II. Indications: Most important agent in Asthma Management
III. 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
- Costs
IV. General
- For dosing below, adult is age 12 or older
V. Preparation: Triamcinolone (Azmacort)
- Dose per puff: 100 mcg/puff
- Low dose
- Adult: 3-4 puffs twice daily ($140/month)
VI. 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)
VII. 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
VIII. 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
IX. 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)
X. 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
- Study: n=9783, age > 66 years
-
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
- Bone: Osteoporosis
- Decreased perimenopausal Bone Mineral Density
- Small increased Fracture risk (1 in 83 on high dose Inhaled Corticosteroid for 3 years)
- 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
- Prospective Controlled (n=268)
- 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
- Adult height potential is not affected
- 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]
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Related Studies
flovent (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
FLOVENT 100 MCG DISKUS | $3.27 each | |
FLOVENT 250 MCG DISKUS | $4.38 each | |
FLOVENT 50 MCG DISKUS | $3.11 each | |
FLOVENT HFA 110 MCG INHALER | Generic | $13.90 per gram |
FLOVENT HFA 220 MCG INHALER | Generic | $21.32 per gram |
FLOVENT HFA 44 MCG INHALER | Generic | $11.51 per gram |
pulmicort (on 8/17/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
PULMICORT 0.5 MG/2 ML RESPULE | Generic | $0.50 per ml |
PULMICORT 180 MCG FLEXHALER | $246.54 each | |
PULMICORT 90 MCG FLEXHALER | $184.42 each |