Inhalers Causing Oral Thrush | Why and What to Do

For some people, inhalers are a part of everyday life. If you live with a condition like asthma, using a handy medicine dispenser is a regular occurrence. You’re probably aware of how to care for your inhaler. But what about your oral health? Did you know that you can get oral thrush from inhalers?

Improper inhaler technique can lead to a yeast infection in your mouth, which sounds about as appealing as “oral thrush,” also called “oral candidiasis.” Symptoms of a yeast infection in your mouth include things like an unpleasant taste or even the loss of taste altogether, a burning sensation, redness inside, and even white patches.

If you think you might have any of
these symptoms, seek out your dentist as soon as possible to prevent the infection
from spreading elsewhere. Treatment of the condition is easy, and don’t worry,
it’s not contagious.

How Does Using an Inhaler
Lead to Oral Thrush?

Your inhaler is used to deliver a
corticosteroid into your lungs via air flow through your mouth. While we’d like
to imagine all the medicine goes straight to where it’s needed most, it is
possible that some gets left behind. A portion of the corticosteroid can remain
in your mouth on places like your tongue, cheeks, or even between your teeth.

If the medicine stays in these places
for too long, you can develop a yeast infection in your mouth. The good news is that preventing oral thrush from your inhaler
is pretty easy.

Here are four tips that will help:

Rinse your mouth after using an inhaler

This simple maneuver of sipping water after use can significantly decrease your risk of developing oral thrush. Flush out remaining medicine and clean away any residue left behind. Water cleanses the mouth and stimulates salivation, which is good for protecting your teeth.

Consider a spacer

Asthma spacers are designed to assist with the application of medicine in two ways. First, they “improve hand-breath coordination,” as many users make errors. Some have trouble limiting their inhalation capacity or not holding their breath for long enough for the medicine to work. The spacer makes this easier. Additionally, it reduces the amount of medicine deposited into the mouth.

Brush and floss regularly

Know the best way to keep unwanted oral debris, whether food or medicine, from turning into an issue? Routinely brush your teeth twice a day and after meals and floss once per day. This will ensure that there’s no plaque or other debris left to cause problems.

Visit your dentist

A trip to the dentist is about more than X-rays and cleanings. Your oral health provider is able to detect other problems like an oral thrush infection or even cancers and other concerning issues. By taking a close look into your mouth during a dental appointment, your dentist can become familiar with your oral health. Routine visits allow them to notice any changes or potentially harmful developments.

Learn more about having a healthy mouth on our blog! | Need to find a dentist? Use our handy search tool.

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4 Common Side Effects of Inhaled Steroids

Inhaled corticosteroids, also known as steroids or glucocorticoids, can cause side effects like insomnia or thrush, and strategies like rinsing your mouth after you use them might help reduce some side effects.

These medications 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. Corticosteroids alleviate chronic airway inflammation, reducing bronchoconstriction (airway narrowing) and bronchospasms (airway contractions).

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

Martin Barraud / Getty Images

Hoarseness

Some people who use inhaled steroids may experience vocal hoarseness, referred to as dysphonia. This side effect 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 because the inhaled steroids affect the function of the vocal cord muscles over 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, in which stomach acids reflux into the throat, causing pain, vocal cord inflammation, and laryngitis. In such cases, the dose may need to be reduced or the formulation switched.

Oral Thrush

People who take inhaled steroids are at risk for oral thrush, a fungal infection of the mouth also known as oral candidiasis. Oral thrush affects roughly 3% of users of inhaled corticosteroids, and there’s an increased risk with a weakened immune system or if the drug is overused or used incorrectly.

Symptoms of oral candidiasis include:

• Sore throat
• Mouth or tongue irritation
• Formation of white patches in the mouth
• Loss of taste
• Pain while eating or swallowing
• A cotton-like feeling in the mouth

With oral thrush, a superficial white growth can be easily scraped off, often exposing inflamed and bleeding tissue underneath. The infection mainly develops on the roof of the mouth or back of the throat, and can also appear on the tongue, gums, and inner cheeks.

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 by attaching a spacer to the mouthpiece of the MDI. The tubular extender allows you to deliver more of the aerosolized inhalant 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.

Osteoporosis

Inhaled steroids are known to place older adults at an increased risk for osteoporosis (progressive 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:

• Back pain
• Loss of height over time
• A stooped posture
• Bones that break very easily

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 combine) is recommended for those at the highest risk of bone fractures, including post-menopausal women or older adults.

Weight-bearing exercises (such as walking) and an adjustment in the steroid dose may also help if the bone loss is severe.

Vision Problems

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 cataracts and glaucoma.

A 2018 study in the Digital Journal of Ophthalmology found that adults who used inhaled budesonide for no less than six months had significant increases in inner eye pressure.

Similarly, inhaled steroid users exposed to a lifetime dose of two million micrograms (suggesting high-dose, long-term use) were found to be at greater risk of cataracts than those who received lower doses. 

Cataract Symptoms

• Blurred, dim, or cloudy vision

• Light sensitivity

• Halos around lights

• Fading or yellowing of colors

• Night blindness

• Need for brighter lights

Glaucoma Symptoms

• Eye pain

• Blurred vision

• Halos around lights

• Eye redness

• Severe headache

• Nausea and vomiting

If you develop glaucoma or cataracts develop due to inhaled steroid use, the benefits and risks of your treatment need to be weighed on an individual basis and your treatment may need to be modified. Surgical intervention may also be considered, including laser trabeculectomy for glaucoma or extracapsular surgery for cataracts.

A Word From Verywell

While some of the side effects of inhaled steroids are concerning, it is always important to weigh the effect on your respiratory function against the possible consequences of use. 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 your healthcare providers OK as this can lead to steroid withdrawal and a rebound of symptoms.

