What is the recommended dosage and treatment regimen for Pulmicort (budesonide) in patients with asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Recommended Dosage and Treatment Regimen for Pulmicort (Budesonide) in Asthma and COPD

For patients with asthma or COPD, Pulmicort (budesonide) should be administered as a controller medication on a regular scheduled basis, not as an as-needed (PRN) medication for symptom relief. 1

Dosing Recommendations for Asthma

Adults and Adolescents:

• Dry Powder Inhaler (Turbuhaler):
  • Mild-to-moderate asthma: 200-600 mcg daily, either as a single dose or divided into two doses 2
  • Moderate-to-severe asthma: 600-1200 mcg daily, divided into two doses 2
  • Severe asthma: >1200 mcg daily, divided into two doses 2

Children (5-11 years):

• Dry Powder Inhaler:
  • Low dose: 180-400 mcg daily 2
  • Medium dose: >400-800 mcg daily 2
  • High dose: >800 mcg daily 2

Young Children (0-4 years):

• Nebulized Suspension (Respules):
  • Initial dose: 0.25-0.5 mg once daily or 0.25 mg twice daily 3
  • For children previously on inhaled corticosteroids: 0.5 mg once daily or 0.25 mg twice daily up to 0.5 mg twice daily 3
  • For children previously on oral corticosteroids: 0.5 mg twice daily 3
  • For symptomatic children not responding to non-steroidal therapy: starting dose of 0.25 mg once daily may be considered 3

Administration Guidance

• Once-daily dosing is effective and comparable to twice-daily regimens in patients with mild-to-moderate asthma 4
• For nebulized budesonide, use only with compressed air-driven jet nebulizers (not ultrasonic devices) 3
• The first treatment should always be administered under supervision 2
• Patients should receive written instructions for ongoing use 2
• After achieving asthma control, the dose should be titrated downward to the minimum effective dose 2, 3

Special Considerations for COPD

• Consider budesonide in COPD patients with:
  • Frequent exacerbations despite optimal bronchodilator therapy 1
  • Fast rate of FEV₁ decline (>50 mL/year) 1
• Evaluate response after 6 weeks and continue only if objective improvement is documented (FEV₁ improvement ≥10% predicted and/or >200 mL) 1
• For severe COPD episodes: Consider combination of a β-agonist with ipratropium bromide 500 µg 4-6 hourly 2

Important Warnings and Precautions

• Not indicated for relief of acute bronchospasm 3
• Monitor for localized Candida albicans infections in the mouth and throat; advise patients to rinse mouth after inhalation 3
• Risk of hypersensitivity reactions including anaphylaxis, rash, contact dermatitis, urticaria, angioedema, and bronchospasm 3
• When transferring patients from systemic corticosteroids to budesonide, taper slowly to reduce risk of adrenal insufficiency 3
• Monitor growth in pediatric patients 3
• Monitor for glaucoma and cataracts, especially in elderly patients 3

Common Pitfalls to Avoid

1. Incorrect use as rescue medication: Budesonide is not for relief of acute symptoms but for long-term control 3
2. Abrupt discontinuation: When switching from oral steroids, taper slowly to avoid adrenal insufficiency 3
3. Inadequate dose adjustment: After achieving control, titrate to the lowest effective dose 2
4. Poor inhaler technique: Ensure proper technique is demonstrated and regularly checked
5. Failure to monitor response: Evaluate objective improvement, especially in COPD patients 1
6. Not rinsing mouth after use: This increases risk of oral candidiasis 3

By following these evidence-based recommendations, clinicians can optimize the therapeutic benefits of Pulmicort while minimizing potential adverse effects in patients with asthma or COPD.