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Inhaled Corticosteroid
Aka: Inhaled Corticosteroid, Inhaled Steroid, Azmacort, Beclovent, AeroBid, Flovent, Pulmicort, Vanceril
- Indications: Most important agent in Asthma Management
- Mild Persistent Asthma
- Moderate Persistent Asthma
- Severe Persistent Asthma
- Efficacy
- Inhaled Corticosteroids reduce Asthma related death
- Mortality risk decreases with steroid Inhalers/year
- Suissa (2000) N Engl J Med 343:332-6 [PubMed]
- Benefits in COPD and Asthma persist for >5 years
- Douma (2002) Chest 121:151-7 [PubMed]
- Costs
- HFA Inhalers are non-generic and costly
- Older CFC Inhalers are no longer available
-
General
- For dosing below, adult is age 12 or older
- Preparation: Triamcinolone (Azmacort)
- Dose per puff: 100 mcg/puff
- Low dose
- Adult: 3-4 puffs twice daily ($140/month)
- Preparation: Beclomethasone Dipropionate (QVAR)
- Qvar Redihaler HFA (breath-actuated MDI) will replace the older Qvar Inhaler
- Ostensibly this patent extending change is so patients need not coordinate breath to actuation
- Dose per puff: 40 mcg/puff or 80 mcg/puff
- Cost: QVAR 80 is $83, QVAR 40 is 66$ (100 puffs each)
- General
- QVAR 80 is same cost of 40 and can use 1/2 puffs
- Small particles allow for using without spacer
- Low dose
- Adult: 160 ug/day (e.g. 80 mcg, 1 puff bid)
- Child: 80 ug/day (e.g. 40 mcg, 1 puff bid)
- Medium dose
- Adult: 320 mcg/day (e.g. 80 mcg, 2 puff bid)
- Child: 80-160 mcg/day (e.g. 40 mcg, 1-2 puff bid)
- High dose
- Adult: 480-640 mcg/day (e.g. 80 mcg, 3-4 puff bid)
- Child: 160 mcg/day (e.g. 40 mcg, 2 puff bid)
- Preparation: Fluticasone propionate (Flovent HFA, ArmonAir)
- May have more systemic absorption than other agents
- Costs (2017, U.S.)
- Flovent HFA 44, 110, 220 mcg: $350 (120 puffs/Inhaler)
- Flovent Discus (dry powder) 50, 100, 250 mcg: $230
- ArmonAir (dry powder) 55, 113, 232: $210
- Low dose
- Adult: 220 mcg (e.g. 110 mcg, 1 puff bid)
- Child: 88 mcg (e.g. 44 mcg, 1 puff bid)
- Medium dose
- Adult: 440 mcg (e.g. 220 mcg, 1 puff bid)
- Child: 220 mcg (e.g. 110 mcg, 1 puff bid)
- High dose
- Adult: 880 mcg (e.g. 220 mcg, 2 puff bid)
- Child: 440 mcg (e.g. 220 mcg, 1 puff bid)
- References
- (2017) Presc Lett 24(10):58
- Preparation: Mometasone
- Costs
- Asmanex 30: $112 per 30 puffs
- Asmanex 60: $112 per 60 puffs
- Asmanex 120: $174 per 120 puffs
- Low dose
- Adult: 1 puff daily of Asmanex 60
- Medium dose
- Adult: 2 puffs daily of Asmanex 120
- High dose
- Adult: 3-4 puffs daily of Asmanex 120
- Preparation: Budesonide DPI (Pulmicort DPI)
- Dose per puff: 200 mcg/dose
- Cost: $184 per 200 puffs
- Low dose
- Adult: 200-400 mcg (1-2 puffs daily)
- Medium dose
- Adult: 400-800 mcg (1-2 puffs bid)
- High dose
- Adult: 1200 mcg (3 puffs bid)
- Adverse Effects
- Dysphonia
- Oral and esophageal Candidiasis
- Rinse mouth after inhalation
- Use a spacer device
- Glaucoma Risk of high dosed Inhaled Corticosteroids
- Study: n=9783, age > 66 years
- 1600 ug Beclomethasone
- 1500 ug Flunisolide
- Glaucoma increased 44% over non steroid users
- Not associated with nasal steroids
- Reference
- Garbe (1997) JAMA 277:722-7 [PubMed]
- Cataract Risk
- Study: n=3,000, Australian, 49-97yo, Cross-Sectional
- Corticosteroid use conferred:
- Nuclear cataract Relative Risk: 1.5
- Posterior subcapsular Cataracts Relative Risk: 1.9
- Reference
- Cumming (1997) N Engl J Med, 337:8-14 [PubMed]
- Bone: Osteoporosis
- Decreased perimenopausal Bone Mineral Density
- Ip (1994) 105:1722 [PubMed]
- Small increased Fracture risk (1 in 83 on high dose Inhaled Corticosteroid for 3 years)
- Loke (2011) Thorax 66:699-708 [PubMed]
- No effect on pediatric bone by DEXA Scanning
- Prospective Controlled (n=268)
- Daily inhaled Budesonide 504 ug/d x4.5y (Mean)
- No detectable effect by DEXA on
- Bone Mineral Density, Bone mineral capacity,
- Total bone Calcium or body composition
- References
- Agertoft (1998) Am J Respir Crit Care 157:178 [PubMed]
- Linear growth suppression
- Uncontrolled Asthma reduces linear growth!
- Variable results on Growth Velocity from studies
- Adult height potential may be reduced up to 1/2 inch on long-term Inhaled Corticosteroids
- Kelly (2012) N Engl J Med 367:904-912 [PubMed]
- Adult height potential is not affected
- Agertoft (2000) N Engl J Med 343:1064-9 [PubMed]
- Short-term linear growth may be affected
- Degree of Growth Delay may be agent specific
- Fluticasone appears to have least growth effect
- De Benedictis (2001) Arch Pediatr Adolesc Med [PubMed]