- ACRONYMS AND DEFINITIONS
- Alb - Albuterol
- COPD - Chronic obstructive pulmonary disease
- HFA - Hydrofluoroalkane propellant
- ICS - Inhaled corticosteroid
- LABA - Long-acting beta agonist
- LAMA - Long-acting muscarinic antagonist
- LTRA - Leukotriene modifier
- NHLBI - National Heart, Lung, and Blood Institute
- PRN - as needed
- RCT - Randomized controlled trial
- INHALED CORTICOSTEROIDS (ICS)
Beclomethasone (Qvar®)
Dosage forms
Qvar® Redihaler 40
- Delivers 40 mcg of beclomethasone per actuation
- Comes in 10.6 g size with 120 actuations
- Inhaler is breath-actuated
Qvar® Redihaler 80
- Delivers 80 mcg of beclomethasone per actuation
- Comes in 10.6 g size with 120 actuations
- Inhaler is breath-actuated
Dosing
Asthma (4 - 11 years)
- Starting: 40 mcg twice a day
- Max: 80 mcg twice a day
- For patients who do not respond to 40 mcg after 2 weeks, the dose may be increased to 80 mcg
- Do not use spacer or volume holding chamber with Redihaler
Asthma (12 years and older)
- Starting: 40 - 80 mcg twice a day
- Max: 320 mcg twice a day
- Patients who are already using an inhaled corticosteroid may require higher starting doses
- Increase dose at two-week intervals if necessary
- Do not use spacer or volume holding chamber with Redihaler
- See NHLBI ICS dosing chart for more detailed recommendations
Generic / Price
- NO/$$$-$$$$Other
- Do not use spacer or volume holding chamber with Redihaler
- Redihaler is breath-actuated meaning the inhaler releases medication when the patient takes a deep breath, and the patient does not need to push anything
- Rinsing mouth after use may help prevent thrush
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Patients 4 years of age and older
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Qvar 320 mcg | Placebo |
|---|---|---|
| Upper respiratory infection | 4% | 2% |
| Thrush | 3% | <1% |
| Nasopharyngitis | 1% | 1% |
| Mouth pain | <1% | <1% |
| Viral upper respiratory infection | <1% | 1% |
| Sinusitis | <1% | <1% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - beclomethasone is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to beclomethasone
Precautions / Contraindications
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.)
- Skin thinning and bruising - long-term ICS use may be associated with skin thinning and bruising
- Liver disease - has not been studied extensively
- Kidney disease - has not been studied extensively
Budesonide (Pulmicort®)
Dosage forms
Pulmicort Flexhaler™
- Pulmicort Flexhaler® 90 - contains 90 mcg of budesonide inhalation powder (60 actuations)
- Pulmicort Flexhaler® 180 - contains 180 mcg of budesonide inhalation powder (120 actuations)
Pulmicort Respules® - nebulizer
- 0.25 mg/2ml
- 0.5 mg/2ml
- 1 mg/2ml
- 30 respules in a carton
Dosing - Flexhaler
Asthma (6 - 17 years)
- Starting: 180 mcg twice a day
- Max: 360 mcg twice a day
- Rinsing mouth after use may help prevent thrush
Asthma (≥ 18 years)
- Starting: 360 mcg twice a day
- Max: 720 mcg twice a day
- Rinsing mouth after use may help prevent thrush
- See NHLBI ICS dosing chart for more detailed recommendations
Dosing - Respules
Asthma (1 - 8 years old)
- Starting: 0.5 mg once daily or 0.25 mg twice a day
- Max: 1 mg once daily or 0.5 mg twice a day
- Rinsing mouth after use may help prevent thrush
- See NHLBI ICS dosing chart for more detailed recommendations
Efficacy
Generic / Price
- Inhaler - NO/$$$$
- Respules (30 ampules) - YES/$
Other
Pulmicort Respules®
- Protect from sunlight
- When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Flexhaler™ - 6 years of age and older
- Respules® - 12 months - 8 years of age
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Budesonide | Placebo |
|---|---|---|
| Nasopharyngitis | 9.3% | 8.3% |
| Nasal congestion | 2.7% | 0.4% |
| Pharyngitis | 2.7% | 1.7% |
| Allergic rhinitis | 2.2% | 1.3% |
| Viral upper respiratory infection | 2.2% | 1.3% |
| Nausea | 1.8% | 0.9% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - budesonide is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to budesonide
Precautions / Contraindications
- Severe milk allergy - (Flexhaler® only) - DO NOT USE - contains small amount of lactose
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.)