Thrush: Causes and Risk Factors

Oral thrush is typically caused by a yeast called Candida albicans. It normally is found in the mouth but its population is kept in balance by your immune system and the other bacteria found there. The yeast can grow out of control and cause oral thrush when your immune system is weakened or your oral bacteria are killed by antibiotics.

Oral thrush is sometimes seen in newborns because their immune systems have not yet fully formed. They may have diaper rash due to Candida at the same time.

© Verywell, 2018

Common Causes

Though Candida albicans is the most common yeast involved in thrush, it may also be caused by similar types, such as Candida glabrata or Candida tropicalis.  Your risk of oral thrush is increased by certain conditions, medications, and treatments that weaken the immune system or upset the normal balance of saliva, bacteria, and yeast in your mouth.

Medications and Treatments

• Oral corticosteroids: When taken long-term for a variety of conditions, these drugs weaken the immune system.
• Inhaled steroids: Inhaled steroids are used for asthma and chronic obstructive pulmonary disease (COPD). They can raise your risk for thrush.
• Chemotherapy and radiotherapy: Your immune system is weakened while you are under chemotherapy or you have radiotherapy to the head and neck.
• Immunosuppressive treatment in organ transplantation: Patients are treated to prevent rejection after an organ transplant and this can increase the risk of thrush.
• Antibiotics: Antibiotics typically kill the oral bacteria but they don’t act against yeast, which is a type of fungus. A newborn is more at risk if the baby or the mother (if breastfeeding) takes antibiotics.
• Medications that reduce saliva: Your saliva carries antibodies and other substances that help prevent overgrowth of the yeast, so medications that reduce saliva also increase the risk of thrush.

Health Concerns

• HIV or AIDS: Thrush can be seen in HIV infection even while someone is under antiretroviral therapy. Candida can grow out of control and become invasive when the CD4 count is less than 200 cells/mL in people with AIDS.
• Immune disorders: Other immune disorders also increase the risk of thrush, including blood cancers such as leukemia and lymphoma.
• Diabetes: High blood sugar with diabetes increases the risk of thrush.
• Long-term illness: Having a chronic condition can weaken the immune system and increase your risk of thrush.
• Oral conditions: Dentures that do not fit properly and damage the mucous membranes can increase risk. Having a condition that causes dry mouth, such as Sjogren’s syndrome, is also a risk factor.
• Pregnancy and newborns: The mother’s immune system is reduced during pregnancy and the baby’s immune system takes months to be fully up to speed. A newborn may pick up Candida during birth if the mother has a vaginal yeast infection, or acquire it after birth. Often thrush is only a minor irritation for a baby. However, frequent oral thrush should always be investigated in infants to find a cause.

Lifestyle Risk Factors

Poor oral hygiene increases your risk of thrush. Brush your teeth twice a day and clean between your teeth daily. If you have dentures, ensure you are cleaning them daily and brushing your tongue and gums.

Don’t neglect your regular dental check-ups.

Smoking tobacco upsets your oral health and increases your risk of oral thrush, although it isn’t clear exactly why. This is one more health reason to stop smoking. There are anecdotal reports (but no clinical studies) that smoking cannabis also raises the risk of thrush.

If you have type 1, type 2, or gestational diabetes, it is important to maintain good blood sugar control through medication and diet.

Increased blood sugar raises the risk of oral thrush because hyperglycemia depresses immune function.

If you use a steroid inhaler, you may reduce your risk of thrush by rinsing your mouth and brushing your teeth after use of the inhaler. If you use a metered-dose inhaler for steroids, a spacer—a chamber placed between your inhaler and your mouth that allows you to more effectively breathe in the medicine—may help prevent or alleviate the symptoms of thrush. 

The spacer helps channel the treatment into the lungs and reduces exposure in the mouth. However, dry powder inhalers (such as Advair, Pulmicort, and Asmanex) don’t use a spacer, and the powder isn’t as easily cleared by brushing after use. In this case, you may want to use an alcohol-based mouthwash like Listerine to help rinse out your mouth.

Frequently Asked Questions

What is the cause of thrush?

Thrush is caused by a type of yeast known as Candida. The species most commonly associated with thrush is Candida albicans (C. albicans), although there are others that can cause oral, genital, skin, or systemic (whole-body) infections.

How many different types of thrush are there?

One large study found 31 different types Candida species in clinical samples, but just five of those account for more than 90% of all infections in humans: C. albicans, C. glabrata, C. kreusi, C. parapsilosis, and C. tropicalis. These species have become increasingly common in recent years, some of which are associated with severe illness (C. tropicalis) or antibiotic resistance (C. parapsilosis).

What causes thrush?

Candida albicans is a fungus found normally in the body. When the immune system is weakened, the fungus can start to grow out of control, leading to thrush. There are also medications and hormonal conditions that can disrupt the normal balance of bacteria and fungus in the body, promoting the overgrowth of Candida.

What are the risk factors for thrush?

You are more likely to get thrush if you:

What can increase the risk of vaginal thrush?

A vaginal yeast infection can be caused by a disruption in the natural vaginal flora, due to factors such as vaginal douching, taking oral contraceptives, or antibiotic therapy.

What can increase the risk of penile thrush?

An uncircumcised penis is the main risk factor for penile thrush, as the skin beneath the foreskin provides the ideal environment for Candida. Poor hygiene and obesity further increase the risk.

What causes thrush in newborns?

Vaginal candidiasis can be passed from mother to newborn during childbirth, causing congenital candidiasis. Congenital candidiasis is exceptionally rare and seen primarily in preterm babies. It causes symptoms ranging from local skin infections to systemic illnesses like sepsis and respiratory distress.

Allergy Inhalers and Dry Mouth

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Do you use inhalers to ease your seasonal allergy symptoms? Allergies can make you feel like your body is under attack. Allergy inhalers, such as Beclomethasone, can be lifesavers, allowing you to control symptoms and get on with your life. Unfortunately, corticosteroid inhalers can cause Dry Mouth. It’s an uncomfortable condition but can be helped by using over-the-counter products.

