a man having an asthma attack using an inhaler

 

The standard treatment for asthma and COPD often involves inhaled corticosteroid drugs like beclomethasone (Qvar), budesonide (Pulmicort, Symbicort) and fluticasone (Advair, Flovent). One side effect that patients may not be warned about is hoarseness or laryngitis. We fear it is considered a minor complication of therapy. Ear, nose and throat specialists (otolaryngologists) recognize that it can be a serious problem for many patients. They even have a name for this condition. SIL, also known as Steroid Inhaler Laryngitis (JAMA Otolaryngology-Head & Neck Surgery, June, 2002) may be far more common than most other health professionals realize.

How Common is Steroid Inhaler Laryngitis (SIL)?

When you search the official prescribing information for an inhaled HFA drug like Advair (fluticasone plus salmeterol) you will discover that throat irritation is listed at around 7 to 9 percent. Hoarseness and dysphonia (difficulty speaking) is 1 to 3 percent. We suspect it is substantially higher.

That is not just our opinion. Here is a comment by Dr, John DelGaudio, an ENT-otolaryngologist in Atlanta, Georgia affiliated with Emory University Hospital:

“The Physicians’ Desk Reference reports the incidence of hoarseness for the various steroid inhaler preparations to range from 1% to 9%, compared with 0 to 3% for nonsteroid inhalers. Clinical studies show the incidence of hoarseness to be much higher, occurring in as many as 55% of patients who use steroid inhalers. Of the inhaled steroids, fluticasone has a greater topical potency and greater tissue retention and half-life. Clinical reports of the incidence of dysphonia with fluticasone are limited, and clinical studies report an incidence that ranges from only 2% to 6%…

“The physical changes that are seen in the larynx of patients using inhaled fluticasone range from minimal to severe. Mild physical findings include edema [swelling] and erythema [redness]. Moderate changes include mucosal thickening and vocal cord bowing. The most dramatic changes include leukoplakia [thickened white patches], granulation, and laryngeal candidiasis [yeast infection].”

What Is It Like to Have Steroid Inhaler Laryngitis?

Q. I work as a public address announcer, so my voice is essential for my job. My asthma inhaler, Advair, makes me so hoarse that it is a real problem. My doctor hasn’t offered anything helpful. Do you have any suggestions?

A. You are not the only person to develop hoarseness (laryngitis) as a side effect of an inhaled corticosteroid. Doctors sometimes tell their patients to gargle after using the inhaler. One reader didn’t get any relief with this tactic:

“Gargling isn’t going to reach the vocal chords. I am a singer and have had to lower the key of all my songs to match my ‘frog-like’ voice.”

Can Mylanta Ease Steroid Inhaler Laryngitis?

Another reader had this suggestion:

“I have COPD and use the same inhaled medication. Initially it made me hoarse. Then I was told by a throat specialist to take some Mylanta after using it. Boy does it help.”

We could find no studies documenting the value of swallowing liquid antacid to avoid laryngitis from a steroid inhaler. That said, it might be worth a try. Check with your doctor to make sure Mylanta won’t interact with any of your other medications.

Other Reports of Steroid Inhaler Laryngitis:

Visitors to this website do not think this is a minor side effect. Here are just a few comments from readers:

“Advair definitely causes hoarseness, and it’s so bad I sounded like I was 100 years old. It was really hard to talk at all. And no, my Doc didn’t seem to care one whit, so why should anyone else?

“Rinsing and gargling didn’t ever help. I have COPD. And no, my Doc doesn’t care about this either. I want to thank The Peoples Pharmacy for ‘outing’ Advair for its abominable side effect of hoarseness. It was hell the whole time I was on it.”

Another readers is caught between a rock and a hard place:

“I used Advair for several years before I started getting hoarse. It got so bad that people were constantly asking me to repeat myself and no one could understand me over the phone. I stopped using the Advair, and the hoarseness went away, but my breathing got worse.