- Skin thinning and bruising - long-term ICS use may be associated with skin thinning and bruising
- Liver disease - has not been studied extensively
- Kidney disease - has not been studied extensively
Ciclesonide (Alvesco®)
Dosage forms
Inhaler
- Alvesco® 80 - delivers 80 mcg of ciclesonide per actuation
- Alvesco® 160 - delivers 160 mcg of ciclesonide per actuation
- Inhalers come with 60 actuations
Dosing
Asthma (12 years and older)
- Starting: 80 mcg twice a day
- Max: 320 mcg twice a day
- Patients taking oral corticosteroids may require higher starting doses
- See NHLBI ICS dosing chart for more detailed recommendations
Generic / Price
- NO/$$$$Other
- Rinsing mouth after use may help prevent thrush
- Prime inhaler before first dose by releasing 3 puffs into the air
- Prime inhaler if not used for more than 10 days
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Patients 12 years of age and older
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Ciclesonide 160 mcg twice daily | Placebo |
|---|---|---|
| Headache | 11% | 7.3% |
| Nasopharyngitis | 8.7% | 7.5% |
| Upper respiratory infection | 8.7% | 6.5% |
| Sinusitis | 5.5% | 3% |
| Nasal congestion | 5.5% | 1.6% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - ciclesonide is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to ciclesonide
Precautions / Contraindications
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.)
- Skin thinning and bruising - long-term ICS use may be associated with skin thinning and bruising
- Liver disease - no dose adjustment necessary
- Kidney disease - has not been studied extensively
Flunisolide (Aerospan™)
Dosage forms
HFA inhaler
- delivers 80 mcg of flunisolide per actuation
- Inhaler comes with 120 actuations
- Inhaler comes with built-in spacer
Dosing
Asthma (6 - 11 years)
- Starting: 80 mcg twice a day
- Max: 160 mcg twice a day
Asthma (≥ 12 years)
- Starting: 160 mcg twice a day
- Max: 320 mcg twice a day
- See NHLBI ICS dosing chart for more detailed recommendations
Generic / Price
- NO/$$$$Other
- Aerospan™ comes with a built-in spacer
- Rinsing mouth after use may help prevent thrush
- Prime before using for the first time by releasing 2 test sprays into the air
- Re-prime inhaler if not used for more than 2 weeks
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Patients 6 years of age and older
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Flunisolide | Placebo |
|---|---|---|
| Pharyngitis | 16.8% | 13.2% |
| Sinusitis | 8.8% | 5.5% |
| Allergic reaction | 4.4% | 2.3% |
| Upset stomach | 3.5% | 1.4% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - flunisolide is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to flunisolide
Precautions / Contraindications
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.)