Inhalation therapy for allergies is a welcome option for many sufferers. Inhalers act locally and are quick and easy to use. However, allergy inhalers can cause Dry Mouth – a condition that can be an unwelcome side effect. Luckily, home remedies are available to help ease the symptoms and let you get on with your life.

Why does it happen?

Corticosteroid inhalers, like Beclomethasone, are widely used to treat respiratory allergy symptoms, as well as related conditions such as asthma. They work by reducing inflammation. While that helps suppress allergy symptoms, it can also cause dryness of oral tissues.

Another possible side effect of corticosteroid inhalers is candidiasis, or oral thrush. Thrush is a fungal infection, characterized by white patches in your mouth and throat. Symptoms include soreness, pain when eating or swallowing and redness or cracking at the sides of your mouth. Thrush has also been linked to reduced saliva production, which results in Dry Mouth.

Dry Mouth isn’t always just thirst

Also known as Xerostomia (say zeer-o-STOE-mee-uh), Dry Mouth occurs when your mouth doesn’t produce as much saliva as it needs in order to stay healthy. This leads to uncomfortable symptoms such as difficulty in swallowing and talking and soreness in your mouth. It can also affect your taste buds and can even cause painful oral fissures and mouth ulcers.

Dry Mouth affects up to 1 in 5 adults in the US and can impact more than just your oral health. A Dry Mouth can make eating dry food more difficult. This, along with speaking difficulties and bad breath, can affect your social life and self-confidence. Having a Dry Mouth can also disturb your sleep, as you might find yourself waking repeatedly to sip water during the night.

Managing Dry Mouth when using allergy inhalers

It’s important to be able to control your allergy symptoms, but also to prevent Dry Mouth from having a negative impact on your daily life. Luckily, there are a few easy ways to reduce the drying effect of your allergy inhalers and help with Dry Mouth symptoms.

• Start by making sure you’re keeping your inhalers clean and dry. It’s recommended that you follow the manufacturer or prescribed directions for inhaler maintenance.
• If recommended by your healthcare provider, use a spacing device with your inhalers. This could help more of your inhaled medication get into your lungs, so less stays in your mouth.
• Rinse your mouth and throat after each inhaler use. Choose a moisturizing oral rinse formulated specifically for Dry Mouth. There are also special sprays and/or lozenges to keep your mouth moist when you’re on the go.
• Stick to a rigorous oral hygiene routine. Make sure you brush twice daily and floss once. Saliva helps fight plaque, so having less of it means you’re more susceptible to plaque and gum disease.

You don’t have to choose between controlling your allergies and managing Dry Mouth. Practice good oral hygiene, take care of your inhalers and choose an oral moisturizing product that can assist you. These can help you benefit from your allergy treatment while minimizing its side effects.

What is Oral Thrush? With Which Inhalers Should I Rinse My Mouth?

How To Prevent Oral Thrush

Dear Dr. Mahler:  

I am concerned about getting thrush. I was diagnosed with severe COPD, and have improved with Stiolto Respimat. My pulmonary doctor said that I am now in the moderate category.  A nurse who works at a community college with me asked if I was rinsing my mouth with water after inhaling the medication. She said that I should do this to prevent thrush. Is that correct?

Sophia from Key Biscayne, FL

Dear Sophia:

Oral thrush is a commonly used phrase for a fungal infection of the mouth and throat (oral cavity). The fungus is called Candida albicans, and the medical condition is called oral candidiasis. This happens when the fungus – Candida albicans – accumulates in your mouth and throat.

Oral thrush with white plaques on the tongue

Candida albicans is a normal organism in your mouth, but sometimes it can overgrow and cause symptoms. It causes creamy white lesions, usually on your tongue, the sides of the mouth, and/or the back of the throat. Although thrush can affect anyone, it’s more likely to occur in the elderly, in people with suppressed immune systems, or  those who take certain medications. Inhaler medications that contain a corticosteroid (prednisone-like medication) increase the chances of it developing.

Symptoms of oral thrush include:

1. loss of taste or an unpleasant taste in the mouth

2. redness inside the mouth and throat

3. cracks at the corners of the mouth

4. a painful, burning sensation in the mouth

Oral thrush is diagnosed by an examination of the tongue and mouth

 Sophia – you are taking Stiolto Respimat – which contains two different types of bronchodilators. There is no inhaled corticosteroid in Stiolto. Therefore, it is not necessary for you to rinse your mouth after using the medication. Advair, Symbicort, and Breo are approved medications for those with COPD that do contain an inhaled corticosteroid. After inhaling these medications, it is recommended to rinse the mouth with water and then spit out the water.

Sincerely,

Donald A. Mahler, M.D.

Steroid inhalers – NHS

Steroid inhalers, also called corticosteroid inhalers, are anti-inflammatory sprays or powders that you breathe in.

They’re mainly used to treat asthma and chronic obstructive pulmonary disease (COPD).

Steroid inhalers are only available on prescription. Common types include:

• beclometasone
• budesonide
• fluticasone
• mometasone 

They’re sometimes called “preventer inhalers” because they can help prevent your symptoms.

How and when to use a steroid inhaler

There are several types of steroid inhaler, which are used in slightly different ways.

A doctor or nurse will show you how to use your inhaler. Make sure you use it exactly as advised. The Asthma UK website has videos explaining how to use the different types of inhaler.

You’ll usually need to take 1 or 2 puffs from your inhaler in the morning and 1 or 2 puffs in the evening.

It’s important to keep using your inhaler, even if you feel better. It will only stop your symptoms if it’s used every day.

If you miss a dose or take too much

If you forget to take a dose, take it as soon as you remember. If it’s nearly time for your next dose, skip the one you missed.

Do not take a double dose to make up for a forgotten dose.

