Monday, July 27, 2009

Do oral or inhaled steroids stunt growth?

Recently someone asked a great question at MyAsthmaCentral.com that got me to thinking, and ultimately lead me to my latest post on my asthma blog.

Question: Severe asthma and on steroids since i was born- do these steroids stunt growth? If a person has severe asthma, and has taken steroids since they were a kid and inhalers, and now advair, do these products stunt your growth or reduce hormone levels? (I almost died of asthma when i was a baby and was pumped with steroids to survive when i was little) Since then i have used inhalers and now advair.

My humble answer: Great questions. There have been many studies that show systemic corticosteroids can cause growth suppression. There have also been studies that show asthma in itself -- especially if not well controlled -- can cause growth suppression.

According to Massoud Mahmoudi in Allergy & Asthma: Practical Diagnosis and Management, "Doses of prednisone as small as 0.1 mg/kg administered daily for as short a period as 3 months have resulted in significant suppression of linear growth."

However, it also should be noted that studies also prove most doses of inhaled corticosteroids (like you receive in meds like Advair) do not cause the same side effects as oral or injected corticosteroids, and therefore should not effect your height.

Honestly, though, when I was 15 back in 1985 I was on oral steroids for over a year and my asthma doctor sent me to a bone specialist who had me undergo a bunch of tests to determine how short I would be when I grew up. He even wanted to take a bone chip out of my hip. I refused that test. To be honest, I didn't really care about how tall I was going to be when I grew up, I just wanted to get my asthma under control. I told my doctors to quit testing my bones, and she duly respected my blunt request. The subject was never brought up again.

However, my doctor did tell me the bone specialist predicted I would grow to be no more than 5'6" tall. It wasn't something I spent much time stressing about, and in the end that turned out to a good thing, because once I was done growing I was 5'8" tall, a pretty normal height. I am the shortest in my family, but that's no big deal.

I think what is important for any asthma doctor and asthmatic combo is to do whatever is necessary to get the asthma under control, because the risk of losing a few inches is a good trade off for being able to live a normal, active life even though you have asthma.

I expounded about my experience in my latest post over at MyAsthmaCentral.com, and whether this is something asthmatics currently taking inhaled (like pulmicort or flovent) or oral steroids need to be worried that their height might be in jeopardy.

To read my latest asthma blog post, please click here and I will morph you there.

A concern for Parents of Asthmatics: Will Corticosteroids stunt my child's growth?
by Rick Frea Wednesday, July 22, 2009: Published at MyAsthmaCentral.com.

So, your son or daughter has been diagnosed with asthma, and his or her doctor has prescribed systemic glucocorticosteroids (GC) like prednisone, and long-term inhaled GCs like Flovent or Pulmicort. Your concern is: Will this stunt my child's growth?

This is a great question. In fact, according to "
Allergy & Asthma: Practical Diagnosis And Management" by Massoud Mahmoudi, growth suppression is one of the top concerns of doctors caring for child asthmatics who need GCs.

According to Mahmoudi, "Regular daily therapy, frequent short courses, or high-dose alternate-day (systemic) GC therapy often results in the suppression of linear growth. Doses of prednisone as small as 0.1 mg/kg administered daily for a short a period as 3 months have resulted in significant suppression of linear growth."

Complicating that, Mahmoudi writes, is the fact that asthma itself -- especially poorly controlled asthma -- has been shown by various studies to stunt growth.

Sometimes doctors don't have a choice, and if systemic GC are needed long term, a dose of 20mg or less on alternate days seems to be, according to studies, a safe dose with limited effect on growth.

Now, what about those highly recommended steroid inhalers your child is on? Do these stunt growth too?

When I was a child,
hardluck asthmatic growing up in the 1980s my doctors would tell me to stop taking my inhaled GC when I was feeling well for fear of side effects (I wrote about this here).

Later research, however, confirmed that not only are inhaled GCs safe, they are the most effective means of managing asthma. The catch here is this: you have to make sure your child rinses his or her mouth out really well after each use.

That aside, Mahmoudi writes that an extensive study on this subject was performed by the Child Asthma Management Program (CAMP) in 2000 that showed children who took 200 micrograms of Pulmicort twice daily were 1.1 cm shorter than those who took a placebo (1 cm is about the diameter of a AAA batter, do give you a visual reference). Thus, the conclusion of the study was that "GC therapy can result in a modest but transient effect on growth that is unlikely to have any adverse effect on adult-attained height."

Another study followed children who were using 412 micrograms of Pulmicort for 9.2 years, and the "investigators found no difference in the measured versus the expected adult heights in any of the groups studied... Of interest, they too noted a transient suppression of growth... but it did not adversely impact adult-attained height."

I have my own personal story regarding GC induced growth suppression. When I was an asthma patient at
National Jewish Health (NJH) back in 1985 my doctor told me all the systemic GC I was on had already effected my height. While I was 15, my bone age was 13.5 years.

In my medical records, my doctor wrote this about me:"Rick's growth and bone development have been affected by his high steroid use. He was evaluated completely in the Pediatric Endocrinology clinic at the children's hospital. Their findings indicate Rick is constitutionally delayed in growth and his severe asthma and requirements for high-dose steroids over the past several years have contributed to this delay. Based on their information, Rick has an estimated adult height of 5 feet 6 inches. Rick also has steroid induced osteoporosis that needs to be dealt with. "

Being the worrying type I was back then, this news caused me much anxiety. Yet my counselor assured me this was nothing to fret about. He said, "Doctor estimations are nothing to worry about. Your main concern right now should be getting your asthma under control and the steroids are helping you with that."

A few months after I was discharged from the asthma hospital, and completely weaned off oral GCs but still on high doses of inhaled ones (4 puffs 4 times a day of
Azmacort), my doctor told me I no longer had osteoporosis. But my height continued to vex me. Even as a senior in high school I had the body of a freshman.

Despite those NJH estimations, however, I am now 5 feet 8 inches tall. Sure all four of my brothers are taller than me, but who cares. My current height works just great for me. If the GC shrunk me 1.1 cm, I can't tell and don't really care.

My advice to you is the same as that given to me by my counselor back in 1985: "It's better to let your doctor do what it takes to treat your asthma now than to risk worse asthma -- or even death -- down the road, even if that includes steroids."

4 comments:

deano said...

Fantastic article. Thanks so much for being informative--you have helped us tremendously in making decisions about our daughters asthma treatment regimen.

Rick Frea said...

You are welcome. Thanks.

Anonymous said...

What a great article..Have a 12 year old going through the pediatric endo tests..failed the growth stim test, etc. etc....he also almost died when he was a baby
and again at three from life threatening asthma..pumped with prednisone many times..on inhaled meds now..This was a VERY helpful article that I found at just the right time reiterating the importance of treating asthma...really no choice....but great to hear your perspective having experienced it yourself.. Thanks

Rick Frea said...

Glad to help!!!