Pharmacology · patient case with 1 question
Inhaled corticosteroid and long-acting beta agonist in asthma
Patient: Female, 44 years old
Chief Complaint: “My mouth has been sore and my tongue feels burnt.”
Background: Asthma controlled on a combined SALMETEROL and fluticasone inhaler twice daily, with an albuterol rescue inhaler. She uses the inhaler last thing at night and does not rinse afterwards. No diabetes, no antibiotics recently.
Vital Signs: BP 122/76 mmHg · HR 78 bpm · T 98.2°F
Findings: Diffuse erythema of the posterior palate and oropharynx with scattered removable white plaques leaving an erythematous base when wiped. Angular cheilitis bilaterally. Reduced salivary flow.
Question 1
Which oral complication does her inhaler regimen most directly cause?
Show answer and explanation
Correct answer: B. Oropharyngeal candidiasis
- A. Squamous metaplasia of the airway is a consequence of chronic SMOKE exposure, not of inhaled medication, and it affects the respiratory epithelium rather than the oral mucosa.
- B. CORRECT. The INHALED CORTICOSTEROID deposits in the oropharynx and produces LOCAL immunosuppression — reduced local cell-mediated immunity and altered epithelial turnover — which allows Candida albicans to overgrow. The risk rises with higher doses, with dosing at night, and above all with FAILURE TO RINSE afterwards. The beta-2 agonist compounds it by reducing salivary flow. Prevention is simple and is the examinable point: use a SPACER, and RINSE and spit after every dose.
- C. Systemic corticosteroids raise blood glucose, but inhaled doses produce minimal systemic absorption and do not meaningfully affect HbA1c at standard doses.
- D. Gingival enlargement is caused by phenytoin, ciclosporin and the dihydropyridine calcium channel blockers — not by corticosteroids or beta agonists.
Note: What this item adds is the ORAL consequence and its prevention. The full inhaler-related oral picture: candidiasis, xerostomia with raised caries and periodontal risk, angular cheilitis, dysgeusia, and enamel erosion from the low pH of some dry-powder formulations. Ask any asthmatic whether they rinse — most do not, and nobody has told them to.