- Skin thinning and bruising - long-term ICS use may be associated with skin thinning and bruising
- Liver disease - has not been studied extensively
- Kidney disease - has not been studied extensively
Fluticasone (ArmonAir®)
Dosage forms
Digihaler powder inhaler
- Digihaler® 55 - delivers 55 mcg of fluticasone propionate per inhalation
- Digihaler® 113 - delivers 113 mcg of fluticasone propionate per inhalation
- Digihaler® 232 - delivers 232 mcg of fluticasone propionate per inhalation
- Each inhaler contains 60 actuations
- ArmonAir Digihaler contains a built-in electronic module which detects, records, and stores data on inhaler events for transmission to a mobile app (Teva Digihaler® app)
Respiclick powder inhaler
- Respiclick® 30 - delivers 30 mcg of fluticasone propionate per inhalation
- Each inhaler contains 60 actuations
Dosing
Asthma (4 - 11 years old)
- Starting (ICS-naïve with less severe asthma): 30 mcg twice daily
- Switching from another ICS: 30 - 55 mcg twice daily
- Doses above 55 mcg twice daily have not been studied in this age group
- Increase dose at intervals of 2 weeks
- Inhale at the same time each day
Asthma (adults and children ≥ 12 years old)
- Starting: 55 mcg twice daily
- Maintenance: 55 - 232 mcg twice daily
- Max: 232 mcg twice daily
- Increase dose at intervals of 2 weeks
- Inhale at the same time each day
- Patients switching from other inhaled corticosteroids may require higher starting doses
Efficacy
Generic / Price
- NO/$$$$Other
- Inhaler does not require priming
- Never wash or put any part of the inhaler in water
- Do not use with a spacer or volume holding chamber
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Children ≥ 4 years of age and adults
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Fluticasone 232 mcg | Placebo |
|---|---|---|
| Nasopharyngitis | 4.8% | 4.4% |
| Upper respiratory infection | 5.5% | 4.8% |
| Oral candidiasis | 4.8% | 0.7% |
| Headache | 4.8% | 4.4% |
| Cough | 3.4% | 2.6% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - fluticasone is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to fluticasone
Precautions / Contraindications
- Severe milk allergy - DO NOT USE - contains small amount of lactose
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections and serious infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.) and/or serious systemic infections
- Hypersensitivity reactions - serious hypersensitivity reactions including anaphylaxis have occurred with ICS
- Paradoxical bronchospasm - paradoxical bronchospasm may occur after dosing
- Eosinophilic Conditions and Churg-Strauss Syndrome - In rare cases, ICS use has been associated with eosinophilic conditions and Churg-Strauss Syndrome. Symptoms include eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy.
- Liver disease - systemic exposure is likely increased. Use with caution.
- Kidney disease - has not been studied
Fluticasone (Arnuity Ellipta®)
Dosage forms
Inhalation powder
- Arnuity™ Ellipta® 100 - delivers 100 mcg of fluticasone furoate per inhalation
- Arnuity™ Ellipta® 200 - delivers 200 mcg of fluticasone furoate per inhalation
- Inhaler contains 30 doses
Dosing
Asthma (≥ 12 years)
- Starting: 100 mcg once daily
- Maintenance: 100 - 200 mcg once daily
- Max: 200 mcg once daily
- Increase dose at intervals of 2 weeks
- Inhale at the same time every day
Efficacy
Generic / Price
- NO/$$$$Other
- Rinsing mouth after use may help prevent thrush
- Protect from direct heat and sunlight
- Discard Arnuity™ Ellipta® inhaler 6 weeks after opening foil tray
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Patients ≥ 12 years of age
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Arnuity Ellipta | Placebo |
|---|---|---|
| Nasopharyngitis | 8% | 5% |
| Bronchitis | 7% | 6% |
| Headache | 6% | 4% |
| Upper respiratory infection | 6% | 5% |
| Pharyngitis | 4% | 3% |
| Sinusitis | 4% | < 1% |
| Oropharyngeal pain | 3% | 0% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - fluticasone is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to fluticasone
Precautions / Contraindications
- Severe milk allergy - DO NOT USE - contains small amount of lactose
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.)
