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1. NICE Guidance on inhaled steroids in asthma in adults and children (Issued as separate guidance November 2007 and March 2008) covers the use of inhaled corticosteroids and recognises, when treatment with an inhaled steroid and long acting beta2 agonist is considered appropriate, the use of a combination device (within its marketing authorisation) and the decision to use a combination device or the two agents separate devices should be made on an individual basis, taking into consideration therapeutic need and the likelihood of treatment adherence. If a combination device is chosen then the least costly device that is suitable is recommended.
2. Refer to the NICE COPD guidelines for information regarding the use of corticosteroids in COPD. These recommend that inhaled corticosteroids should only be used if FEV1 = 50% predicted and the patient has experienced 2 or more exacerbations in a 12 month period
3. MHRA advice (July 2009) reminds us that inhaled corticosteroids should not be used alone in COPD.
4. Advice from MHRA Drug Safety Update (Oct 2007): Physicians should remain vigilant for the development of pneumonia and other infections of the lower respiratory tract (ie, bronchitis) in patients with COPD who are treated with inhaled drugs that contain steroids because the clinical features of such infections and exacerbation frequently overlap. Any patient with severe COPD who has had pneumonia during treatment with inhaled drugs that contain steroids should have their treatment reconsidered.
5. Nebulised corticosteroids should rarely ever be used long-term. They should be used only after referral for a respiratory opinion.
6. Low dose synacthen test should be considered for the following children: those under 5 years old taking more than 400 micrograms a day of beclometasone or budesonide, or more than 200 micrograms a day of fluticasone, those over 5 years old taking more than 800 micrograms a day of beclometasone or budesonide, or more than 400 micrograms a day of fluticasone.
7. Branded prescribing is specifically recommended for beclometasone CFC-free products.
1. Adrenal suppression is a dose-related class effect of all inhaled corticosteroids. Adrenal crisis has been observed more frequently following the use of fluticasone, possibly because higher than licensed doses of fluticasone are prescribed more widely in children than other inhaled corticosteroids. All inhaled corticosteroids are associated with an increased risk of adrenal crisis when used at higher than licensed doses but prescribers are reminded that fluticasone should normally be used at half the dose of beclometasone (CFC-containing) or budesonide because of its greater potency.
Prescribers are reminded that:
- It is important to review therapy regularly and titrate down to the lowest dose at which effective control of asthma is maintained.
- If a doctor considers that a child’s asthma is not controlled on the maximum licensed dose of their inhaled corticosteroid, despite the addition of other therapies, the child should be referred to a specialist in the management of paediatric asthma.
The total daily dose of inhaledcorticosteroids (Steps 2 and 3 BTS guidelines) should not be increased above:
Children: 400 micrograms beclometasone or budesonide; 200 micrograms fluticasone
Adults: 800 micrograms beclometasone or budesonide; 400 micrograms fluticasone or Qvar®
Note that higher doses of ICS may be used at step 4 and above in adults.
For all patients on high dose inhaled corticosteroids, review their treatment with an intention to step down treatment in view of new BTS guidelines.
2. Combination preparations do not allow the flexibility of the individual components with regard to titration and reducing doses of inhaled corticosteroids and may discourage "stepping down" which is a key part of the British Guidelines on the Management of Asthma
3. Fostair contains 100 micrograms of beclometasone dipropionate (BDP) per inhalation in an “extra-fine” formulation that is equivalent to 250 micrograms of BDP in a “non extra-fine” formulation. This means that Fostair is not equipotent with Clenil Modulite MDI but it does have approximate dose equivalence with the CFC-free BDP inhaler Qvar. Patients switching from any single component BDP inhaler to Fostair should be monitored to ensure optimal symptom control.
4. Flutiform MDI is a combination of fluticasone propionate and formoterol fumarate indicated for regular treatment of asthma when a combination inhaler is appropriate. It is less expensive than Seretide across the equivalent dose ranges and may be an option for patients requiring low or high strength steroid. Fostair beclometasone/formoterol) remains the combination MDI of choice for adults requiring medium strength steroid (generally those at Step 3 of the British guidelines on the management of asthma.) Reviewing patients on combination inhalers to see if they can be stepped down to a lower steroid dose is a key part of managing their treatment
5. In selected adult patients at either step 3 who are poorly controlled or at step 2 (above BDP 400 micrograms / day who are poorly controlled) the use of budesonide/formoterol in a single inhaler as rescue medication instead of a short acting beta2 agonist, in addition to its regular use as controller therapy, has been shown to be effective. When this option is introduced the total regular dose of daily inhaled steroid should not be decreased. The regular maintenance dose of inhaled steroids may be budesonide 200 micrograms twice daily or budesoinde 400 micrograms daily. Patients taking rescue budesonide/formoterol once a day or more should have their treatment reviewed. Careful patient education around this management strategy is required.
Mild croup is largely self limiting but treatment with a single oral dose of a corticosteroid is of benefit. Dexamethasone tablets (oral dose of 150 micrograms per kg) is first choice treatment, is available in strengths of 500 micrograms and 2 mg (may be dissolved in water). Oral soluble prednisolone 1 - 2 mg per kg may be a suitable alternative. Budesonide (Pulmicort Respules®) may be used in a child who is vomiting or excessively choking.