What are examples of ultrafine inhaled corticosteroid (ICS) formulations?

Ultrafine (Extrafine) ICS Formulations — Examples

Bold recommendation: Use extrafine beclomethasone dipropionate (HFA)–based inhalers when seeking small-airway deposition; validated extrafine ICS options include beclomethasone HFA pMDI (alone) and beclomethasone/formoterol extrafine combinations (e.g., Modulite pMDI, NEXThaler DPI). 1, 2

• Single-agent ICS (extragenic/ultrafine particle, MMAD <2 μm):

  • Beclomethasone dipropionate HFA pMDI (extrafine solution) 1
  • Ciclesonide HFA pMDI (prodrug; extrafine aerosol) [highest-quality supportive clinical deployment is extrafine; not explicitly enumerated in EPR-3 tables but recognized as HFA ultrafine class] 1

• Fixed-dose ICS/LABA extrafine combinations:

  • Beclomethasone dipropionate/formoterol extrafine (Foster/Trimbow platforms)
    • Modulite solution pMDI (extrafine) 3
    • NEXThaler DPI (extrafine) 3, 2

• Not ultrafine (for contrast; larger particle):

  • Fluticasone propionate HFA/DPI, fluticasone furoate DPI, budesonide DPI/Turbohaler, mometasone DPI (standard/fine particles) 1, 2

Practical notes (to protect morbidity, mortality, QoL)

• Rationale: Extrafine formulations improve peripheral (small-airway) deposition and may enhance control and QoL at lower ICS doses versus fine particles in real-world/FRI data, though head-to-head clinical outcome superiority is mixed; choose extrafine when small-airway targeting is desired. 2, 4, 5, 6
• Pitfalls:
  • Don’t assume dose equivalence across devices; adjust when switching. 1
  • Spacer data with ultrafine HFA pMDIs are limited; ensure correct technique. 1
• Technique priorities to maximize outcomes:
  • For extrafine pMDI solutions (e.g., Modulite/ciclesonide): slow deep inhalation with breath hold. 1
  • For DPIs (e.g., NEXThaler): adequate inspiratory flow; avoid exhaling into device. 1, 2