page205
to 7 days after initiation. Beclometasone dipropionate,
budesonide,
fluticasone propionate,
and mometa-
sone furoate appear to be equally effective.
Prepara-
tions that combine a corticosteroid with a long-acting
beta
2
agonist may be helpful
for patients stabilised on
the individual components in the same proportion.
In adults using an inhaled corticosteroid and a long-
acting beta
2
agonist for the prophylaxis of asthma,
but
who are poorly controlled,
(see step 3 of
the Manage-
ment
of
Chronic Asthma table,
p.
172)
Symbicort
c
(budesonide with formoterol) can be used as a reliever
(instead of a short-acting beta
2
agonist), in addition to its
regular use for the prophylaxis of asthma.
Symbicort
c
can also be used in this way in adults using an inhaled
corticosteroid with a dose greater than beclometasone
dipropionate 400 micrograms daily
1
, but who are poorly
controlled (see step 2 of
the Management
of
Chronic
Asthma table, p.
172). When starting this treatment, the
total regular daily dose of inhaled corticosteroid should
not be reduced. Patients must be carefully instructed on
the appropriate dose and management of exacerbations
before initiating this therapy,
see
Symbicort
c
p.
188.
Patients using budesonide with formoterol as a reliever
once
a
day or
more
should have
their
treatment
reviewed regularly.
This management approach is also
used by
some
specialists
in children 12–18
years
[unlicensed]. It has not been investigated with combina-
tion inhalers containing other corticosteroids and long-
acting beta
2
agonists.
High doses of inhaled corticosteroid can be prescribed
for
patients
who respond only partially to standard
doses
with a
long-acting
beta
2
agonist
or
another
long-acting bronchodilator (see Management of Chronic
Asthma table,
p.
172).
High doses should be continued
only if
there is clear benefit over the lower dose.
The
recommended maximum dose of
an inhaled cortico-
steroid should not generally be exceeded. However, if a
higher dose is required,
then it should be initiated and
supervised by a specialist.
The use of
high doses of
inhaled corticosteroid can minimise the requirement for
an oral corticosteroid.
Systemic corticosteroid therapy may be necessary dur-
ing episodes of stress, such as severe infection, or if the
asthma is worsening, when higher doses are needed and
access of inhaled drug to small airways may be reduced;
patients may need a reserve supply of
corticosteroid
tablets.
Chronic obstructive pulmonary disease
In
chronic
obstructive pulmonary disease
inhaled corticosteroid
therapy may reduce exacerbations when given in com-
bination with an inhaled long-acting beta
2
agonist,
see
section 3.1, p.
171.
Cautions of inhaled corticosteroids
Paradoxical bronchospasm
The potential for paradox-
ical bronchospasm (calling for discontinuation and alter-
native therapy)
should be borne in mind—mild bron-
chospasm may be prevented by inhalation of
a short-
acting beta
2
agonist beforehand (or by transfer from an
aerosol inhalation to a dry powder inhalation).
CFC-free inhalers
Chlorofluorocarbon (CFC)
propel-
lants in pressurised aerosol inhalers have been replaced
by hydrofluoroalkane (HFA) propellants.
Doses for corticosteroid CFC-free pressurised metered-
dose inhalers may be different
from traditional
CFC-
containing inhalers and may differ between brands, see
MHRA/CHM advice below.
For interactions: see Appendix 1 (corticosteroids)
MHRA/CHM advice (July 2008)
.
Beclometasone
dipropionate
CFC-free
pres-
surised
metered-dose
inhalers
(
Qvar
c
and
Clenil
Modulite
c
) are not interchangeable and
should be prescribed by brand name;
Qvar
c
has
extra-fine particles,
is more potent
than tradi-
tional
beclometasone
dipropionate
CFC-con-
taining inhalers,
and is approximately twice as
potent as
Clenil Modulite
c
;
.
Fostair
c
is
a
combination
beclometasone
dipropionate
and formoterol
fumarate
CFC-
free pressurised metered-dose inhaler;
Fostair
c
has extra-fine particles and is more potent than
traditional
beclometasone
dipropionate CFC-
free inhalers.
Side-effects of
inhaled corticosteroids
Inhaled
corticosteroids
have
considerably
fewer
systemic
effects
than oral
corticosteroids
(section 6.3.2),
but
adverse effects have been reported.
High doses of inhaled corticosteroids (see Management
of
Chronic Asthma table,
p.
172)
used for
prolonged
periods can induce adrenal
suppression.
Inhaled corti-
costeroids have been associated with adrenal crisis and
coma in children;
excessive doses should be avoided.
Patients
using high doses
of
inhaled corticosteroids
should be given a ‘steroid card’
(section 6.3.2)
and
specific written advice to consider corticosteroid repla-
cement
during an episode of
stress,
such as severe
intercurrent illness or an operation.
High doses of
inhaled corticosteroid have been asso-
ciated with lower respiratory tract infections,
including
pneumonia,
in older patients with chronic obstructive
pulmonary disease.
Bone mineral
density may be reduced following long-
term inhalation of higher doses of corticosteroids,
pre-
disposing patients to osteoporosis (section 6.6).
It
is
therefore sensible to ensure that the dose of an inhaled
corticosteroid is no higher
than necessary to keep a
patient’s asthma under good control.
In children, growth restriction associated with systemic
corticosteroid therapy does
not
seem to occur
with
recommended doses of inhaled therapy; although initial
growth velocity may be reduced, there appears to be no
effect on achieving normal
adult height.
However,
the
height
of
children receiving prolonged treatment
of
inhaled corticosteroid should be monitored;
if
growth
is slowed,
referral
to a paediatrician should be consid-
ered.
Large-volume spacer devices should be used for
administering inhaled corticosteroids in children under
5 years (see NICE guidance, section 3.1.5); they are also
useful
in older children and adults,
particularly if
high
doses
are required.
Spacer
devices
increase airway
deposition and reduce oropharyngeal deposition.
A small
risk of glaucoma with prolonged high doses of
inhaled corticosteroids
has
been reported;
cataracts
have also been reported with inhaled corticosteroids.
Hoarseness and candidiasis of the mouth or throat have
been reported,
usually only with large doses (see also
below).
Hypersensitivity reactions (including rash and
1.
For
standard doses of
other
inhaled corticosteroids,
see
Management of Chronic Asthma table,
p.
172.
BNF 61
3.2 Corticosteroids
185
3
Respiratory system