• Maintenance treatment of asthma as prophylactic therapy.
• May decrease the need for or eliminate use of systemic corticosteroids in patients with asthma.

Contraindicated in:

• Some products contain alcohol or lactose and should be avoided in patients with known hypersensitivity or intolerance
• Acute attack of asthma/status asthmaticus.

Use Cautiously in:

• Active untreated infections
• Diabetes or glaucoma
• Underlying immunosuppression (due to disease or concurrent therapy)
• Systemic corticosteroid therapy (should not be abruptly discontinued when inhalation therapy is started; additional corticosteroids needed in stress or trauma)
• Hepatic impairment (fluticasone)
• OB: Lactation: Safety not established
• Pedi: Prolonged or high-dose therapy may lead to complications.

CNS: headache, agitation, depression, dizziness, fatigue, insomnia, restlessness.

EENT: dysphonia, hoarseness, cataracts, glaucoma, nasal congestion, pharyngitis, sinusitis.

Resp: bronchospasm, cough, wheezing.

GI: diarrhea, dry mouth, dyspepsia, esophageal candidiasis, taste disturbances, nausea.

Endo: adrenal suppression (↑ dose, long-term therapy only), ↓ growth (children), ↓ bone mineral density.

MS: back pain.
Misc: ANDHYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS, LARYNGEAL EDEMA, URTICARIA, BRONCHOSPASM, CHURG-STRAUSS SYNDROME.

Drug-Drug:

• Strong CYP3A4 inhibitors, including ritonavir, atazanavir, clarithromycin, conivaptan, indinavir, itraconazole, ketoconazole, lopinavir, nefazodone, nelfinavir, saquinavir, and voriconazole↓ metabolism and ↑ levels of budesonide, mometasone, and fluticasone; concurrent use with fluticasone not recommended.

Beclomethasone

• Inhalation aerosol: 40 mcg/metered inhalation in 8.7-g canister (delivers 120 metered inhalations); 80 mcg/metered inhalation in 8.7-g canister (delivers 120 metered inhalations);
  • Cost:
    - 40 mcg/metered inhalation; price/quantity: $130.16/inhaler
    - 80 mcg/metered inhalation; price/quantity: $173.67/inhaler.

Budesonide

(Generic available)

• Inhalation powder (Flexhaler): 90 mcg/metered inhalation (delivers 60 metered inhalations); 180 mcg/metered inhalation (delivers 120 metered inhalations);
  • Cost:
    - 90 mcg/metered inhalation; price/quantity: $143.87/inhaler
    - 180 mcg/metered inhalation; price/quantity: $192.65/inhaler.
• Inhalation suspension (Respules): 0.25 mg/2 mL in single-dose ampules (5 ampules/envelope); 0.5 mg/2 mL in single-dose ampules (5 ampules/envelope); 1 mg/2 mL in single-dose ampules (5 ampules/envelope);
• In combination with: formoterol (Symbicort). See Appendix [not included in this PDA edition].

Fluticasone

• Inhalation aerosol (propionate) (Flovent-HFA): 44 mcg/metered inhalation in 10.6-g canisters (delivers 120 metered inhalations); 110 mcg/metered inhalation in 12-g canisters (delivers 120 metered inhalations); 220 mcg/metered inhalation in 12-g canisters (delivers 120 metered inhalations);
  • Cost:
    - 44 mcg/inhalation; price/quantity: $137.82/inhaler
    - 110 mcg/inhalation; price/quantity: $181.43/inhaler
    - 220 mcg/inhalation; price/quantity: $278.14/inhaler.
• Powder for inhalation (propionate) (Flovent Diskus): 50 mcg/blister; 100 mcg/blister; 250 mcg/blister;
  • Cost:
    - 50 mcg; price/quantity: $144.47/60 blisters
    - 250 mcg; price/quantity: $134.71/28 blisters.
• Powder for inhalation (furoate) (Arnuity Ellipta): 100 mcg/blister; 200 mcg/blister;
• In combination with: salmeterol (Advair), vilanterol (Breo Ellipta). See Appendix [not included in this PDA edition].

Mometasone

• Inhalation aerosol (Asmanex HFA): 100 mcg/metered inhalation in 13-g canisters (120 metered inhalations); 200 mcg/metered inhalation in 13-g canisters (120 metered inhalations);
• Powder for inhalation (Asmanex Twisthaler): 110 mcg (delivers 100 mcg/metered inhalation; in packages of 7 and 30 inhalation units); 220 mcg (delivers 200 mcg/metered inhalation; in packages of 14, 30, 60, and 120 inhalation units);
  • Cost:
    - 110 mcg; price/quantity: $88.75/7 inhalation units
    - 110 mcg; price/quantity: $157.90/30 inhalation units
    - 220 mcg; price/quantity: $88.75/14 inhalation units
    - 220 mcg; price/quantity: $170.47/30 inhalation units
    - 220 mcg; price/quantity: $200.32/60 inhalation units
    - 220 mcg; price/quantity: $287.09/120 inhalation units.