- Skin thinning and bruising - long-term ICS use may be associated with skin thinning and bruising
- Liver disease - systemic exposure is increased; use with caution in moderate-to-severe liver disease
- Kidney disease - no dose adjustment necessary
Fluticasone (Flovent®)
Dosage forms
Flovent® HFA inhaler
- Flovent® 44 - 44 mcg per actuation
- Flovent® 110 - 110 mcg per actuation
- Flovent® 220 - 220 mcg per actuation
- HFAs have 120 actuations
Flovent® Diskus - inhalation powder
- Flovent® Diskus 50 - 50 mcg per actuation
- Flovent® Diskus 100 - 100 mcg per actuation
- Flovent® Diskus 250 - 250 mcg per actuation
- Diskus have 60 actuations
Dosing - Flovent HFA
Asthma (4 - 11 years)
- Dosing: 88 mcg twice a day
Asthma (12 years and older)
- Starting: 88 mcg twice a day
- Max: 880 mcg twice a day
- Maximum benefit seen after 2 weeks
- See NHLBI ICS dosing chart for more detailed recommendations
Dosing - Flovent Diskus
Asthma (4 - 11 years)
- Starting: 50 mcg twice a day
- Max: 100 mcg twice a day
- Maximum benefit seen after 2 weeks
Asthma (12 years and older)
- Starting: 100 mcg twice a day
- Max: 1000 mcg twice a day
- Maximum benefit seen after 2 weeks
- See NHLBI ICS dosing chart for more detailed recommendations
Efficacy
Generic / Price
- NO/$$$-$$$$Other
Flovent® HFA
- Shake well before using
- Rinsing mouth after use may help prevent thrush
- Prime before using for the first time by releasing 4 test sprays into the air
- Re-prime inhaler with 1 test spray if not used for more than 7 days or if dropped
Flovent® Diskus
- Protect from light
- Rinsing mouth after use may help prevent thrush
- Diskus should be discarded 6 weeks (50 mcg strength) or 2 months (100 and 250 mcg strengths) after removal from the moisture-protective foil pouch
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Patients 4 years of age and older
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Flovent HFA | Placebo |
|---|---|---|
| Upper respiratory infection | 16% | 14% |
| Throat irritation | 8% | 5% |
| Sinusitis | 7% | 3% |
| Headache | 7% | 6% |
| Upper respiratory infection | 16% | 14% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - fluticasone is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to fluticasone
Precautions / Contraindications
- Severe milk allergy - (Flovent Diskus® only) - DO NOT USE - contains small amount of lactose
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.)
- Skin thinning and bruising - long-term ICS use may be associated with skin thinning and bruising
- Liver disease - has not been studied extensively
- Kidney disease - has not been studied extensively
Mometasone (Asmanex®)
Dosage forms
Asmanex® HFA
- Asmanex® HFA 50 mcg
- Asmanex® HFA 100 mcg
- Asmanex® HFA 200 mcg
- Each inhaler delivers 120 actuations
Asmanex Twisthaler® - inhalation powder
- Asmanex® 110 - 100 mcg per actuation
- Asmanex® 220 - 200 mcg per actuation
- Asmanex® 110 - 30 actuation inhaler
- Asmanex® 220 - 30, 60, and 120 actuation inhalers
Dosing - HFA
Asthma (5 - 11 years old)
- Dosing: 2 inhalations of 50 mcg HFA twice daily
- Max: 200 mcg/day
Asthma (≥ 12 years)
- Starting: 200 mcg twice daily
- Max: 800 mcg/day
- If receiving chronic oral corticosteroids, recommended dosing is 400 mcg twice daily
- Titrate dose at intervals of 2 weeks
- See NHLBI ICS dosing chart for more detailed recommendations
Dosing - Twisthaler
Asthma (4 - 11 years)
- Dosing: 110 mcg once daily in the evening
- Max: 110 mcg/day
Asthma (≥ 12 years)
- Starting: 220 mcg once daily in the evening
- Max: 440 mcg/day
- If receiving chronic oral corticosteroids, recommended dosing is 440 mcg twice daily
- Titrate dose at intervals of 2 weeks
- See NHLBI ICS dosing chart for more detailed recommendations
Generic / Price
- NO/$$$$Other
- Rinsing mouth after use may help prevent thrush
- Discard the twisthaler 45 days after opening the foil pouch
Mechanism of action
- Corticosteroid - has multiple anti-inflammatory effects; inhibits both inflammatory cells and release of inflammatory mediators
FDA-approved indications
Asthma
- Patients 4 years of age and older
- ICS are indicated for maintenance and prophylactic therapy
- NOTE: ICS are NOT indicated for the relief of acute bronchospasm
Side effects
| Side effect | Mometasone | Placebo |
|---|---|---|
| Headache | 17% | 20% |
| Allergic rhinitis | 11% | 13% |
| Pharyngitis | 8% | 7% |
| Upper respiratory infection | 8% | 7% |
| Sinusitis | 6% | 5% |
Other
|
||
Drug interactions
- CYP3A4 strong inhibitors - mometasone is a CYP3A4 substrate. Strong CYP3A4 inhibitors may increase systemic exposure to mometasone
Precautions / Contraindications
- Severe milk allergy - DO NOT USE - contains small amount of lactose
- Linear growth in children - long-term ICS use in children may inhibit linear growth. See linear growth in children for more.
