What are the guidelines for using Pulmicort (budesonide) in an elderly patient with influenza A and COVID-19, without chronic obstructive pulmonary disease (COPD) or asthma, and with diabetes mellitus (DM)?

Guidelines for Using Pulmicort (Budesonide) in Elderly Patients with Influenza A and COVID-19 with Diabetes Mellitus

Inhaled budesonide (Pulmicort) should be used for a maximum of 14 days in elderly diabetic patients with influenza A and COVID-19 who do not have COPD or asthma, as it can reduce time to recovery and potentially decrease hospital admissions. 1

Indications and Benefits

Inhaled budesonide has shown specific benefits for COVID-19 patients:

• Reduces time to recovery by approximately 3 days (11.8 days vs 14.7 days) 1
• Decreases combined endpoint of hospital admission or death (6.8% vs 8.8%) 1
• Increases resolution of initial symptoms at day 14 2
• May have direct antiviral activity against SARS-CoV-2 and its variants 3

Dosing Recommendations

• Dose: 800 μg twice daily 1, 4
• Administration: Via dry powder inhaler (turbohaler)
• Duration: Continue for 14 days or until symptom resolution, whichever comes first 4
• Maximum treatment period: 14 days 1, 4

Special Considerations for Elderly Diabetic Patients

Elderly patients with diabetes require additional monitoring when using inhaled budesonide:

• Diabetes significantly increases risk of severe COVID-19 outcomes (up to 50% higher mortality) 5
• Monitor blood glucose levels more frequently as respiratory infections can destabilize glycemic control 5
• Be vigilant for signs of diabetic ketoacidosis, which has been reported in COVID-19 patients with diabetes 5
• Continue standard diabetes medications with adjustments as needed:
  • Consider stopping metformin if dehydration occurs 5
  • SGLT2 inhibitors should be discontinued due to risk of ketoacidosis 5

Monitoring During Treatment

1. Respiratory symptoms:

   • Monitor for improvement in breathlessness using positioning techniques and breathing exercises 5
   • Track fever and oxygen saturation daily

2. Diabetes-specific monitoring:

   • Check blood glucose levels at least 4 times daily
   • Monitor for signs of ketoacidosis (nausea, vomiting, abdominal pain)
   • Ensure adequate hydration (no more than 2 liters per day) 5

3. Treatment response indicators:

   • Resolution of fever
   • Improvement in respiratory symptoms
   • Stable oxygen saturation (≥94% on room air) 6

When to Discontinue or Seek Emergency Care

Discontinue budesonide and seek emergency care if:

• Severe breathlessness develops
• Oxygen saturation drops below 94% on room air 6
• Signs of diabetic ketoacidosis appear
• No improvement in symptoms after 5 days of treatment

Potential Pitfalls and Caveats

1. Do not use for prevention: Budesonide is for treatment of symptomatic disease, not prophylaxis.

2. Drug interactions: Reduce polypharmacy and adjust drug doses according to age (1/2 to 3/4 of standard adult dose for elderly patients) 6

3. Oral thrush: Common side effect of inhaled corticosteroids. Advise patients to rinse mouth after each use.

4. Not a substitute for vaccination: Encourage vaccination against influenza, COVID-19, and pneumococcal disease, as vaccination rates remain suboptimal in diabetic patients 7

5. Limited evidence in influenza: While evidence supports use in COVID-19, data specifically for influenza is more limited. The recommendation is based on COVID-19 evidence.

In conclusion, inhaled budesonide offers a therapeutic option for elderly diabetic patients with respiratory viral infections, particularly COVID-19, with a favorable risk-benefit profile when used for the recommended duration of up to 14 days.