Accidentally taking too many puffs from a steroid inhaler is unlikely to be harmful if it’s a one-off. Speak to a doctor, nurse or a pharmacist if you’re worried.

Using a steroid inhaler too much over a long period can increase your chances of getting side effects.

Stopping treatment

Do not stop using your inhaler unless you’re advised to by a doctor.

When you stop your treatment, you usually need to reduce your dose gradually.

This can help avoid unpleasant side effects (withdrawal symptoms), such as severe tiredness, joint pain, being sick and dizziness.

Side effects of steroid inhalers

Steroid inhalers usually cause few or no side effects if used correctly and at normal doses.

Some people get:

• a sore mouth or throat
• a hoarse or croaky voice
• a cough
• oral thrush – a fungal infection that causes white patches, redness and soreness in the mouth
• nosebleeds

If you’re taking a high dose for a long time, there’s also a small chance you could get some of the side effects of steroid tablets, such as an increased appetite, mood changes and difficulty sleeping.

You can report any suspected side effect to the Yellow Card scheme.

Coping with side effects of steroid inhalers

The following tips may help reduce the side effects of steroid inhalers:

• use your inhaler exactly as you’ve been shown – speak to a doctor or nurse if you’re not sure how to use your inhaler correctly
• use your inhaler with a spacer, a hollow plastic tube or container with a mouthpiece at one end and a hole for the inhaler at the other
• rinse your mouth out with water and spit it out or brush your teeth after using your inhaler

If you’re taking a high dose for a long period of time, you may be given a steroid treatment card that explains how you can reduce the risk of side effects.

Using steroid inhalers with other medicines, food or alcohol

Some medicines can interfere with the way steroid inhalers work, but this is uncommon if you’re only taking low doses for a short period.

Tell a doctor if you take any other medicines, including herbal remedies and supplements, before starting to use a steroid inhaler.

If you’re already using an inhaler, ask a doctor or pharmacist for advice before taking any other medicines, remedies or supplements.

You can usually drink alcohol while using a steroid inhaler and you should be able to eat most foods. Do not smoke though, as this can make your medicine less effective and make your symptoms worse.

Who can use steroid inhalers

Most people can use steroid inhalers.

Tell your doctor before starting treatment if you:

• have had an allergic reaction to steroids in the past
• have tuberculosis (TB) or another infection of your lungs or airways
• are pregnant, breastfeeding or trying for a baby

Steroid inhalers are normally safe to use while breastfeeding and during pregnancy, but it’s a good idea to get medical advice first.

If you need to take a high dose during pregnancy, you may need regular check-ups to check for any side effects.

How steroid inhalers work

Steroids are a man-made version of hormones normally produced by the adrenal glands, which are 2 small glands found above the kidneys.

When they’re inhaled, steroids reduce swelling (inflammation) in your airways.

This can help reduce symptoms of asthma and COPD, such as wheezing and shortness of breath.

Steroid inhalers are different to the anabolic steroids that some people use illegally to increase their muscle mass.

Page last reviewed: 15 January 2020
Next review due: 15 January 2023

Oral candidiasis associated with inhaled corticosteroid use: comparison of fluticasone and beclomethasone

Background:

Inhaled steroids such as fluticasone propionate and beclomethasone dipropionate play a central role in the treatment of bronchial asthma. Fluticasone exhibits excellent clinical effectiveness; however, oral adverse effects can occur.

Objective:

To compare the frequency of oral candidiasis in asthmatic patients treated with fluticasone and beclomethasone, to evaluate the effect of gargling with amphotericin B, and to measure the inhalation flow rate on candidiasis.

Methods:

The study consisted of 143 asthmatic patients who were treated with inhaled steroids, 11 asthmatic patients not treated with inhaled steroids, and 86 healthy volunteers. Quantitative fungal culture was performed by aseptically obtaining a retropharyngeal wall swab from these patients. Patients with positive results were treated with gargling using a 1:50 dilution amphotericin B solution. In asthmatic patients treated with fluticasone, the inhalation flow rate was measured using an inspiratory flow meter.

Results:

The amount of Candida spp. was significantly greater in asthmatic patients taking inhaled steroids compared with those who were not. It was also significantly greater in patients with oral symptoms than asymptomatic patients and significantly greater in asthmatic patients treated with fluticasone than in those treated with beclomethasone. Although the presence of Candida did not correlate with the inhaled dose of beclomethasone, it did increase with the dose of fluticasone. Gargling with amphotericin B was effective in most asthmatic patients with candidiasis. Candidiasis was not due to inappropriate flow rates during inhalation of steroids.

Conclusions:

Fungal culture of a retropharyngeal wall swab may be useful for predicting the risk of developing oral candidiasis in asthmatic patients treated with inhaled steroids. The amount of isolated Candida was significantly greater in asthmatic patients treated with fluticasone than in those treated with beclomethasone. Attention to dosage is required as the amount of Candida increased with dose of fluticasone. Gargling with a 1:50 dilution of amphotericin B is effective in treating oral candidiasis of asthmatic patients treated with inhaled steroids.

What you need to know about combination inhalers for asthma – Health

Combined inhalers for asthma are important tools for the long-term management of asthma symptoms. They combine two different inhaled drugs – a corticosteroid and a long-term beta-agonist

Contents

Combined asthma inhalers are essential tools for the long-term management of asthma symptoms. They combine two different inhaled drugs, a corticosteroid and a long-acting beta-agonist (LABA), which together can reduce airway hyperresponsiveness that can lead to an asthma attack.

Five such FDA-approved asthma inhalers: Advair HFA, Advair Diskus, Breo Ellipta, Dulera and Symbicort. Each has its own advantages, disadvantages and limitations.