Beclomethasone

• Inhaln (Adults and Children 12 yr): Previously on bronchodilators alone — 40–80 mcg twice daily (not to exceed 320 mcg twice daily); Previously on inhaled corticosteroids — 40–160 mcg twice daily (not to exceed 320 mcg twice daily).
• Inhaln (Children 5–11 yr): Previously on bronchodilators alone — 40 mcg twice daily (not to exceed 80 mcg twice daily); Previously on inhaled corticosteroids — 40 mcg twice daily (not to exceed 80 mcg twice daily).

Budesonide (Pulmicort Flexhaler)

• Inhaln (Adults): 180–360 mcg twice daily (not to exceed 720 mcg twice daily).
• Inhaln (Children 6 yr): 180–360 mcg twice daily (not to exceed 360 mcg twice daily).

Budesonide (Pulmicort Respules)

• Inhaln (Children 1–8 yr): Previously on bronchodilators alone — 0.5 mg once daily or 0.25 mg twice daily (not to exceed 0.5 mg/day); Previously on other inhaled corticosteroids — 0.5 mg once daily or 0.25 mg twice daily (not to exceed 1 mg/day); Previously on oral corticosteroids — 1 mg once daily or 0.5 mg twice daily (not to exceed 1 mg/day).

Fluticasone (Aerosol Inhaler)

• Inhaln (Adults and Children 12 yr): Previously on bronchodilators alone — 88 mcg twice daily initially, may be ↑ up to 440 mcg twice daily; Previously on other inhaled corticosteroids — 88–220 mcg twice daily initially, may be ↑ up to 440 mcg twice daily; Previously on oral corticosteroids — 440 mcg twice daily initially, may be ↑ up to 880 mcg twice daily.
• Inhaln (Children 4–11 yr): 88 mcg twice daily (not to exceed 88 mcg twice daily).

Fluticasone (Dry Powder Inhaler)

• Inhaln (Adults and Children 12 yr): Previously on bronchodilators alone — Propionate: 100 mcg twice daily initially, may be ↑ up to 500 mcg twice daily; Furoate: 100 mcg once daily, may be ↑ up to 200 mcg once daily after 2 wk; Previously on other inhaled corticosteroids — Propionate: 100–250 mcg twice daily initially, may be ↑ up to 500 mcg twice daily; Previously on oral corticosteroids — Propionate: 500–1000 mcg twice daily.
• Inhaln (Children 4–11 yr): Previously on bronchodilators alone — 50 mcg twice daily initially, may be ↑ up to 100 mcg twice daily; Previously on other inhaled corticosteroids — 50 mcg twice daily, may be ↑ up to 100 mcg twice daily.

Mometasone (Aerosol Inhaler)

• Inhaln (Adults and Children 12 yr): Previously on medium-dose inhaled corticosteroids — Two 100–mcg inhalations twice daily; Previously on high-dose inhaled corticosteroids or oral corticosteroids — Two 200–mcg inhalations twice daily (not to exceed 800 mcg/day).

Mometasone (Dry Powder Inhaler)

• Inhaln (Adults and Children 12 yr): Previously on bronchodilators or other inhaled corticosteroids — 220 mcg once daily in evening, up to 440 mcg/day as a single dose or 2 divided doses; Previously on oral corticosteroids — 440 mcg twice daily (not to exceed 880 mcg/day).
• Inhaln (Children 4–11 yr): 110 mcg once daily in evening (not to exceed 110 mcg/day).

beclomethasone: QVAR

budesonide: Pulmicort Respules, Pulmicort Flexhaler

fluticasone: Arnuity Ellipta, Flovent Diskus, Flovent HFA

Mometasone: Asmanex HFA, Asmanex Twisthaler

• Potent, locally acting anti-inflammatory and immune modifier.

• Decreased frequency and severity of asthma attacks.
• Improves asthma symptoms.

Therapeutic Classification: antiasthmatics, corticosteroids

Pharmacologic Classification: corticosteroids (inhalation)

Absorption: Beclomethasone — 20%; budesonide — 6–13% (Flexhaler), 6% (Respules); fluticasone — <7% (aerosol), 8–14% (powder); mometasone — <1%. Action is primarily local after inhalation.

Distribution: 10–25% is deposited in airways if a spacer device is not used. All cross the placenta and enter breast milk in small amounts.

Metabolism/Excretion: Beclomethasone — after inhalation, beclomethasone dipropionate is converted to beclomethasone monopropionate, an active metabolite that adds to its potency, primarily excreted in feces (<10% excreted in urine; Budesonide, fluticasone, mometasone — metabolized by the liver (primarily by CYP3A4) after absorption from lungs; Budesonide — 60% excreted in urine, 40% in feces; fluticasone — primarily excreted in feces (<5% excreted in urine); mometasone — 75% excreted in feces.

