II. Indications: Most important agent in Asthma Management

III. 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

IV. General

  1. For dosing below, adult is age 12 or older

V. Preparation: Triamcinolone (Azmacort)

  1. Dose per puff: 100 mcg/puff
  2. Low dose
    1. Adult: 3-4 puffs twice daily ($140/month)

VI. Preparation: Beclomethasone Dipropionate (QVAR)

  1. Dose per puff: 40 mcg/puff or 80 mcg/puff
  2. Cost: QVAR 80 is $83, QVAR 40 is 66$ (100 puffs each)
  3. General
    1. QVAR 80 is same cost of 40 and can use 1/2 puffs
    2. Small particles allow for using without spacer
  4. 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)
  5. 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)
  6. 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)

VII. Preparation: Fluticasone propionate (Flovent HFA)

  1. May have more systemic absorption than other agents
  2. Costs
    1. Flovent HFA 44 mcg: $93 for 120 puffs/Inhaler
    2. Flovent HFA 100 mcg: $125 for 120 puffs/Inhaler
    3. Flovent HFA 220 mcg: $194 for 120 puffs/Inhaler
  3. Low dose
    1. Adult: 220 mcg (e.g. 110 mcg, 1 puffs bid)
    2. Child: 88 mcg (e.g. 44 mcg, 1 puffs bid)
  4. Medium dose
    1. Adult: 440 mcg (e.g. 220 mcg, 1 puffs bid)
    2. Child: 220 mcg (e.g. 110 mcg, 1 puffs bid)
  5. High dose
    1. Adult: 880 mcg (e.g. 220 mcg, 2 puffs bid)
    2. Child: 440 mcg (e.g. 220 mcg, 1 puffs bid)

VIII. 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

IX. 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)

X. 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]

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Cost: Medications

flovent (on 6/22/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
FLOVENT 100 MCG DISKUS $2.56 each
FLOVENT 250 MCG DISKUS $3.41 each
FLOVENT 50 MCG DISKUS $2.45 each
FLOVENT HFA 110 MCG INHALER $17.38 per gram
FLOVENT HFA 220 MCG INHALER $26.90 per gram
FLOVENT HFA 44 MCG INHALER $14.51 per gram
pulmicort (on 1/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
PULMICORT 0.25 MG/2 ML RESPUL Generic $2.37 per ml
PULMICORT 0.5 MG/2 ML RESPULE Generic $2.76 per ml
PULMICORT 1 MG/2 ML RESPULE Generic $8.99 per ml
PULMICORT 180 MCG FLEXHALER $193.76 each
PULMICORT 90 MCG FLEXHALER $144.56 each

Ontology: Pulmicort (C0678162)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D019819
English pulmicort, Pulmicort

Ontology: Beclovent (C0699071)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D001507
English Beclovent, GlaxoSmithKline Brand 3 of Beclomethasone Dipropionate

Ontology: Vanceril (C0699073)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D001507
English vanceril, Vanceril, Schering Brand 2 of Beclomethasone Dipropionate

Ontology: Azmacort (C0699690)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D014222
English azmacort, Azmacort

Ontology: AeroBid (C0718284)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH C007734
English AeroBid-M, aerobid, aerobid m, aerobid-m, AeroBid, Forest Brand of Flunisolide

Ontology: Flovent (C0720466)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C065382
English Flovent, flovent