How asthma is treated

Uses

FDA-approved combination inhalers for asthma (by date of approval):

• Advair HFA , a combination of the steroid fluticasone and salmeterol LABA (approved 2000)
• Advair Discus , a combination of the steroid fluticasone and salmeterol LABA (approved in 2000)
• Symbicort , a combination of the steroid budesonide and LABA formoterol (approved in 2006)
• Douler , a combination of steroid and momoterol LABA formoterol (approved 2010)
• Breo Ellipta , a combination of the steroid fluticasone and vilanterol LABA (approved 2015)

Advair generic forms are now available under the brand names AirDuo Respiclick, Wixela Inhub and others.Generic symbicort is also available, usually sold as a budesonide / formoterol inhaler.

Do over-the-counter asthma inhalers work?

How They Work

The two classes of drugs used in combination inhalers have different mechanisms of action that contribute to the long-term control of asthma symptoms:

• Corticosteroids , also known as steroids, mimic the hormone cortisol, which the body uses to control inflammation.When used daily, corticosteroids help control inflammation that contributes to airway hyperresponsiveness.
• LABA are classified as bronchodilators, which means that they help open (widen) the airways of the lungs, that is, the bronchi and bronchioles. Although their mechanism of action is similar to that of an emergency inhaler, they are longer lasting and, when taken daily, are effective in preventing bronchospasm and airway constriction.

Other approved and non-standard uses

Symbicort and Breo are also approved for the daily treatment of chronic obstructive pulmonary disease (COPD). Advair Diskus, a dry powder formulation, is also approved for the treatment of COPD, although its aerosol form, Advair HFA, has not been approved.

Studies have shown that salmeterol, a LABA used in Advair HFA, increases the risk of pneumonia in people with COPD. Although Advair Diskus also contains salmeterol, the dosage is much lower and is considered safer for continuous use.

Duler is not yet approved for the treatment of COPD, although his application is pending. Although some doctors prescribe Duhler off-label in patients with COPD, its safety and effectiveness for this purpose have not yet been established.

Should I use a general asthma inhaler?

Before taking

You can use the combination inhaler for asthma if you cannot control your asthma symptoms with one rescue inhaler. Generally speaking, your asthma is poorly controlled if:

• You use an emergency inhaler more than twice a week.
• You wake up at night with asthma symptoms more than twice a month.
• You must refill your emergency inhaler prescription more than twice a week.

In the past, inhaled corticosteroids were the first drugs to be used as a control drug when a rescue inhaler could not adequately control asthma symptoms. Today, instead of waiting for LABA to be added to the treatment plan, many public health authorities, including the Global Asthma Initiative (GINA), are endorsing the combined use of inhaled corticosteroids and inhaled LABA from the outset.

This does not mean that the combination inhaler is a one-stop solution. 2015 study Annals of the American Thoracic Society stated that inhaled steroids were as effective in controlling asthma symptoms as steroid / LABA combination therapy and allowed dose adjustments as needed.

Other studies suggest that because of their convenience, combination inhalers are more likely to increase adherence to treatment and in turn improve the health of people with asthma.Moreover, combination inhalers require a lower dose of steroids to achieve the same control benefits as single steroid inhalers.

2013 review at Cochrane Database of Systematic Reviews concluded that people who used combination inhalers were less likely to be hospitalized or required an emergency department visit than those who used two different inhalers, and less likely to need stronger oral steroids in the future.

Precautions and contraindications

The only absolute contraindication to the use of a combination inhaler is a known allergy to any active or inactive ingredient used in the inhaler. This includes milk allergy, as milk powder is the central inactive ingredient in both Advair Diskus and Breo Ellipta.

LABAs are known to affect blood pressure, blood sugar, heart rate, thyroid hormone production and brain cell activation.These effects are somewhat mitigated by the use of inhaled corticosteroids, which allows LABA to be delivered in lower doses.

There is also evidence that prolonged use of inhaled corticosteroids can affect the eyes and impair the body’s ability to fight infections.

Because of these concerns, combination inhalers for asthma should be used with caution in people with the following conditions:

• Cardiac arrhythmia
• Cataracts
• Ischemic heart disease
• Diabetes
• Epilepsy
• Glaucoma
• Hyperthyroidism
• Uncontrolled pressure

People with any of these conditions should be monitored regularly for any changes in their health while taking combination inhalers.In some cases, it may be necessary to discontinue treatment if symptoms worsen.

All asthma combination inhalers are classified as pregnancy category C drugs, which means that animal studies suggest potential harm to the fetus, but there are no well-controlled studies in humans.

Although there is no evidence of an increased risk of birth defects in pregnancy registers, it is still important to speak with your doctor to weigh the benefits and risks of treatment if you are pregnant, breastfeeding, or planning to become pregnant.

Use of asthma medications during pregnancy

Dosage

Combination inhalers for asthma currently approved by the FDA can be categorized by mode of delivery:

• Advair HFA, Dulera and Symbicort are metered-dose inhalers (MDI) that deliver medication using a propellant in the form of an aerosol.
• Advair Diskus and Breo Ellipta are dry powder inhalers (DPI) that deliver a dose of medication in powder form, which you simply inhale through the mouthpiece.

The recommended dose may vary depending on age. As a rule, at the beginning of treatment, lower doses are prescribed and they are increased only if the drug does not provide adequate control of symptoms.