- Glaucoma - long-term ICS use may be associated with a higher risk of glaucoma
- Cataracts - long-term ICS use may be associated with a higher risk of cataracts
- Osteoporosis - long-term ICS use may be associated with a higher risk of osteoporosis
- Hypothalamic-pituitary-adrenal (HPA) suppression - ICS may suppress the HPA axis. This is rare at typical doses.
- Lung infections - Use with caution in patients with serious lung infections (e.g. tuberculosis, fungal infections, etc.)
- Skin thinning and bruising - long-term ICS use may be associated with skin thinning and bruising
- Liver disease - has not been studied extensively
- Kidney disease - has not been studied extensively
- ICS + LABA
Advair® | Wixela Inhub® (fluticasone + salmeterol)
Dosage forms
Inhalation powder (Advair® Diskus | Wixela Inhub®)
- Strength is expressed as fluticasone/salmeterol
- Advair® 100/50 - 100/50 mcg per inhalation
- Advair® 250/50 - 250/50 mcg per inhalation
- Advair® 500/50 - 500/50 mcg per inhalation
- Inhalation powder packaged in diskus with 60 doses
HFA (Advair®)
- Strength is expressed as fluticasone/salmeterol
- Advair HFA® 45/21 - 45/21 mcg per actuation
- Advair HFA® 115/21 - 115/21 mcg per actuation
- Advair HFA® 230/21 - 230/21 mcg per actuation
- Inhaler with 120 actuations per inhaler
Dosing - Diskus
Asthma
- 4 - 11 years old
- One inhalation of 100/50 twice daily
- 12 years of age and older
- Dose: one inhalation twice daily
- Starting: strength will depend on asthma severity
- Max dose: 500/50, one inhalation twice daily
- Maximum benefit seen after 2 weeks
COPD
- 1 inhalation of 250/50 twice daily
Dosing - HFA
Asthma in children ≥ 12 years and adults
- Dose: two inhalations twice daily
- Starting: strength will depend on asthma severity
- Max dose: 230/21, two inhalations twice daily
- Maximum benefit seen after 2 weeks
Generic / Price
- Diskus - YES/$$
- HFA - NO/$$$$
Other
Advair® HFA
- Shake well for 5 seconds before use
- Prime before using for the first time by releasing 4 test sprays
- In cases where the inhaler has not been used for more than 4 weeks or when it has been dropped, prime the inhaler again by releasing 2 test sprays
- Rinse mouth after use
Advair® Diskus
- The device should be discarded 1 month after removal from the moisture-protective foil overwrap pouch
- Rinse mouth after use
FDA-approved indications
Advair® Diskus
- Asthma in children ≥ 4 years and adults
- Chronic Obstructive Pulmonary Disease (COPD)
- NOT for relief of acute bronchospasm
Advair® HFA
- Asthma in children ≥ 12 years and adults
- NOT for relief of acute bronchospasm
AirDuo RespiClick® (fluticasone + salmeterol)
Dosage forms
Powder inhaler (fluticasone/salmeterol)
- AirDuo RespiClick® 55/14 - 55/14 mcg per inhalation
- AirDuo RespiClick® 113/14 - 113/14 mcg per inhalation
- AirDuo RespiClick® 232/14 - 232/14 mcg per inhalation
- Each inhaler contains 60 actuations
Dosing
Asthma (≥ 12 years old)
- Starting: 55/14 mcg twice daily
- Maintenance: 55/14 - 232/14 mcg twice daily
- Max dose: 232/14 mcg twice daily
- Increase dose at intervals of 2 weeks
- Inhale at the same time each day
- Patients switching from other inhaled corticosteroids may require higher starting doses
Generic / Price
- YES/$Other
- Inhaler does not require priming
- Never wash or put any part of the inhaler in water
- Do not use with a spacer or volume holding chamber
FDA-approved indications
- Asthma in children ≥ 12 years and adults
- NOT for relief of acute bronchospasm
Breo Ellipta® (fluticasone + vilanterol)
Dosage forms
Inhaler
- Inhaler delivers 100 mcg of fluticasone powder and 25 mcg of vilanterol powder per inhalation
- Inhaler comes with 30 inhalations
Dosing
COPD
- One inhalation once daily
Asthma (≥ 18 years old)
- One inhalation once daily
Generic / Price
- NO/$$$$Other
- See Breo Ellipta® PI for complete prescribing information
- Discard inhaler 6 weeks after opening the foil tray
- DO NOT USE in patients with severe milk allergy
- Vilanterol is a CYP3A4 substrate. Use caution with strong CYP3A4 inhibitors.
