, San Francisco School of Medicine and currently practices at Central Coast Allergy and Asthma in Salinas, California.

Jurairat J. Molina, MD, is a board-certified allergist who has been practicing in field of allergy and clinical immunology for the past two decades. She owns Corpus Christi Allergy Associates in Corpus Christi, Texas.

Inhaled corticosteroids, also known as steroids or glucocorticoids , are generally used on an ongoing basis to control symptoms of asthma, chronic obstructive pulmonary disease (COPD), or other chronic breathing disorders.

Inhaled steroids work by mimicking cortisol, a hormone produced by the body that normally reduces inflammation (swelling of tissues). By doing so, they relieve chronic airway inflammation, reducing bronchoconstriction (airway narrowing) and bronchospasms (airway contractions).

These medications can have side effects, however. Some of these may be serious. This article will explain the four most common side effects of inhaled corticosteroids. It will also discuss ways they can be treated or prevented.

Corticosteroids should not be confused with anabolic steroids, which are used to stimulate muscle growth.

Some people who use inhaled steroids may develop a hoarse voice. This is referred to as dysphonia. This can occur due to the drug's effect on the muscles of the vocal cords.

Dysphonia affects more than 30% of people on steroid inhalers, although the symptom tends to be mild and pose no long term risks. Generally, dysphonia lasts for days to weeks at a time.

Metered-dose inhalers (MDIs) like Flovent HFA (fluticasone), Asmanex HFA (mometasone), and Qvar Redihaler (beclomethasone) tend to cause less vocal hoarseness than dry-powder inhalers (DPIs) like Flovent Diskus, Asmanex Redihaler, and Pulmicort Flexihaler (budesonide).

Rarely, high-dose steroids may cause laryngopharyngeal reflux. With this, stomach acids back up into the throat, causing pain, vocal cord inflammation, and laryngitis. In such cases, the dose may need to be reduced or the formulation switched.

People who take inhaled steroids are at risk for oral thrush. This fungal infection of the mouth is also known as oral candidiasis. Oral thrush affects roughly 3% of users of inhaled corticosteroids. The risk is increased in people with a weakened immune system as well as in those who overuse the drug or use it incorrectly.

Symptoms of oral candidiasis include:

The infection causes white patches to develop on the roof of the mouth or back of the throat; they can also appear on the tongue, gums, and inner cheeks. If these are scraped off they will reveal inflamed and bleeding tissue underneath.

Thrush can be prevented by rinsing your mouth thoroughly with water and brushing your teeth immediately after inhaled corticosteroid use. Instead of water, some people prefer an alcohol-based mouthwash.

You can also reduce your risk of oral thrush by attaching a spacer to the mouthpiece of the MDI. The tubular extender allows you to deliver the inhaled drug into your throat instead of the mouth. (Spacers do not work in DPIs, which have an opening rather than a tube-like mouthpiece.)

If thrush does develop, it can be treated with an antifungal mouth rinse or with Diflucan (fluconazole) tablets for more severe cases.

Inhaled steroids are known to place older adults at an increased risk for osteoporosis (thinning and weakening of bones). Though osteoporosis is far more likely when taking oral steroids, high-dose inhalants can also contribute to bone brittleness.

Studies suggest that adults who use long-term, high-dose inhaled steroids have a 27% greater risk of fractures due to osteoporosis.

Symptoms of osteoporosis may include:

Many people with osteoporosis do not even realize they have it until they experience an unexpected bone fracture.

A calcium-rich diet paired with a daily calcium supplement (1,000 to 1,500 milligrams combined) is recommended for those at the highest risk of bone fractures. This includes post-menopausal women and older adults.

Weight-bearing exercises (such as walking and lifting weights) can help prevent osteoporosis. If bone loss is severe, it may be necessary for your healthcare provider to adjust your steroid dose.

The long-term use of oral steroids is known to increase the risk of cataracts (clouding of the eye lens) and glaucoma (optic nerve damage caused by increased inner eye pressure). It is possible for inhaled steroids to do the same, especially in older adults already at high risk of these conditions.

A 2018 study in the Digital Journal of Ophthalmology found that adults who used inhaled budesonide for six months or more had significant increases in inner eye pressure.

Similarly, people who take high doses over a long period of time were found to be at greater risk of cataracts than those who received lower doses.

Blurred, dim, or cloudy vision

Fading or yellowing of colors

If you develop glaucoma or cataracts due to inhaled steroid use, your treatment may need to be modified. Surgical intervention may also be considered. Surgical options include laser trabeculectomy for glaucoma and extracapsular surgery for cataracts.

Inhaled corticosteroids are an effective way to treat symptoms of asthma and COPD. They work by reducing inflammation. This relieves narrowing and constriction of the airways. Inhaled steroids can have side effects, however. Some of these are mild and easily treated, such as hoarseness and oral thrush. More serious side effects include osteoporosis and vision problems, such as cataracts and glaucoma.

While some of the side effects of inhaled steroids are concerning, it is always important to weigh the benefits of these medications on your respiratory function against the risks. In most cases, inhaled steroids can be taken safely under the supervision and routine care of a healthcare provider.

If you are experiencing side effects from a steroid drug, speak with your healthcare provider about alternatives or adjustments that may help. But never stop treatment without their approval. Doing so can lead to steroid withdrawal and a return of symptoms.

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