45 mcg fluticasone / 230 mcg salmeterol
• 150 mcg fluticasone / 230 mcg salmeterol
• 230 mcg fluticasone / 230 mcg salmeterol Discus Discus

12 hours apart

Recommended dosages
Drug, agent, medication	Compositions in micrograms (mg)	Approved for	Recommended dose
Adults and children from 12 years old	2 inhalations twice a day with an interval of 12 hours
• 100 mcg fluticasone / 50 mcg salmeterol • 250 mcg fluticasone / 50 mcg salmeterol • 500 mcg fluticasone / 50 mcg salmeterol	Adults and children from 4 years old	2 inhalations twice a day
Breo Ellipta	• 100 μg fluticasone / 25 μg vilanterol • 200 μg fluticasone / 25 μg vi lanterol	Adults 18 years and over	1 inhalation per day
Doulera	• 100 mcg mometasone / 5 mcg formeterol • 200 mcg mometasone / 5 mcg formeterol	2 Adults and children from 12 years old twice a day with an interval of 12 hours
Symbicort	• 80 mcg budesonide / 4.5 mcg formeterol (children) • 160 mcg budesonide / 4.5 mcg formeterol (adults)	Adults and children 6 years of age and older and older	2 inhalations twice a day at intervals of 12 hours

There is no single combination asthma inhaler that is inherently “better” than others.Some may be more appropriate depending on age, while cost, delivery system, and dosage requirements (once a day or twice a day) can also influence the decision.

Talk to your doctor to fully understand the benefits and limitations of each option, and why some may be better for you than others.

How to take and store

MDI and DPI have their pros and cons. MDIs deliver precise doses and are easy to use, but require hand-coordinated breathing.DPIs do not have buttons or require hand coordination, but they can deliver different doses depending on how hard you inhale the medicine.

Learning how to use your device correctly can help you obtain optimal benefits.

To use MDI such as Advair HFA, Dulera or Symbicort:

1. Remove the cap from the mouthpiece.
2. If you have not used it recently, prime the inhaler by shaking the can for five seconds and spraying it from your face in short portions.Repeat this one more time. If the inhaler does not require refilling (i.e. you have used it recently), simply shake well for five seconds.
3. Exhale fully to empty the lungs.
4. Insert the mouthpiece into your mouth and wrap your lips tightly to seal.
5. Simultaneously press the inhaler button while taking a deep breath.
6. Hold your breath for 10 seconds.
7. Exhale gently.
8. Repeat steps 3 through 7 to deliver the second dose.
9. Close the cover until you hear a click.
10. Rinse mouth with water to remove any drug residue. Do not swallow.

MDI should be cleaned once a week by wiping the mouthpiece with a damp cloth and cleaning the aerosol hole with a dry cotton swab. Do not immerse the canister in water.

Are you using the metered dose inhaler correctly?

To use DPI like Advair Diskus or Breo Ellipta:

1. Open the mouthpiece cover.Do not shake the inhaler.
2. Press down on the loading lever until you hear a click. This will deliver the prescribed dose of medication.
3. Exhale fully.
4. Place your lips around the mouthpiece to press tightly.
5. To inhale the medicine, inhale quickly through the mouth only.
6. Hold your breath for 10 seconds.
7. Exhale gently.
8. Repeat steps 2 to 7 if you are using Advair Diskus. You don’t need to repeat this if you are using the Breo Ellipta.
9. If necessary, wipe the mouthpiece with a dry cloth.(DPIs do not require regular cleaning.)
10. Slide the mouthpiece cover fully to close the device.
11. Rinse mouth with water and spit. Do not swallow.

Both the MDI and DPI have built-in dose counters that show how many doses are left after each inhalation. Be sure to refill the recipe when the counter drops to “20” (or “10” for the Breo Ellipta).

MDI and DPI can be safely stored at room temperature, ideally between 68 and 77 degrees F.Do not store the MDI near heat sources or open flames as this may cause an explosion. Keep out of reach of children and pets.

Do not use the inhaler or any medicine that has expired.

How long will my asthma inhaler last?

Side effects

Like all medicines, combination inhalers for asthma can cause side effects. Many of them are relatively mild and gradually go away as the body adapts to treatment.Tell your doctor if any side effects are serious, persist, or get worse.

General

The general side effects are largely the same for different inhalation products. Those that affect 2% or more of users are:

• Stuffy nose or runny nose
• Sneezing
• Headache
• Sore throat
• Hoarseness
• Cough
• Sinus pain
• Dizziness
• Flu-like symptoms
• Nausea or vomiting
• Upper respiratory tract infection
• Oral thrush (candidiasis)

Of the various dosage forms, Dulera has the least side effects (primarily nasal congestion or runny nose, sneezing, headache and sinus pain) …

The risk of thrush can be reduced by using a CI spacer. Since DPIs such as the Advair Diskus and Breo Ellipta cannot use a pad, the only way to reduce the risk of thrush is to rinse your mouth thoroughly with water after each use.

4 common side effects from inhaled steroids

Severe

An unusual but serious side effect of combined inhalers for asthma is paradoxical bronchospasm, in which asthma symptoms worsen rather than improve.LABA are the agents responsible for this effect, although the exact cause of the reaction is poorly understood.

Paradoxical bronchospasm appears to occur in people with severe airway inflammation who first use inhalants.

Sudden onset of shortness of breath, wheezing, chest pain and cough after Use of a combination inhaler for asthma should always be considered a medical emergency. People who experience paradoxical bronchospasm should not be given the same drug again.

Anaphylaxis, a potentially life-threatening whole body allergy, is a rare occurrence with combination asthma inhalers, but cases have been reported in people using Advair Diskus or Breo Ellita due to an underlying milk allergy.

Call 911 or seek emergency help if you experience the following symptoms after using the combination inhaler for asthma:

• Sudden severe rash or hives
• Shortness of breath
• Wheezing
• Dizziness
• Arrhythmia
• Facial edema, tongue or lips
• Feeling of impending doom

If left untreated, anaphylaxis can lead to shock, coma, asphyxia, heart or respiratory failure, and death.

Side effects of asthma medications by class

Warnings and interactions

Corticosteroids are known to affect bone density, but there appears to be less risk with inhaled corticosteroids than with oral corticosteroids. However, young children should be supervised as long-term use of combination inhalers may impair their growth. The risk is greatest in toddlers with severe persistent asthma.

A number of common drugs and drug classes are known to interact with combination inhalers for asthma.

