Uses Adrenal corticosteroids are effective drugs in treating nearly all allergic disorders. When used over long periods, however, their poten­tial for causing serious side effects limits their usefulness in treating hay fever, eczema, or long-term hives. They are used to relieve acute, chronic asthma that cannot be controlled by other treatment and to treat allergic pneumonia and serum sickness (various combinations of arthritis, rashes, fever, and swollen lymph nodes, or "glands"). Corticosteroids are also used to treat asthma patients who have had to take steroids recently and who now must undergo surgery, or who are having other physical stress. Corticosteroids are sometimes used in cases of acute hives, acute reactions involving multiple organ sys­tems, or for reactions to drugs, serum, or transfusions. Representative Drugs Corticotropin (ACTH, Acthar, and H.P. Acthar Gel) is a hormone secreted by the pituitary that stimulates the release of cortisone by the adrenal glands. The results of treat­ment with this drug are unpredictable, though, and it has no advan­tages over therapy with adrenal corticosteroids or similar drugs. Cortisone (Cortone) and hydrocortisone (available under several trade names) are fast-acting steroids used briefly during treatment of life-threatening forms of asthma, for reactions involving more than one organ system, and for other acute conditions. Methylprednisolone (Medrol and Solu-Medrol), prednisolone (available under various trade names), and prednisone (also avail­able under various trade names) are fast-acting preparations that are active over brief periods. Useful in treating acute allergic conditions, they are also suitable for administration on alternate days in cases requiring prolonged therapy. Alternate-day administration has been shown to reduce many adverse effects of prolonged steroid therapy. Depo-Medrol, a long-acting, injectable form of methylprednisolone, is also available. Cloprednol, another corticosteroid, is active over a shorter period than either methylprednisolone, prednisolone, or prednisone. Yet it may offer the same advantages in alternate-day therapy as the other three. Cloprednol, however, is still experimental and is not licensed by the Food and Drug Administration. Some long-acting corticosteroid derivatives are betamethasone (Celestone), dexamethasone (available under various trade names), fluprednisolone (Alphadrol), paramethasone acetate (Haldrone), and triamcinolone (Aristocort and Kenacort). These compounds are not suitable for alternate-day therapy.

One aerosol steroid used in treating asthma is beclomethasone dipropionate (Beclovent [Becotide in Great Brit­ain and France] and Vanceril). It has also been used experimentally in treating hay fever but is not licensed for this purpose by the Food and Drug Administration. Dexamethasone sodium phosphate (Deca-dron Turbinaire and Decadron Respihaler) is available for the treat­ment of hay fever, nasal polyps, and asthma; betamethasone valerate and triamcinolone acetonide are experimental preparations not avail­able in the United States.

The most common side effects of aerosol steroid preparations are dry mouth and hoarseness, which usually disappear promptly when the drug is discontinued. The major side effects are fungal infections (called Candida albicans or Asper­gillus niger) of the mouth, the pharynx (upper air passages), or occa­sionally the larynx (voice box). These effects often can be prevented by rinsing the mouth with water each time the medication is taken. Discontinuing the aerosol or treating the infection with an antifungal drug nearly always relieves the condition. On rare occasions, rashes occur, and cataracts have been reported but are considered rare. Replacing prednisone or other orally administered corticosteroids with aerosol corticosteroids whenever possible is an effective way to reduce the side effects of the former. The adrenal glands, however, stop producing natural hormones during treatment with oral corti­costeroids. This effect, called adrenal suppression, does not subside for months after all external sources of corticosteroids (those admin­istered orally, by injection, or, to a lesser extent, by inhalation into the lungs, spraying into the nose, or application to the skin) have been removed. Although the adrenal hormones (to which corticos­teroids are related chemically) are harmful in large doses over long periods, they are necessary in small amounts for many body functions. For some functions, the body may be without an adequate supply of adrenal hormones between the time oral corticosteroids are discon­tinued and the time the adrenal glands resume normal production. This inadequacy —called adrenal insufficiency—is a major concern when aerosol corticosteroids replace oral corticosteroids.

No serious side effects from guaifenesin have been reported. The iodides Potassium Iodide USP and Organidin can cause various allergic manifestations and such side effects as nausea, abdominal cramps, and diarrhea. A group of symptoms called iodism often accompany chronic use; this group usually includes an unpleasant brassy taste, a burning sensation in the mouth and throat, sore teeth and gums, and increased salivation. Other symptoms are: sneezing; runny stuffy nose; eye irritation and swelling of the eyelids; headaches; coughing; a variety of rashes which resemble acne; enlarged painful salivary glands similar to those in mumps; fluid in the lungs (pul­monary edema) and rashes, which may be severe and can on rare occasions cause death. Fever, loss of appetite, and depression, occur occasionally. Iodism usually subsides within a few days after the drug is discontinued. Hypothyroidism, impaired functioning of the thryoid gland, has also been known to occur. Iodides should not be used during pregnancy. Water intoxication sometimes occurs among people suffering from neurotic or psychotic forms of compulsive drinking, or from certain other diseases. Persons with active asthma or chronic obstructive respiratory diseases, however, usually do not drink enough water.

