A 28-year-old woman with moderate persistent asthma is prescribed inhaled fluticasone propionate 250 µg twice daily. She is counselled on proper inhaler technique and side effects. All of the following are true regarding ICS-related adverse effects EXCEPT:

Explanation

## Adverse Effects of Inhaled Corticosteroids **Key Point:** ICS have an excellent safety profile at recommended doses. Systemic effects are MINIMAL at low-to-moderate inhaled doses due to high first-pass hepatic metabolism. Bone loss is NOT a significant clinical concern at therapeutic ICS doses in adults. ### Local vs. Systemic Adverse Effects | Adverse Effect | Type | Frequency | Management | |---|---|---|---| | **Oral candidiasis** | Local | Common (5–10%) | Spacer + mouth rinse post-inhalation | | **Dysphonia** | Local | Mild, transient | Usually resolves; reduce dose if persistent | | **Throat irritation** | Local | Mild | Spacer, mouth rinse | | **HPA axis suppression** | Systemic | Rare at therapeutic doses; more common in children on high doses | Monitor in children on prolonged high-dose therapy | | **Bone mineral density loss** | Systemic | NOT clinically significant at low-to-moderate doses in adults | High doses in children may warrant monitoring | | **Cataracts** | Systemic | Rare; no clear link at therapeutic doses | Not a routine concern | ### Why Bone Loss Is NOT a Major Concern at Therapeutic ICS Doses **High-Yield:** The question stem is asking about **inhaled** corticosteroids at **therapeutic doses** (e.g., fluticasone 250 µg BD). At these doses: - Systemic bioavailability is very low (< 20% for fluticasone due to high first-pass metabolism) - Studies in adults show **no clinically significant bone loss** at low-to-moderate ICS doses - Bone loss is a concern only with **systemic corticosteroids** (oral prednisolone) or **very high ICS doses** in children - The risk of asthma exacerbation and its complications FAR outweighs any theoretical bone risk **Clinical Pearl:** A patient on inhaled fluticasone 250 µg BD does NOT require routine DEXA scanning or calcium/vitamin D supplementation for bone protection. Routine bone monitoring is reserved for patients on systemic corticosteroids or very high-dose ICS in children. **Warning:** Do not confuse ICS (inhaled, low systemic absorption) with oral corticosteroids (high systemic absorption, definite bone loss risk). This is a classic NEET PG trap. ### Correct Statements About ICS Safety 1. **Oral candidiasis** — Common local effect; spacer + mouth rinse are effective prevention 2. **HPA axis suppression** — Possible at high doses, especially in children; monitor in prolonged therapy 3. **Dysphonia and throat irritation** — Local effects; usually mild and transient [cite:Harrison 21e Ch 297; KD Tripathi 8e Ch 27]