Pharmacology: Pain Management and Sedation Case

A 12-year-old African-American male has an 8-year history of severe persistent asthma.
Pharmacology: Pain Management and Sedation Case

He uses 2 puffs of an albuterol metered-dose inhaler (MDI) for treatment of acute respiratory symptoms and 2 puffs twice daily of fluticasone, 44 mcg/puff MDI, for maintenance control. Over the past 2 months, he has needed four refills of albuterol while obtaining a monthly refill of his fluticasone. He states he is using his albuterol inhaler five or six times a day with minimal relief of symptoms. He wakes up at night a couple of times a week with coughing. His asthma is poorly controlled and needs additional therapy; therefore, you decide to increase his fluticasone to 220 mcg/puff, in 2 puffs twice a day.

Which of the following adverse effects is/are associated with long-term inhaled corticosteroid use?

A. Increased heart rate.

B. Longitudinal growth suppression.

C. Skin thinning.

D. Serum electrolyte abnormalities.

The correct answer is “B.” Option “A” may be associated with short-acting beta-agonist use (eg, albuterol), option “C” may be associated with topical corticosteroids, and option “D” is unrelated. Adverse effects of long-term inhaled corticosteroids are dose dependent and include hoarseness, oropharyngeal candidiasis, adrenal suppression, cataracts, glaucoma, immunosuppression, short stature, and decreased bone mineralization. Inhaled corticosteroids are used to minimize systemic adverse effects of long-term systemic corticosteroids. Although inhaled corticosteroids have high topical potency in the airways, they have limited—but still some—systemic effects, especially in high doses. Management includes using the lowest dose possible or using alternative (nonsteroidal) medications.


Question & Explanation: Peterson AR, Wood KE. Pediatrics Examination and Board Review. New York, NY: McGraw-Hill Education; 2017.

Photo: Wells RG. Diagnostic Imaging of Infants and Children; 2015.