FDA-approved indications
- Maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)
- Asthma in patients ≥ 18 years old that is not well-controlled with other medications
- NOT for relief of acute bronchospasm
Dulera® (mometasone + formoterol)
Dosage forms
Inhaler (mometasone/formoterol)
- Dulera® 50/5 - 50 mcg/5 mcg per actuation
- Dulera® 100/5 - 100 mcg/5 mcg per actuation
- Dulera® 200/5 - 200 mcg/5 mcg per actuation
- Comes in inhaler with 120 actuations
Dosing
Asthma
- 5 - 11 years old
- Dosing: 2 inhalations of 50 mcg/5 mcg twice daily
- Max daily dose: 200 mcg/20 mcg
- ≥ 12 years old
- Dosing: 2 inhalations twice daily
- Medium-dose corticosteroids: Dulera® 100 mcg/5 mcg, two inhalations twice daily
- High-dose corticosteroids: Dulera® 200 mcg/5 mcg, two inhalations twice daily
- Max daily dose: 800 mcg/20 mcg
- Maximum benefit seen after 2 weeks
Generic / Price
- NO/$$$$Other
- Shake well before use
- Prime inhaler by releasing 4 test sprays
- Re-prime if not used for ≥ 5 days
FDA-approved indications
- Maintenance treatment of Asthma
- NOT for relief of acute bronchospasm
Symbicort® (budesonide + formoterol)
Dosage forms
Inhaler (budesonide/formoterol)
- Symbicort® 80/4.5 - 80 mcg/4.5 mcg per actuation
- Symbicort® 160/4.5 - 160 mcg/4.5 mcg per actuation
- Comes in inhaler with 120 actuations
Dosing
Asthma
- 6 to 11 years old
- Dose: Symbicort 80/4.5 two inhalations twice daily
- ≥ 12 years old
- Dose: two inhalations twice daily
- Starting - may start with 80/4.5 or 160/4.5, depending on severity
- Max: Symbicort 160/4.5 two inhalations twice daily
- Maximum benefit seen after 2 weeks
COPD
- Symbicort 160/4.5 two inhalations twice daily
Generic / Price
- YES/$$$$Other
- Shake well for 5 seconds before use
- Inhaler is good for 3 months after removal from foil pouch
- If you do not use your inhaler for more than 7 days or if you drop it, you will need to prime again
- See patient instructions for details
FDA-approved indications
- Maintenance treatment of Asthma
- Maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)
- NOT for relief of acute bronchospasm
- LABA + LAMA + ICS
Breztri Aerosphere™ (budesonide + glycopyrrolate + formoterol)
Dosage forms
Inhalation aerosol
- Inhaler delivers 160 mcg of budesonide, 9 mcg of glycopyrrolate, and 4.8 mcg of formoterol per inhalation
- Inhaler comes with 120 inhalations
Dosing
COPD
- Two inhalations twice daily
Generic / Price
- NO/$$$$FDA-approved indication
- Maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)
- NOT for relief of acute bronchospasm
Trelegy Ellipta® (fluticasone + umeclidinium + vilanterol)
Dosage forms
Inhalation powder
- Fluticasone / Umeclidinium / Vilanterol
- 100 mcg/62.5 mcg/25 mcg
- 200 mcg/62.5 mcg/25 mcg
- Inhaler comes with 30 inhalations
Dosing
COPD
- One inhalation once daily of 100/62.5/25 mcg
Asthma (adults)
- One inhalation once daily of 100/62.5/25 mcg or 200/62.5/25 mcg
- When choosing a dose consider disease severity and current dose of ICS
Generic / Price
- NO/$$$$Other
- See Trelegy Ellipta® PI for complete prescribing information
- Discard inhaler 6 weeks after opening the foil tray
- DO NOT USE in patients with severe milk allergy
- Vilanterol is a CYP3A4 substrate. Use caution with strong CYP3A4 inhibitors.