“My doctor told me voice hoarseness from fluticasone is rare. It might be rare, but I have it, and it is a bummer. I sound like I am straining to talk all the time. In fact, I sound like I am 90 years old, but I am 53. Talking is uncomfortable, so I say less, which my wife probably likes.”

This singer came up with an alternative therapeutic approach thanks to a pulmonologist.

“I am a singer and an asthmatic with allergies. Everything this bleepin allergist gave me made me more hoarse with coughing. He switched every time I complained loudly.

“Finally, I went to a pulmonary doctor and told him I wanted nothing with steroids Lo, and behold…I started to get better with Spiriva and montelukast for the allergies. I am now singing everything from Santa Baby to I Dreamed a Dream and counting my blessings every day.”

What’s your Experience?

If you have used an inhaled corticosteroid, have you experienced steroid inhaler laryngitis? Has one been better or worse than another? Please share your story in the comment section below.

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  1. Jean
    Reply

    WHAT ABOUT VENTOLIN? I have never had any problems with this inhaler and it is one of the few brands that has any real medication in it so says my pulmonary doctor.

  2. Gayle
    SC
    Reply

    I am a 72 year-old with well controlled asthma thanks to Advair. 150/50. Never made me hoarse but I only use it once per day. A miracle for me!

  3. Val
    Calif.
    Reply

    I’ve been using Advair since it first came out. My doctor gave me a free trial and taught me how to use it. Stand up straight, head held up, breathe in deeply, and hold for 5 seconds. Breathe out, and wash mouth out well, then gargle for a few seconds as deeply as possible, some times twice. He was a user also and knew how to do it. I have never had voice problems of any kind and often someone will comment how young my voice sounds. I am 80 years old.

  4. Megan Schlick
    Cleveland, Ohio
    Reply

    My pulmonary doc prescribed Advair for my asthma. He could have cared less that I am a singer, and that the other musicians are not inclined to change the key of an aria just because the doc didn’t warn me that my vocal range might go lower by 2 whole steps! I now Sing Mezzo or Alto Arias.

  5. Gina
    Reply

    I used Qvar for less than six months because of the hoarseness it caused. My voice returned to normal once I stopped.

  6. jean
    CA
    Reply

    Thanks for all the ideas. No laryngitis yet. I plan to do the triple gargle and water swallow to reduce the likelihood of it occurring. .

  7. Joyce
    Missouri
    Reply

    I have hoarseness too from Breo and all the other inhalers I have used. I’m wondering if a nebulizer would have the same side effect?

  8. Kathy
    Ohio
    Reply

    I have used Advair Diskus for several months and began experiencing hoarseness intermittently. My CNP suggested I inhale deeper (I am a shallow breather) and gargle/rinse thoroughly. I am using the inhaler only once daily (not the recommended twice daily) and that combination seems to be working. I developed a rash around my mouth two months ago, and medication clears it, and then it comes back.

  9. Carole
    Virginia
    Reply

    I used dulera inhaler with a spacer for allergic asthma for 4 years in which I became increasing hoarse. I always gargled. I thought it was due to sicca syndrome, a dryness condition that I have, until I read that the inhaler propellant could cause hoarseness. I read the drug insert and hoarseness is not listed. My pulmonologist confirmed that dulera caused it. Put me on Alvesco which has a different propellant. Only been using it about 2 weeks, so I hope it works. With my insurance it costs almost 4 times as much as dulera, but it will be worth it if it cures the hoarsness.

  10. Carl
    IN
    Reply

    I’ve used Advair for several years and I have not experienced any hoarseness; however, I follow the instructions that say to rinse your mouth and gargle with water after each use. I never omit doing this. Maybe this helps to prevent the hoarseness.

  11. Joyce
    CO
    Reply

    I have COPD and asthma and have used Dulera ( mometasone furoate) for 5 years and have never experienced hoarseness. I love this inhaler, so much, that when I am almost forced (by doctor, insurance, etc) to use a different product, I refuse. The stuff really works and is gentle.

