Chapter
35
Monitoring for Side Effects from Treatment
Christine A. Sorkness and Valerie A. Schend
Clinical Pearls
l Optimal asthma therapy involves balancing efficacy of a
medication with its side-effect profile.
l Patients most at risk for adverse events with the use of
inhaled corticosteroids are children, the elderly, diabetic
patients, immunocompromised patients, and individuals
with a high daily cumulative dose or prolonged multiple-
year therapy due to persistent disease severity.
l Prolonged administration of high doses of inhaled cor-
ticosteroids has been associated with increased risks of
posterior subcapsular cataracts, ocular hypertension, or
open-angle glaucoma. Annual eye exams are warranted for
patients at risk, especially those requiring intermittent oral
corticosteroids and those with concurrent medical risks.
l Side effects of short-acting beta2-agonists are generally
transient in nature but can be prolonged with long-acting
beta2-agonists. Tachycardia and tremor are the most com-
mon side effects. Active investigation is ongoing regarding
safety of long-acting beta-agonists. At present, they should
be used only in combination with inhaled corticosteroids.
l The most common adverse event noted with leukotriene
modifiers is headache and it is not considered a therapy-
ending occurrence. The reported incidence of headache is
between 12% and 20%, similar to the frequency reported
with placebo. With zileuton, liver function monitoring is
required at baseline and every 2 to 3 months for a 1-year
period, and every 6 months thereafter.
Health care practitioners have the responsibility to balance
the anticipated therapeutic benefits versus the potential risks
of asthma treatments prescribed. The goal is to achieve the
lowest doses of medication needed to achieve and maintain
disease control with the fewest adverse effects possible (ide-
ally none) due to the medications. Adverse effects can be
deleterious to the patient by causing unwanted physiologic
events or misuse or underuse of asthma medications as a
means to minimize unwanted side effects. This chapter dis-
cusses monitoring approaches for side effects from asthma
treatments, with a goal of maximizing therapeutic benefit
from these agents.
Inhaled Corticosteroids
Inhaled corticosteroids (ICSs) are the most effective agents
available for the treatment of persistent asthma in both chil-
dren and adults. Available agents are not equipotent although
algorithms exist to estimate microgram dose equivalencies.
There is abundant literature describing ICS efficacy in improv-
ing all aspects of asthma control including decreased asthma
symptoms and rescue medication use, improved lung function
measurements, improved exercise tolerance, decreased rates
of exacerbations, and improved quality of life. Due to the
robustness of such literature, ICSs are being used more fre-
quently for persistent asthma, in younger and older patients,
and for longer durations of treatment. ICSs are generally
well tolerated at recommended doses. However, the fear of
adverse effects or “steroid-phobia” may result in underuse of
these agents. Discussing the differences between glucocorti-
coids and anabolic steroids may allay some of the patient/fam-
ily fears of unwanted side effects. The inhaled delivery system
allows for the expression of adverse effects both locally (oro-
pharyngeal cavity) and systemically due to absorption of the
ICS into the circulation. Systemic absorption occurs through
the gut (the portion of the dose deposited on the orophar-
ynx and swallowed) and the lungs (systemic absorption via
the lung surface). Patients and physicians voice more concern
regarding systemic side effects of ICS even though localized
adverse effects are implicated more often in actual physical
findings and may lead to underuse or misuse of prescribed
therapy. Patients most at risk for adverse events with the use
of inhaled corticosteroids are children, the elderly, diabetic
patients, immunocompromised patients, and individuals with
a high daily cumulative dose or prolonged multiple-year ther-
apy due to persistent disease severity. Monitoring measures to
minimize adverse effects of ICS are outlined in Tables 35-1
and 35-2, and are discussed briefly in the following sections.
Table 35-1
Monitoring Measures to Minimize Adverse Effects of ICS
l Use appropriate dosage regimens, with the lowest dose of ICS required
to achieve and maintain disease control
l Consider combination pharmacotherapy, e.g., decrease dose of ICS
and add long-acting beta-agonists or leukotriene receptor agonists
l Use a spacer device with MDI when appropriate
l Reinforce good administration technique (slow inhalation for
metered-dose inhaler, good oral hygiene measures)
l Assess for concurrent risk factors
° ○Age/pubertal status
° Gender
° Concurrent medical conditions (e.g., diabetes,
immunocompromised status)
° Smoking status
°○  Concurrent medications
l Monitor with regular objective measures
°○  Oropharyngeal exams
°○  Stadiometric height measurements and Tanner staging
° Ophthalmic examinations of lens and intraocular pressure measurements
° Bone mineral densitometry
l Initiate specific prevention or treatment strategies
ICS, inhaled carticosteroids.
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