FDA-approved indication
- Chronic Obstructive Pulmonary Disease (COPD) - maintenance treatment
- Asthma - maintenance treatment in adults
- NOT for relief of acute bronchospasm
- NHLBI ICS DOSING CHART
- ICS AND LINEAR GROWTH IN CHILDREN
- Overview
- Long-term ICS use in childhood may cause stunting of linear growth
- A study published in the NEJM in 2012 looked at the effect of ICS on height. The study involved a group of asthmatics who had been randomized to budesonide, nedocromil, or placebo in childhood. The active part of the trial lasted an average of 4.3 years. The participants were then followed into adulthood and their adult heights were compared.
- The study found the following:
- The average adult height was 1.2 cm lower in the budesonide group (95%CI [-1.9 cm to -0.5 cm])
- The decrease in growth-velocity was primarily seen in the first 2 years of treatment
- The effect was largely seen in prepubertal participants
- In general, participants with a longer duration of asthma had shorter adult heights
- The trial used a budesonide dose of 400 mcg/day [3]
- Conclusions
- Use of ICS in prepubertal children may cause a small decrease in adult height (1.2 cm on average)
- The benefits of good asthma control provided by ICS will likely outweigh this small downside in most patients
- PRICE ($) INFO / ASSISTANCE
Pricing legend
- $ = 0 - $50
- $$ = $51 - $100
- $$$ = $101 - $150
- $$$$ = > $151
- Pricing based on one month of therapy at standard dosing in an adult
- Pricing based on information from GoodRX.com®
- Pricing may vary by region and availability
| Patient Assistance Programs for Inhaled Corticosteroids | ||||
|---|---|---|---|---|
| Drug | Manufacturer | Ships to | PAP info | Application |
| Advair® diskus and HFA (fluticasone + salmeterol) | GlaxoSmithKline | Patient or other | Link | Link |
| Arnuity Ellipta® (fluticasone) | GlaxoSmithKline | Patient or other | Link | Link |
| Asmanex® HFA and Twisthaler (mometasone) | Merck | Patient or doctor | Link | Link |
| Breo Ellipta® (fluticasone + vilanterol) | GlaxoSmithKline | Patient or other | Link | Link |
| Dulera® (mometasone + formoterol) | Merck | Patient or doctor | Link | Link |
| Flovent® Diskus and HFA (fluticasone) | GlaxoSmithKline | Patient or other | Link | Link |
| Pulmicort® Flexhaler (budesonide) | AstraZeneca | Patient or doctor | Link | Link |
| Qvar® (beclomethasone) | Teva | Patient or doctor | Link | Link |
| Symbicort® (budesonide + formoterol) | AstraZeneca | Patient or doctor | Link | Link |
| Trelegy Ellipta® (fluticasone + umeclidinium + vilanterol) | GlaxoSmithKline | Patient or other | Link | Link |
- BIBLIOGRAPHY
- 1 - NHLBI 2007 guidelines
- 2 - Manufacturer's package insert
- 3 - PMID 22938716