    What I find that gives me discomfort is ipritropium bromide. Either in the form of Spiriva or nebulized liquid. The stuff is just like inhaling razor blades sometimes and leaves me with that awful gravelly voice and irritated bronchi. But, it works so well! I have discovered that nebulizing albuterol sulfate after wards makes thus problem go away.

    I hope this helps! Thankyou for allowing me to share.

  12. Monica
    OH
    Reply

    Advair and Qvar created terrible voice hoarseness. I’ve been on Singular for years and switched to use of Xopenex via a nebulizer for those times when my asthma flares–the best combo I’ve been able to come up with.

  13. Julia
    Chapel Hill, NC
    Reply

    I have had a chronic cough for 25 years. I’ve seen MANY doctors over the years, taken every OTC antihistamine, nasal spray, anti-acids, nasal rinses, numerous prescription antihistamines and nasal sprays; you name it, I’ve tired it. Most don’t work forth a fig.

    In 2013 my primary care physician prescribed Flovent. While I’ve never been diagnosed with asthma, he thought it was worth a shot. It seemed to work better than anything else at controlling the cough. About 2 years ago I noticed that my voice seemed to be getting weaker. I remember my Dr. telling me that it’s important to rinse my mouth out after using the inhaler in order to avoid thrush in my mouth. I began to think that perhaps if this medication can cause problems in the mouth, it might also cause problems in the throat, and rinsing won’t help there.

    I asked my Dr. about this theory, but he discounted it.

    My voice has continued to get weaker and I continue to get very frustrated with the whole thing. My husband and I are in our 70’s. He is hard of hearing and I can barely speak above a whisper. This is not a good combination! I am glad that this article has brought out some evidence that perhaps I was correct in the first place. I will pursue this further, thank you!

  14. Patty
    Illinois
    Reply

    Spiriva gave me horrid laryngitis to the point that people thought I was sick and would back away from me for fear they would catch my “bug”. I did OK on Advair but am now on Serevent with no problems.

  15. Bill
    New Mexico
    Reply

    Unfortunately all the doctors in new Mexico lump everything into one basket and call it copd and just keep switching inhalers on us

  16. Demian
    Colorado
    Reply

    My doctor, a lung specialist at National Jewish Hospital, advertised as the best respiratory hospital in the country, prescribed fluticasone (100 mcg). It definitely causes hoarseness, and I will discontinue it as soon as I can get his permission. I teach university classes, and am straining to speak after a half hour; also, sometimes the straining causes a sore throat and an almost complete loss of voice (which disturbs my wife greatly). I don’t feel that it helps anything anyway.

  17. Betty
    Texas
    Reply

    I have used these since the 1980’s…the secret it gargle deeply 3 times, then drink LOTS of water to wash vocal cords and deeper. I have never had a problem.

  18. Daniel
    California
    Reply

    Last year, my nose doctor prescribed fluticasone propionate, 50mg, for my stuffed sinus. I barely took a few sniffs for a few days when I developed a large cyst inside of my right cheek. I stopped taking it immediately, and the cyst slowly disappeared. I also went to my dentist for a cleaning, and he indicated that it would eventually subside. I won’t be taking this again. It may be okay for some people, but not for me. It did cause me pain whenever I brushed my teeth, so I had to be careful when brushing my right cheek.

  19. Marilynn
    Chicago suburbs
    Reply

    Fluticasone made me terribly hoarse, worst in the norming. When I read it could do this, I stopped using it, and the hoarseness became minimal. But my runny nose and eyes got so bad that I went back to it, although trying to minimize usage. So far, it’s doing ok.