Corticosteroids and LABA are metabolized by a liver enzyme called cytochrome P450 (CYP450) and may interact with other drugs that use the same enzyme for metabolism. This competition can slow the rate at which the drug is cleared from the body. This can either increase the concentration of the drug (along with its side effects) or lower the concentration of the drug (and reduce its effectiveness).

Among the drugs of greatest concern are:

• Antibiotics like clarithromycin, telithromycin and troleandomycin
• Antifungal like ketoconazole, itraconazole and voriconazole
• Non-carcinogenic antidepressants
• Atypical antidepressants
• HIV , such as Kaletra (ritonavir / lopinavir), Crixivan (indinavir), and Invirase (saquinavir)

LABA themselves can interact differently with four classes of drugs.These include:

• Beta blockers such as Lopressor (metoprolol) or Sectral (acebutolol) can block the action of the combination inhaler and even cause bronchospasm.
• Monoamine oxidase inhibitor (MAOI) Antidepressants such as parnat (tranylcypromine) can cause heart rhythm problems.
• Non potassium-sparing diuretics such as hydrochlorothiazide, may cause low potassium levels (hypokalemia) and cause heart problems.
• Tricyclic antidepressants Like Elavil (amitriptyline), may also cause irregular heart rhythms when used with LABA.

To avoid drug interactions, tell your doctor about any medication you are taking, be it prescription, over-the-counter, herbal, or recreational.

Black box warning

Until the end of 2017, the FDA issued a black box warning for all corticosteroid / LABA inhalers, advising consumers that these drugs are associated with an increased risk of asthma-related death.The advice was based on early studies that reported 13 deaths among 13,176 LABA users over a 28-week study period.

On December 20, 2017, the FDA canceled the order when it was shown that the risk of death occurs when using LABA alone (in monotherapy). Current research has shown that the combined use of LABA and corticosteroids does not do this harm.

Although the black box warning has been removed from the packaging of the combination inhaler for asthma, it remains on all LABA one-way products.

Why the Advair black box warning was removed

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How is thrush transmitted – “Healthy family”

Thrush is a disease that causes the Candida fungus. From this came the medical name of this disease – candidiasis, which is most common in women. Fungal infection affects the vaginal mucous membranes and causes the growth of pathogenic microflora.

Causes of thrush:

• Taking antibiotics that destroy the normal microflora;
• Climate change;
• Change of sexual partner;
• Wearing synthetic tight underwear;
• Use of substandard tampons and pads;
• Pregnancy;
• Severe stress;
• Diabetes mellitus;
• Improper diet, abuse of sweets;
• Use of hormonal contraceptives;
• Non-observance of the rules of personal hygiene.

Unfortunately, if a woman has thrush, she can also infect her family members. When asked whether thrush is transmitted to a child, the answer is unequivocal: it is transmitted. This happens often during childbirth. Older children, just like men, can become infected through the household route: through a towel, bed linen, etc.

How is thrush transmitted from woman to man?

Is thrush transmitted orally? Definitely yes. In men, candidiasis most often occurs through oral sex.If a woman is sick, then the fungus settles on the mucous membrane of the man’s mouth, and in the future, through a kiss, through saliva, it can infect other people. At the same time, the question of whether thrush is transmitted sexually is difficult to answer unequivocally. Men, as a rule, do not run the risk of contracting candidiasis even after unprotected intercourse, since the stronger sex have better health and a stable hormonal background. However, in some cases, the disease can be transmitted. Therefore, it will not be superfluous at the time of illness to abstain from sexual intercourse at all or to protect oneself.The fungal infection will not penetrate through the condom.

What are the signs of thrush?

There are a lot of photos on the network in which you can see how the fungus affects the mucous membrane of a woman’s intimate organs. With this disease, an increased amount of vaginal discharge appears, which is a white cheesy mass, has an unpleasant smell of rotten fish and causes itching and burning in the external genital area. An asymptomatic form of thrush is also rare, when a woman does not experience any discomfort, and candidiasis is detected after taking smears at an appointment with a gynecologist.What consequences for men and women can arise if you do not pay attention to the symptoms of the disease and leave it untreated? The infection will multiply rapidly in the body and can cause other concomitant diseases, such as cystitis in women, urethritis and prostatitis in men, and in the most advanced cases, candidiasis can cause infertility. And although many treat the thrush negligently and believe that if not treated, there can be no consequences, this is an erroneous opinion.

Women often have thrush during pregnancy due to dramatically changing hormonal levels.While carrying a child, it is useless to fight it, but on the eve of childbirth, treatment for this disease is mandatory. After all, thrush during childbirth and its consequences for the child can be dire. During childbirth, the child will get sick with candidiasis, in which case the baby has a white plaque on the mucous membrane in the mouth, which gives the newborn discomfort. He cannot suckle and cries all the time.
As for the symptoms of thrush in men, most often it is redness of the foreskin of the genital organ, dryness and peeling of the skin, itching.

How to treat thrush?

Candidiasis is treated in two stages: at the first stage, they get rid of the fungal infection. The doctor usually prescribes vaginal suppositories or pills for a woman, which bring relief after just a few uses. Pimafucin, livarol, polygynax – the pharmaceutical industry provides a wide selection of drugs to get rid of this ailment. The course of treatment for women is three to seven days. At the second stage of the treatment of thrush, an important role is played by the colonization of the mucosa with beneficial lactobacilli.For this, there are preparations in the form of suppositories. Having sex with thrush is undesirable, since during this period it is easy to damage the vaginal mucosa, which is devoid of natural protection.

In men, treatment is reduced to the use of an antifungal cream, which should be applied to the penis. Thrush in the mouth is treated with the use of antifungal agents, vitamins, rinsing the oral cavity with disinfectants and alkaline solutions, resorption of lozenges with bactericidal properties, and the use of dental gels.If you answer the question of how to treat chronic thrush, then, first of all, it is important to observe the correct lifestyle and hygiene. You should wash yourself with water using special means for intimate hygiene, wear only cotton underwear, consume more fermented milk products, and limit sweets in the diet. And the last thing: how to treat thrush during breastfeeding, only a doctor can answer, because not only the health of the mother, but also the child depends on the choice of treatment.

