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CORTICOSTEROID, ANTI-INFLAMMATORY

Hydrocortisone Use: Oral inhalation to treat steroid-dependent asthma, nasal inhalation for the management of the symptoms of seasonal or perennial rhinitis

Beclomethasone diproprionate Beclovent, Beconase Nasal Inhaler, QVAR, Vancenase Nasal Inhaler, Vanceril, Vanceril D, Vancenase AQ		Asthma: Adult: Oral inhaler 2 inhalations t.i.d. or q.i.d. up to 20 inhalations/d; may try to reduce systemic steroids after 1 wk of concomitant therapy; QVAR 40–80 mcg b.i.d. (max 320 mcg/d). Child: 6–12 y: Oral inhaler 1–2 inhalations t.i.d. or q.i.d. up to 10 inhalations/d; QVAR 5–11 y, 40–80 mcg b.i.d. (max 160 mcg/d). Allergic Rhinitis: Adult: Nasal inhaler 1 spray in each nostril b.i.d. to q.i.d. Child >6 y: 1 spray q.d.
Budesonide Pulmicort, Turbuhaler, Pulmicort, Respules, Rhinocort, Rhinocort Aqua, Rhinocort, Turbuhaler		Asthma, Maintenance Therapy: Adult: Oral inhalation 1 or 2 inhalations (200 mcg/inhalation) q.d.–b.i.d. (max 800 mcg b.i.d). Child ≥6y: Oral inhalation 1 inhalation (200 mcg/inhalation) q.d.–b.i.d. (max 400 mcg b.i.d.) Child 12 mo–8 y: Nebulization 0.5 mg/d in 1–2 divided doses. Rhinitis: Adult, Child ≥6 y: Intranasal 2 sprays in each nostril in the morning and evening or 4 sprays in each nostril in the morning. Each actuation releases 32 mg from the nasal adapter.
Dexamethasone Aeroseb-Dex, Decadron, Decaspray		Adult: Oral Inhalation Up to 3 inhalations t.i.d. or q.i.d. (max 12 inhalations/d). Intranasal 2 sprays in each nostril b.i.d. or t.i.d. (max 12 sprays/d) Child: Oral Inhalation Up to 2 inhalations q.i.d. (max 8 inhalations/d). Intranasal 1 or 2 sprays in each nostril b.i.d. (max 8 sprays/d).
Flunisolide AeroBid, Nasalide, Nasarel		Allergic Rhinitis: Adult: Inhaled/Intranasal 2 sprays orally, or intranasally in each nostril, b.i.d.; may increase to t.i.d., if needed. Child: Inhaled/Intranasal 6–14 y, 1 spray orally, or intranasally in each nostril t.i.d. or 2 sprays b.i.d.
Fluticasone Flonase, Flovent		Seasonal Allergic Rhinitis: Adult: Intranasal 100 mcg (1 inhalation) in each nostril 1–2 times daily (max 4 times daily). Inhalation 1–2 inhalations b.i.d. Child ≥4 y: Intranasal 1 spray in each nostril once daily. May increase to 2 sprays in each nostril once daily if inadequate response, then decrease to 1 spray in each nostril once daily when control is achieved.
Mometasone furoate monohydrate Nasonex		Adult: Intranasal 2 sprays (50 mcg each) in each nostril once daily. Child ≥2 y: Intranasal 1 spray in each nostril once daily.
Triamcinolone acetonide Azmacort, Tri-Nasal		: Adult: Inhalation 2 puffs 3–4 times/d (max 16 puffs/d) or 4 puffs b.i.d. Nasal spray 2 spray/nostril once daily (max 8 sprays/d) Child 6–12 y: Inhalation 1–2 sprays t.i.d. or q.i.d. (max 12 sprays/d) or 2–4 sprays b.i.d.

Contraindicated in:

• Nonasthmatic bronchitis,
• primary treatment of status asthmaticus,
• acute attack of asthma.

Cautious use in:

• Patients receiving systemic corticosteroids;
• use with extreme caution if at all in respiratory tuberculosis,
• untreated fungal,
• bacterial, or viral infections, and ocular herpes simplex;
• nasal inhalation therapy for nasal septal ulcers,
• nasal trauma, or surgery.

Adverse Effects:

• Oral inhalation: Candidal infection of oropharynx and occasionally larynx, hoarseness, dry mouth, sore throat, sore mouth.

• Nasal (inhaler): Transient nasal irritation, burning, sneezing, epistaxis, bloody mucous, nasopharyngeal itching, dryness, crusting, and ulceration; headache, nausea, vomiting.

• Other: With excessive doses, symptoms of hypercorticism.

Clinical Implications: Note that oral inhalation and nasal inhalation products are not to be used interchangeably.

• Oral inhaler: Emphasize the following: (1) Shake inhaler well before using. (2) After exhaling fully, place mouthpiece well into mouth with lips closed firmly around it. (3) Inhale slowly through mouth while activating the inhaler. (4) Hold breath 5–10 sec, if possible, then exhale slowly. (5) Wait 1 min between puffs. Clean inhaler daily. Separate parts as directed in package insert, rinse them with warm water, and dry them thoroughly. Rinsing mouth and gargling with warm water after each oral inhalation removes residual medication from oropharyngeal area. Mouth care may also delay or prevent onset of oral dryness, hoarseness, and candidiasis.
• Nasal inhaler: Directions for use of nasal inhaler provided by manufacturer should be carefully reviewed with patient. Emphasize the following points: (1) Gently blow nose to clear nostrils. (2) Shake inhaler well before using. (3) If 2 sprays in each nostril are prescribed, direct one spray toward upper, and the other toward lower part of nostril. (4) Wash cap and plastic nosepiece daily with warm water; dry thoroughly. Inhaled steroids do not provide immediate symptomatic relief and are not prescribed for this purpose.