Half-life: Beclomethasone — 2.8 hr; budesonide — 2–3.6 hr; fluticasone — 7.8 hr (propionate); 24 hr (furoate); mometasone — 5 hr.

(improvement in symptoms)

†Improvement in pulmonary function; ↓ airway responsiveness may take longer.

†2–8 days for budesonide respule.

• Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Instruct patient to read the Patient Information and Instructions for Use before using and with each Rx refill, in case of new information. Advise patient not to discontinue medication without consulting health care professional; gradual decrease is required.
• Advise patients using inhalation corticosteroids and bronchodilator to use bronchodilator first and to allow 5 min to elapse before administering the corticosteroid, unless otherwise directed by health care professional.
• Advise patient that inhalation corticosteroids should not be used to treat an acute asthma attack but should be continued even if other inhalation agents are used.
• Patients using inhalation corticosteroids to control asthma may require systemic corticosteroids for acute attacks. Advise patient to use regular peak flow monitoring to determine respiratory status.
• Caution patient to avoid smoking, known allergens, and other respiratory irritants.
• Advise patient to notify health care professional if sore throat or sore mouth occurs.
• Advise patient to stop using medication and notify health care professional immediately if signs and symptoms of hypersensitivity reactions occur.
• Advise female patients to notify health care professional if pregnancy is planned or suspected or if breast feeding.
• Instruct patient whose systemic corticosteroids have been recently reduced or withdrawn to carry a warning card indicating the need for supplemental systemic corticosteroids in the event of stress or severe asthma attack unresponsive to bronchodilators.
• Metered-Dose Inhaler: Instruct patient in proper use of metered-dose inhaler. Most inhalers require priming before first use. Shake inhaler well. Exhale completely, and then close lips firmly around mouthpiece. While breathing in deeply and slowly, press down on canister. Hold breath for as long as possible to ensure deep instillation of medication. Remove inhaler from mouth and breathe out gently. Allow 1–2 min between inhalations. Rinse mouth with water or mouthwash after each use to minimize fungal infections, dry mouth, and hoarseness. Clean mouthpiece weekly with clean, dry tissue or cloth. Do not place in water (see Appendix F).
• Pulmicort Flexhaler: Advise patient to follow instructions supplied. Before first-time use, prime unit by turning cover and lifting off; hold upright with mouthpiece up and twist brown grip fully to right, then fully to left until it clicks. To administer dose, hold upright, twist brown grip fully to right, then fully to left until it clicks. Turn head away from inhaler and exhale (do not blow into inhaler). Do not shake inhaler. Place mouthpiece between lips and inhale deeply and forcefully. Remove inhaler from mouth and exhale (do not exhale into mouthpiece). Repeat procedure if 2nd dose required. Replace cover; rinse mouth with water (do not swallow).
• Pulmicort Respules: Administer with a jet nebulizer connected to adequate air flow, equipped with a mouthpiece or face mask. Adjust face mask to avoid exposing eyes to nebulized medication. Wash face after use of face mask. Ultrasonic nebulizers are not adequate for administration and not recommended. Store respules upright, away from heat and protected from light. Do not refrigerate or freeze. Respules are stable for 2 wk at room temperature after opening aluminum foil envelope. Open respules must be used promptly. Unused respules should be returned to aluminum foil envelope.
• Flovent Diskus/Arnuity Ellipta: Do not use with a spacer. Exhale completely and then close lips firmly around mouthpiece. While breathing in deeply and slowly, press down on canister. Hold breath for as long as possible to ensure deep instillation of medication. Remove inhaler from mouth and breathe out gently. Allow 1–2 min between inhalations. After inhalation, rinse mouth with water and spit out (see Appendix F). Never wash the mouthpiece or any part of the Diskus inhaler. Discard Diskus inhaler device (Flovent Diskus) 6 wks (50-mcg strength) or 2 mo (100-mcg and 250-mcg strengths) or blister tray (Arnuity Ellipta) 6 wks after removal from protective foil overwrap pouch or after all blisters have been used (whichever comes first).
• Asmanex Twisthaler: Advise patient to remove cap while device is in upright position. To administer dose, exhale fully, then place mouthpiece between lips and inhale deeply and forcefully. Remove device from mouth and hold breath for 10 sec before exhaling (do not exhale into mouthpiece). Wipe the mouthpiece dry, if necessary, and replace the cap on the device. Rinse mouth with water. Advise patient to discard twisthaler 45 days from opening or when dose counter reads "00", whichever comes first.

beclomethasone: be-kloe-METH-a-sone

budesonide: byoo-DESS-oh-nide

fluticasone: floo-TI-ka-sone

Mometasone: mo-MET-a-sone