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3.2 Corticosteroids

Beclometasone aerosol inhaler, easi-breathe
Budesonide turbohaler
Ciclesonide inhaler - restricted to use in patients with recurring oropharyngeal candidiasis on other inhaled corticosteroids despite appropriate use via spacer devices
Fluticasone aerosol inhaler, Evohaler, accuhaler

 

Combination inhalers
Beclometasone/formoterol aerosol inhaler (Fostair) - first-line - see note
Budesonide\formoterol dry powder inhaler (DuoResp)
Fluticasone / Formoterol (Flutiform) inhaler
Budesonide\Formoterol turbohaler (Symbicort)
Fluticasone furoate / vilanterol (Relvar Ellipta)
Fluticasone Propionate\Salmeterol inhaler (AirFluSal Fospiro for patients switching from Seretide Accuhaler; All others: Aerivio Spiromax)

Notes:

1. Inhaled corticosteroids (ICS) are the first-choice regular preventer therapy for adults and children with asthma. BTS/SIGN guidance is that the dose should be titrated to the lowest dose at which effective control of asthma is maintained to minimise side-effects. Doubling the dose of ICS at the time of an exacerbation is of unproven value and is no longer recommended.

NICE TA 131: 'Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years' is available here.

NICE TA 138: 'Inhaled corticosteroids for the treatment of chronic asthma in adults and children aged 12 years and over' is available here.

BTS/SIGN guideline on management of asthma is available here

2. The NICE technology appraisal guidance on ICS for the treatment of chronic asthma in adults and children aged 12 years and over recommends a combination inhaler, within its marketing authorisation, as an option if treatment with an ICS and a LABA is considered appropriate.

3. When high dose steroids are used delivery should be via a spacer device. This form of administration improves delivery of drug to the airways reducing local effects e.g. oral candida, and also reduces the need for co-ordinated technique.

4. SIDE EFFECTS Prolonged use of high doses of inhaled corticosteroids carries a risk of systemic side-effects (e.g. adrenal suppression or crisis, growth retardation in children and young people, decreased bone mineral density, cataracts, and glaucoma). Steroid treatment cards should be routinely provided to patients who require prolonged treatment with high doses of inhaled steroids. See link.

5. Osteoporosis is an important potential effect of high dose inhaled steroids; doses should therefore be the lowest consistent with control of symptoms.

6. Fluticasone should be used in accordance with the Derbyshire guidelines but is viewed by the respiratory consultants as an alternative to systemic corticosteroids. The equivalent dose is half that of beclometasone

7. Maintenance systemic steroid may be required if control is inadequate with other therapies. The smallest dose should be used. Inhaled steroid has a significant oral steroid-sparing effect and should always be given.

8. For short courses of oral steroids (less than three weeks) it is unnecessary to 'tail off' the dose unless patients have had repeated courses of systemic steroids. Gradual withdrawal should also be considered if patients have been receiving doses of systemic corticosteroid greater than 40mg per day, when a short course has been prescribed within one year of long term therapy or if there are other reasons for adrenocortical insufficiency. (CSM "Current Problems" Vol 24 May 1998).

9. Fostair is a combination inhaler which contains beclometasone and the long-acting beta agonist formoterol. It is licensed for use in asthma, and has been placed on the formulary as randomized controlled trials have shown it to be therapeutically equivalent to more expensive inhalers such as Seretide and Symbicort.

 

 

For BNF section link: 3.2 Corticosteroids