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Symbicort is a very popular drug for asthma that is actually a combination of two drugs, budesonide, which is a steroid used to relieve inflammation, and formoterol, which is a beta-2 agonist, a drug that activates nerve endings that help keep air passages open. While inhaled budesonide and formoterol don't cause side effects of the same severity when they are inhaled, rather than taken systemically, they do have many side effects of lesser impact on day to day health. That doesn't mean those side effects are trivial or unimportant.

Budesonide, like other steroids, stimulates weight gain. The way it does this is by stimulating the release of sugar (glucose) from the stored sugar (glycogen) in the liver. When your blood sugar levels go up, your body releases insulin to make them go back down (or if you are a diabetic, you need more insulin to achieve the same level of glucose control). When insulin levels go up, fat cells are less able to use an enzyme called hormone-sensitive lipase, which they need to break down "globs" of fat (triglycerides) into "droplets" of fat (fatty acids) that can circulate through the bloodstream to muscles where they are burned during prolonged exercise.

Of course, it if you weren't exercising anyway, you don't get any fatter just because your fat cells can't release fatty acids for your muscles to burn. However, it's not unusual for adults to put on 5 to 10 pounds (2 to 4 kilos) of additional body mass when they go on Symbicort.

In children, there is a different set of concerns. There is a slight increase in weight gain in children who use Symbicort, but it's just a few grams (a fraction of an ounce) a day. There is a bigger problem when they go off Symbicort. That's when they may fail to gain weight or suffer hypoglycemia, because their systems have difficulty adjusting to the absence of budesonide.

The whole point of using a product that is a combination of budesonide and formoterol, however, is not having to use it as often. People who use inhalers other than Symbicort typically use them, on average, every day. People who use Symbicort use it, on average, three days out of four. Users get a lower total dose of steroids from Symbicort than from other, similar medications.

The side effects of the steroid in Symbicort are generally lower than the side effects of other kinds of steroids in other inhalers.

Weight gain, however, is not the only side effect or even the most important side effect of inhaled steroids. A larger concern is the effects of taking a steroid every day, even if it is inhaled, on the pituitary-hypothalamic-adrenal axis, the complex interrelationships of endocrine glands that regulate stress hormones. Even when steroids are taken in an inhaled form, they reduce the need of the hypothalamus to send signals to the adrenal glands to release the natural steroid hormone cortisol. The adrenal glands can shrink from disuse, although this doesn't happen right away after starting an inhaled steroid (it takes at least a few weeks), and it doesn't happen when the dosage of steroids is minimal.

Steroids, including inhaled steroids, can also weaken the immune system. Ironically, users of asthma inhalers are at greater risk for developing pneumonia because of the effects of the steroids on immune response. White blood cells aren't as responsive to signals sent by the lungs to come to the rescue when infections set in after the use of steroids. Steroids can also affect growth of the skin and lenses of the eyes. Users of steroids are more likely to develop cataracts at an early age.

The key to using Symbicort successfully is to limit the dosage. Don't use it when you don't need it. Make sure your doctor is giving you the lowest effective dosage. When you need it, you need it, but the less you use, the milder its side effects will be.

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