The bischromones, used primarily in treating allergic asthma and exercise-induced asthma, are sometimes used in treating patients with intrinsic asthma. Although bischromones can prevent symptoms of asthma, they should not be used to treat acute, or actively symp­tomatic, asthma, both because they do not dilate the air passages of the lungs, and because some bischromones are irritants. Bischromones have been tested for treatment of gastrointestinal allergy as well as some forms of inflammation of the lungs (pneu­monia) associated with allergic mechanisms. Dosages of the bischro-mone cromolyn, used in experimental work, have been as large as 400 milligrams (20 capsules) when taken orally four times a day. Avoiding the food that causes the allergy, however, is safer, simpler, more certain, and much less expensive. Use of the bischromones in studies of various allergic lung diseases has provided researchers with valuable information about the body’s immune mechanisms.

Cromolyn sodium (Intal) is the only bischromone drug now li­censed by the Food and Drug Administration. It is available as a powder in capsule form. Using a special device called a Spin-Haler, the capsule is punctured and the powder is inhaled into the lungs. Xanthone, another bischromone, is an experimental preparation for oral administration and is not licensed in the United States. Side Effects and Precautions Side effects of bischromones occur infrequently. Throat irritation, hoarseness, coughing, and wheezing are the most common. Nausea, vomiting, and dizziness also occur occasionally. Coughing and wheez­ing often can be prevented by the administration of an aerosolized adrenergic bronchodilator before using cromolyn. Serious but rare side effects are: swelling similar to that of hives under the skin (angioedema); hives; other rashes, allergic reactions involving more than one organ; allergic pneumonia (inflammation of the lungs); gastroenteritis (inflammation of the stomach and intestines); poly­myositis (inflamed muscles); and pericarditis (inflammation of the heart covering) . These effects subside, however, when use of the drug is discontinued. The safety of cromolyn when used during pregnancy has not been determined. Studies in animals indicate decreased fetal weight when an animal is given a dose that produces a toxic effect in the mother; but no tumor-producing effect has been reported, even when enor­mous doses were given intravenously during pregnancy. Potential damaging effects on human fetuses are not known. Expectorants Uses Expectorants promote the removal of mucus from the respiratory tract. They are used in treating asthma and chronic obstructive lung diseases such as chronic bronchitis, emphysema, and bronchiectasis. The last disease named is a condition in which dilatations similar to sacs chronically form in the lungs’ air passages. Representative Drugs The most widely used expectorants are guaifenesin (glyceril guaia-colate, Robitussin, 2/G, and Glycotuss) and iodides (Potassium Io­dide USP and Organidin). Water is still the most effective expectorant, however. Evidence of the effectiveness of other agents is insufficient to justify their use as expectorants; these agents are: ammonium chloride, ipecac, guaiacolsulfonate potassium, and terpin hydrate.

The most frequent side effects of corti­costeroids are those of water retention and weight gain. In the vast majority of patients, however, these effects aren’t severe enough to necessitate stopping the therapy. Other effects are increased sus­ceptibility to bruising, stretch marks, more body hair, insomnia, an inappropriate sense of well-being, leg cramps, an increased number of white blood cells (a condition known as leukocytosis), and a pecu­liar obesity characterized by a rounded face and thin arms and legs. More serious complications attributed to corticosteroid therapy are: Reduced activity of the adrenal glands Diabetes High blood pressure Heart failure Clots within blood vessels Inflammation of the arteries (arteritis) Inflammation of the stomach (gastritis) Inflammation of the esophagus (esophagitis) Inflammation of the pancreas (pancreatitis) Depression of the tissues that produce some of the white blood cells Muscle weakness and pain Rupture of tendons Thinning of bones Destruction of bone tissue Stunted growth in children Cataracts (which can lead to blindness) Glaucoma (another cause of blindness) Protrusion of the eyes An increase in fungal and viral infections (especially Herpes species of virus) of the cornea of the eye Psychosis Increased pressure within the head Seizures Weakness Increased susceptibility to infection Increase in body-fat tissue Peptic ulcer and activation of latent tuberculosis infections have been attributed to corticosteroids, but this is contradicted by recent data. The role of steroids in causing these problems remains controversial. Corticosteroids usually cause adverse effects only after substantial doses have been administered over extensive periods of time, and most are reversible when the drug is discontinued or the dosage is reduced. There are, however, some irreversible effects, including cataracts and thinning or destruction of bone tissue. Test results from animal studies suggest an increased incidence of fetal malformation, fetal death, and premature birth when corti­costeroids are administered to pregnant women, but the data have not been confirmed in humans. The risk of damage to the fetus from lack of oxygen resulting from uncontrolled asthma in the mother seems far greater than from corticosteroid therapy. Aerosol Uses Aerosol steroids are topical preparations that are inhaled in the treatment of chronic asthma or sprayed intranasally in treating in tractable rhinitis. Whenever it is feasible, topically administered cor­ticosteroids are used to minimize the adverse effects of these drugs.