  20. Susan
    Buffalo, NY
    Reply

    Had the same experience with many of these inhalers, although they work extremely well for my asthma. My allergist prescribed a spacer to use with the Symbacort, suggesting that the larger particles that irritate, drop down into the spacer chamber and only the smaller particles get into your throat. My doctor said the larger particles are more irritating and only serve the purpose of propelling the powder. This has worked tremendously and my voice is 90% better

  21. Joanne
    Reply

    I’ve used Pulmicort for years for asthma. Yes, my throat is hoarse. Will discuss with my allergist. Thanks for bringing this to our attention

  22. margaret
    Minneapolis, Mn.
    Reply

    I have had the hoarseness reaction to all of the steroid inhalers; my pulmonologist kept switching my prescription and it did not improve. Finally I went back to Advair and I take half the dosage and the hoarseness disappeared. I am not sure it is the right choice for my asthma, but the hoarseness was quite extreme and i knew that could not be good. I will appreciate hearing solutions to this.

  23. Jane
    Reply

    I believe the horseness happens in probably 98% of users of inhaled steroids. I quit the Advair because of it but now I’m on Trelegy and although that causes horseness too, I’ve learned to rinse out my throat and to drink just a few sips of water after inhalations and that sure helps. I think Pulmonary docs are pretty worthless overall for helping with this or anything else. My allergist is the one who knows how to manage my COPD. My recommendation would be to rinse out your throat well…hold water at the throat level and move the throat up and down quickly to rinse, then just swallow a few sips of water. Good luck! It’s not fun to sound like you’re 100 years old and to struggle so hard just to talk.

  24. Carol N,
    Salem Oregon
    Reply

    Advair, tho wonderful for asthma, gave me voice hoarseness and dysphonia. I can NOT deal with my daily business unable to speak!

    I tried Qvar and broke out in pimples in my mouth, down my throat and a red swollen tongue after first use!

    Insurance insisted I use a dry powder inhaler next. (forgot its name) I cannot breathe in dry powder inhalers. They actually CAUSE a worse asthma attack.

    After nearly begging on hands and knees, then simply refusal to take it, my Dr agreed to Flovent. Ive had that drug most of my life. Its never bothered me at all!

    He agreed, to one inhalation twice a day (Advair was 2 inhalations twice a day). It took about a month on just FLovent to stop the hoarseness. That was a yr ago, and I’ve not had a single day of hoarseness since. I also take Singulair, the Zenopex for rescue. (age 65)

  25. Jane
    Wisconsin
    Reply

    Many years ago, I had tried a number of inhaled cortico-steroids for asthma, all of which caused hoarseness. My pulmonologist put me on Serevent, which I have used with no problems ever since.

  26. Nancy
    South Carolina
    Reply

    Yes, I have COPD and have been on steroid inhalers for several years, including Advair. My voice is very hoarse, at times very bad like laryngitis.

  27. Mary
    Wisconsin
    Reply

    Hi. I too use the steroid Symbicort for mild COPD. I too have a change in my voice and lately a metal taste in my mouth! I don’t even sound like myself when I’m talking. My doctor also said to gargle but it does not make a difference!

    • S.
      Houston, Tx.
      Reply

      In September 2017 became hoarse and feeling ill. Went to ENT Dr and she did the Scope through the nose and discovered Fungal infection ( Thrush) on vocal cords. I use Symbicort and always rinse 3/4 times after using, but can not rinse deep down in vocal cords. Had to use a liquid solution Nystatin, to swish and swallow. Took 2 weeks to clear up.

      Steriods cause upper respiratory infections and I ended up with bronchitis and 4 days in the hospital in January; another side effect. Need to try Singular. Xopenex is my rescue inhaler which never had issues with. I am allergic to pure Albuterol. Makes my breathing worse. I brought COPD on myself from many years of smoking cigarettes.

  28. Chris
    Andrew, IA
    Reply

    I tried Spiriva and it made my voice worse and gave me a sore throat! But Advair is just a little easier on my throat, but still get hoarse and cough a lot. I have Asthma and COPD. I like breathing, but sure wish there was some other inhaler!!

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