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Studies reporting exacerbations requiring OCS showed no difference between the two add-ons, but our confidence in the effect was low due to inconsistency between studies and because the confidence intervals ( CI ) included significant benefit of either treatment ( odds ratio ( OR ) , 95% CI to ; 1753 participants; 3 studies); three more people per 1000 might have an exacerbation on LAMA, but the CIs ranged from 29 fewer to 61 more. Imprecision was also an issue for serious adverse events and exacerbations requiring hospital admission, rated low (serious adverse events) and very low quality (exacerbations requiring hospital admission), because there were so few events in the analyses.

Use of QVAR with a spacer device in children less than 5 years of age is not recommended. In vitro dose characterization studies were performed with QVAR 40 mcg/actuation with the OptiChamber and AeroChamber Plus ® spacer utilizing inspiratory flows representative of children under 5 years old. These studies indicated that the amount of medication delivered through the spacing device decreased rapidly with increasing wait times of 5 to 10 seconds as shown in Table 2. If QVAR is used with a spacer device, it is important to inhale immediately.

There is some evidence that sun exposure can accelerate steroid-induced skin atrophy, the development of which can be limited by protecting the skin, particularly the face and arms, from the sun.  Daily use of a broad-spectrum sunscreen (UVB and UVA block) and appropriate protective clothing is recommended. 10 , 12 - 14   Patients on corticosteroids should also be encouraged to regularly use moisturisers on their arms and legs, as these may reduce bruising and tearing of the skin from minor trauma. 11   Evidence suggests that topical tretinoin can increase the epidermal thickness of sun-damaged atrophic skin, but long-term use may be necessary. 14   In dermatological practice, topical retinoids are used to help reverse skin atrophy caused by sun exposure or corticosteroid use.

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