Use of Inhaled Corticosteroids and the Risk of Cataracts

ABSTRACT & COMMENTARY

Synopsis: Among 3654 people aged 49-97 years, the use of inhaled corticosteroids at any time was associated with a significantly increased prevalence of nuclear cataracts and posterior cataracts.

Source: Cumming RG, et al. N Engl J Med 1997;337:6-14.

The prevalence of cataracts in 3,654 people 49-97 years of age (mean, 65 years) was studied in Australia. Cataracts were diagnosed by retroillumination photography, a technique considered less sensitive than slit-lamp examination. Photographs of the lens were interpreted without knowledge of the history of corticosteroid use. The use of inhaled and systemic corticosteroids was determined by questionnaire, whereby 241 subjects had used only inhaled corticosteroids, 177 used only systemic corticosteroids, and 111 subjects had employed both.

The use of inhaled corticosteroids at any time was associated with a significantly increased prevalence of nuclear cataracts and posterior cataracts. There was a highly significant (P < 0.001) trend for increasing risk for posterior subcapsular cataracts, with increasing lifetime dose of beclomethasone; however, after elimination of those with a history of systemic corticosteroid use, the trend was less evident (P = 0.06).

COMMENT BY SHELDON L. SPECTOR, MD

The value of any medical therapy is assessed by weighing potential benefit vs. potential risk. Inhaled corticosteroids are probably the most effective medications for moderate-to-severe asthmatic subjects, according to various published guidelines.1,2 Yet, in the study, the authors tried to eliminate the possible effects of systemic steroids. In my experience, this is difficult since patients often do not know the nature of an injection they have received, or even the name or mode of action of a pill prescribed to them in the past. Nevertheless, it is unlikely that those who denied use of systemic steroids would have used them in sufficient quantities to explain the observed increased risk of cataracts. It is surprising that the authors did not assess the use of nasal corticosteroids in their questionnaire, since this is a possible confounding variable and would influence the total dose of steroids absorbed.

Despite these reservations, it seems likely the authors have identified an increased risk for cataracts in patients who use inhaled corticosteroids, especially when moderate- or high-dose inhaled steroids are used over a long period of time. Periodic ophthalmologic evaluations, including slit-lamp, would seem prudent under such circumstances. Finally, the results of this study reinforce the importance of step-down therapy of asthma—tapering inhaled steroids to the lowest dose required to control asthma, and employing other classes of medications with "steroid- sparing" properties.3

References

1. National Heart, Lung, and Blood Institute. International consensus report on diagnosis and management of asthma. 1992.

2. Spector S, Nicklas R (eds). Practice parameters for the diagnosis and treatment of asthma. J Allergy Clin Immunol 1995;96:707-870.

3. Spector SL. Leukotriene inhibitors and antagonists in asthma. Ann Allergy Asthma Immunol 1995;75: 563-570.