90,000 Causes and risk factors for thrush

Oral candidiasis is usually caused by the yeast Candida albicans.It is usually found in the mouth, but its population is supported by your immune system and other bacteria found there. Yeast can get out of hand and cause oral thrush when your immune system is weakened or the bacteria in your mouth are destroyed by antibiotics.

Oral candidiasis is sometimes seen in newborns because their immune systems are not yet fully developed.1 They may simultaneously develop diaper rash due to Candida.

Common causes

Although Candida albicans is the most common yeast that causes thrush, it can also be caused by similar types such as Candida glabrata or Candida tropicalis.The risk of thrush in the mouth is increased due to certain conditions, medications, and treatments that weaken the immune system or disrupt the normal balance of saliva, bacteria, and yeast in the mouth.

Medicines and treatments

• Oral corticosteroids: When taken for a long time in various conditions, these drugs weaken the immune system.

• Inhaled steroids: Inhaled steroids are used for asthma and chronic obstructive pulmonary disease (COPD).They can increase the risk of thrush.

• Chemotherapy and radiation therapy: Your immune system is weakened during chemotherapy or radiation therapy to the head and neck.

• Immunosuppressive treatment for organ transplant: Patients are treated to prevent rejection after organ transplantation and this may increase the risk of thrush.

• Antibiotics: Antibiotics usually kill oral bacteria, but they do not work against yeast, which is a type of fungus.The newborn is at greater risk if the baby or mother (while breastfeeding) takes antibiotics.

• Medicines that reduce salivation: 1 Your saliva contains antibodies and other substances that help prevent overgrowth of yeast, so medicines that reduce salivation also increase the risk of thrush.

Health problems

• HIV or AIDS: 1 Thrush can occur with HIV infection, even if someone is on antiretroviral therapy.Candida can get out of control and become invasive when the CD4 count is less than 200 cells / ml in people with AIDS.

• Immune Disorders: Other immune disorders also increase the risk of thrush, including blood cancers such as leukemia and lymphoma.

• Diabetes: 1 High blood sugar in diabetes increases the risk of thrush.

• Long-term illness: Chronic illness can weaken the immune system and increase the risk of thrush.

• Oral diseases: Dentures that do not fit properly and damage mucous membranes can increase the risk. A condition that causes dry mouth, such as Sjogren’s syndrome, is also a risk factor.

• Pregnancy and newborns: The mother’s immune system decreases during pregnancy and the baby’s immune system takes months to fully recover. A newborn can become infected with Candida during childbirth if the mother has a vaginal yeast infection, or become infected with it after birth.Thrush is often just a minor irritation to the baby. However, frequent oral candidiasis should always be investigated in infants to find the cause.

Lifestyle risk factors

Poor oral hygiene increases the risk of thrush. Brush your teeth twice a day and brush between your teeth daily. If you have dentures, make sure you brush them daily and brush your teeth on your tongue and gums.

Do not neglect regular dental check-ups.

Tobacco smoking impairs oral health and increases the risk of thrush, although it is unclear exactly why. This is another reason to quit smoking. There are isolated reports (but no clinical studies) that smoking cannabis also increases the risk of thrush.

If you have diabetes 1, 2, or gestational diabetes, it is important to maintain good blood sugar control through medication and diet.

Elevated blood sugar increases the risk of oral thrush because hyperglycemia suppresses immune function.

If you are using a steroid inhaler, you can reduce the risk of thrush by rinsing your mouth and brushing your teeth after using the inhaler.1 If you are using a metered-dose steroid inhaler, a spacer should be placed between your inhaler and your mouth. the medicine may help prevent or relieve the symptoms of thrush.

Spacer helps target treatment to the lungs and reduces exposure to the mouth. However, dry powder inhalers (such as Advair, Pulmicort, and Asmanex) do not use a spacer and the powder is not easy to brush off after use.In this case, you can use an alcohol-based mouthwash such as Listerine to rinse your mouth.

Frequently Asked Questions

What is the cause of thrush?

Thrush is caused by a yeast known as Candida. Candida albicans (C. albicans) is most commonly associated with thrush, although there are other species that can cause oral, genital, skin, or systemic (whole body) infections 2.

How many different types of thrush are there?

One large study identified 31 Candida species in clinical samples, but only five account for more than 90% of all infections in humans: C.albicans, C. glabrata, C. kreusi, C. parapsilosis and C. tropicalis. … In recent years, these species have become more common, some of which are associated with severe illness (C. tropicalis) or antibiotic resistance (C.

What causes thrush?

Candida albicans is a fungus that is commonly found in the body. When the immune system is weakened, the fungus can spiral out of control, leading to thrush. There are also medications and hormonal conditions that can disrupt the normal balance of bacteria and fungi in the body, contributing to Candida overgrowth.

What are the risk factors for thrush?

You are more likely to get thrush if you: 2

• Weakened immune system, including HIV.

• You have uncontrolled diabetes

• Experiencing long-term illness

• You are taking certain medications, such as antibiotics or steroids.

• Wear dentures

• Xerostomia (dry mouth) develops

What can increase the risk of vaginal yeast infection?

Vaginal yeast infection can be caused by disturbances in the natural flora of the vagina due to factors such as douching, oral contraceptives, or antibiotic therapy.

What may increase the risk of a yeast infection of the penis?

An uncircumcised penis is a major risk factor for thrush because the skin under the foreskin provides an ideal environment for Candida. Poor hygiene and obesity further increase the risk5.

What causes thrush in newborns?

Vaginal candidiasis can be passed from mother to newborn during childbirth, causing congenital candidiasis.