Inhaled Corticosteroid

Aka: Inhaled Corticosteroid, Inhaled Steroid, Azmacort, Beclovent, AeroBid, Flovent, Pulmicort, Vanceril

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