• Take into account the use of other systemic or topical corticosteroids when assessing risk.
• Elderly people and children may be particularly susceptible to adverse effects.

Local adverse effects:

• Oral candidiasis, sore mouth, dysphonia, and hoarseness are commonly recognized problems with inhaled corticosteroid (ICS) use, especially in high doses:
• For people using a pressurized metered-dose inhaler, these effects may be reduced by using a large-volume spacer device (which reduces oropharyngeal deposition by filtering out larger particles) [DTB, 2000; RPSGB, 2006].
• Oral candidiasis can be minimized by rinsing the mouth with water after ICS inhalation.
• Oropharyngeal deposition is high with dry-powder inhalers and autohalers.

Systemic adverse effects — adults:

• Osteoporosis: there are concerns that inhaled corticosteroids may affect bone mineral density, particularly when given in high doses for long periods, but the evidence regarding this is conflicting [SIGN and BTS, 2009]:
• In people who require high doses of ICS for prolonged periods of time, general measures to counteract osteoporosis (such as regular exercise, smoking cessation, and adequate dietary calcium) are prudent.
• Adrenal suppression: evidence indicates that high doses of ICS (equivalent to 1.5 mg/day CFC-containing beclometasone) result in significant adrenal suppression [EBM, 1999]. The risk of adrenal insufficiency is dose related and is largely due to use of oral corticosteroids, although inhaled corticosteroids may have an effect when they are taken at higher doses [Mortimer et al, 2006]:
• Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained [SIGN and BTS, 2009].

Systemic adverse effects — children:

• The Committee on Safety of Medicines has 'strongly advised that the paediatric licensed doses of all inhaled corticosteroids should not be exceeded' [CSM, 2002]. Use the lowest dose of ICS that will maintain disease control. If adequate control is not achieved, consider using add-on agents rather than increasing the dose of ICS [SIGN and BTS, 2009].
• Childhood growth: some initial slowing of growth may occur in children who have used ICS, but final adult height does not appear to be affected [Childhood Asthma Management Program Research Group, 2000; MeReC, 2002]:
• All children receiving prolonged treatment with ICS should have their height regularly and accurately monitored using a growth chart [CSM, 1998]. Any slowing of growth should prompt a reduction in dose if possible, or referral to a specialist, or both.
• Bone mineral density: one long-term study in children with chronic asthma treated with ICS suggests no adverse effect of ICS on bone mineral density in children [Agertoft and Pedersen, 2000]. Further long-term studies are needed to confirm this. However, experts suggest that with careful ICS dose adjustment, this risk is likely to be outweighed by the ability of ICS to reduce the need for multiple courses of oral corticosteroids [Kelly et al, 2008].
• Acute adrenal crisis: in a small number of children, doses of inhaled ICS at or above 400 micrograms per day of beclometasone have been associated with growth failure and adrenal suppression. The exact dose and duration of ICS treatment to put a child at risk of adrenal insufficiency is unknown, but it is likely to be 1000 micrograms or more of beclometasone or equivalent daily [SIGN and BTS, 2009]:
• Specific written advice about steroid replacement in the event of a severe intercurrent illness should be part of the management plan for children treated with 800 micrograms or more of beclometasone or equivalent daily.
• Any child receiving this dose should be under the care of a specialist paediatrician for the duration of the treatment.
• Consider use of a steroid treatment card.
• Consider the possibility of adrenal insufficiency in any child maintained on inhaled steroids presenting with shock or decreased consciousness:
• Check serum biochemistry and blood glucose levels urgently.
• Consider whether intramuscular hydrocortisone is required.