Mechanism of Action

Suppress airway inflammation LOCALLY — inhibiting release of inflammatory mediators (cytokines, leukotrienes, prostaglandins) and reducing mucosal edema, mucus hypersecretion, and bronchial hyperresponsiveness over time. This is the cornerstone CONTROLLER therapy for persistent asthma, NOT a rescue mechanism: ICS produce no bronchodilation and will not relieve an acute attack. Benefit takes 1–2 weeks of consistent daily use, with maximum effect at 4–8 weeks, so they must be taken every day even when well. Local delivery means minimal systemic absorption at standard doses — exactly why they are preferred over oral steroids for long-term control. When paired with a separate bronchodilator inhaler, the bronchodilator goes FIRST.

Common Medications

fluticasonePrototype

budesonide

beclomethasone

Indications

persistent asthma

cornerstone daily controller therapy

moderate-to-severe COPD

maintenance, usually with a long-acting bronchodilator

Side Effects

oropharyngeal candidiasis Hallmark

thrush — white patches on tongue/buccal mucosa; most common local effect; prevent by rinse-and-spit, treat with nystatin

dysphonia

hoarseness from steroid deposition on the larynx; second most common local effect — NOT an infection, no antibiotics

throat irritation

Contraindications & Interactions

use as a rescue inhaler

will not relieve acute bronchospasm — use a SABA for rescue

abrupt discontinuation after prolonged high-dose use

adrenal crisis risk — taper

Administration & Monitoring

use a spacer with the MDI

improves lung deposition, lowers oropharyngeal deposition/thrush/hoarseness

bronchodilator first, then ICS

open airways so the steroid penetrates deeper

shake canister; inhale slowly and deeply

rapid inhalation impacts drug in the oropharynx

inspect mouth for white patches

screen for thrush

assess voice for hoarseness

monitor height in children

monitor for signs of systemic absorption

high-dose: round face, weight gain, hyperglycemia

Patient Teaching

rinse and spit after each use

rinse mouth with water and spit; prevents thrush — do NOT swallow the rinse

take every day even when feeling well

controller, not rescue

this is not your rescue inhaler

keep a SABA for acute symptoms

use a spacer device

use the bronchodilator before the ICS

when both are prescribed separately

rinsing is specific to steroid inhalers

not needed for bronchodilators

report white mouth patches or hoarseness

do not self-adjust the dose

call the provider if symptoms worsen

Report Nowescalate immediately

adrenal suppression Hallmark

long-term HIGH-dose use; abrupt stop after prolonged high-dose use risks adrenal crisis — taper

growth suppression in children

monitor height percentile; document and notify provider on a decline — do not change dose independently

signs of systemic absorption

round face, weight gain, hyperglycemia — high-dose only

Clinical Pearl

Bronchodilator before corticosteroid — open the door, then deliver the medicine. ICS every day, not just on bad days. And rinse, gargle, spit (never swallow) after every dose, or expect white patches within weeks.