Altered Swallowing Physiology and Aspiration in COPD.

cortisol deficiency associated with low-dose corticosteroid therapy for asthma. Pediatrics 1996; 97:921–923 7 Tabachnik E, Zadik Z. Diurnal cortisol secretion during therapy with inhaled beclomethasone dipropionate in children with asthma. We thank Doctors Caballero-Fonseca and Sanchez-Borges for their interest in our abstract (October 2001 supplement). 1 We reported on a large case series of patients who had experienced acute adrenal crisis due to inhaled steroids, nearly all due to fluticasone (Ͼ 94%). Acute adrenal crisis was an extremely rare phenomenon before the introduction of fluticasone in the United Kingdom in 1994. We believe that our study highlighted important differences among the inhaled corticosteroid agents, and it specifically opposes the view that the most recently introduced inhaled steroid, fluticasone, has the best benefit/risk ratio. However, we would like to emphasize that all the authors of our article are very enthusiastic prescribers of inhaled steroids as a first-line treatment for patients with all but the mildest forms of asthma. Inflammatory processes are absolutely fundamental to the pathogenesis of asthma, and inhaled steroids are by far the most effective drugs at reducing inflammation in asthma patients. They are also the most effective drugs at reducing the burden of asthma (ie, improving exercise tolerance, reducing days lost from school, preventing acute exacerbations, preventing hospital admissions , and decreasing the risk of death from asthma). In the vast majority of patients, the benefits greatly outweigh the risks. For example, in a long-term study (mean study duration, 9.92 years) of budesonide treatment (patient age range, 3 to 13 years) with a mean daily dose of 412 ␮g/d (dose range, 110 to 887 ␮g/d), there was no effect on final adult height and no evidence of any other significant side effects. 2 This is most compelling and reassuring evidence of the long-term safety at least of this particular inhaled steroid in children. We therefore believe in the early introduction of inhaled steroids in adequate dosages for the control of asthma, as is advised by all national and international guidelines, and that the safest amount of an inhaled steroid to administer to any child is the minimum amount required to control the asthma. Under these circumstances, the benefits of inhaled steroids greatly outweigh the morbidity and mortality associated with uncontrolled asthma. For example, it is important to remember that since the introduction of inhaled budesonide Ͼ 20 years ago, there have been Ͼ 10 billion patient-days of use …