What are examples of inhaled corticosteroids (ICS) used to manage asthma and other respiratory conditions?

Examples of Inhaled Corticosteroids (ICS) for Asthma and Respiratory Conditions

Inhaled corticosteroids (ICS) are the most consistently effective long-term control medications at all steps of care for persistent asthma, and they improve asthma control more effectively in both children and adults than any other single long-term control medication. 1

Common Inhaled Corticosteroids

Available ICS Medications

• Budesonide - Available in various formulations including nebulizer suspensions for children as young as 12 months 2
• Beclomethasone dipropionate - Available in metered-dose inhalers (MDIs) with both chlorofluorocarbon (CFC) and hydrofluoroalkane (HFA) propellants 1
• Fluticasone propionate - Available in both MDIs and dry powder inhalers (DPIs), considered at least twice as potent as beclomethasone or budesonide 3
• Ciclesonide - A newer ICS with potential for fewer local side effects 1
• Flunisolide - Available in MDI formulation 1
• Mometasone - Available in DPI formulation 1
• Triamcinolone acetonide - Available in MDI formulation 1

Delivery Devices for ICS

Types of Delivery Systems

• Metered-dose inhalers (MDIs) - Can be used with spacers or valved holding chambers to improve delivery, particularly beneficial for children and elderly patients 1
• Dry powder inhalers (DPIs) - Require sufficient inspiratory flow (may not be suitable for children under 4 years) 1
• Nebulizers - Particularly useful for young children, elderly patients, or those unable to use other devices properly 4
• Breath-actuated MDIs - May be useful for patients unable to coordinate inhalation and actuation 1

Role in Asthma Management

Stepwise Approach to ICS Use

• Step 1: No controller treatment needed for mild intermittent asthma 1
• Step 2: Low-dose ICS is the preferred controller treatment for mild persistent asthma 1
• Step 3: Medium-dose ICS or low-dose ICS plus long-acting beta-agonist (LABA) for moderate persistent asthma 1
• Step 4: Medium-dose ICS plus LABA or other add-on therapy 1
• Step 5-6: High-dose ICS plus LABA, with consideration of add-on biologics like omalizumab for severe persistent asthma 1

Efficacy and Benefits

• ICS reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation, and block late-phase reaction to allergens 1
• They improve asthma symptoms, lung function, and prevent exacerbations 5
• ICS are more effective than leukotriene receptor antagonists (LTRAs) or other single long-term control medications 1
• The dose-response curve for ICS is relatively flat, with most benefits achieved at lower doses 5

Safety Considerations

Potential Side Effects

• Local effects: Oral candidiasis, hoarseness, and dysphonia 1, 6
• Systemic effects: At higher doses may include hypothalamic-pituitary-adrenal axis suppression, reduced growth velocity in children, decreased bone mineral density, and increased risk of diabetes 6
• Most side effects are dose-dependent and can be minimized by using spacers, proper inhaler technique, and mouth rinsing after use 1

Special Populations

• Children: Growth velocity may be affected, but effects are generally minimal at recommended doses 2, 6
• Severe asthma: Higher doses increase risk of adverse effects; consider add-on therapies rather than continually increasing ICS dose 1, 6

Comparative Potency

• Fluticasone propionate is approximately twice as potent as beclomethasone, budesonide, or triamcinolone acetonide 3
• The DICE study established a rank order of systemic effect potency: flunisolide (1), triamcinolone (1.19:1), beclomethasone (1.69:1), fluticasone DPI (2.08:1), budesonide DPI (3.45:1), and fluticasone CFC (8.33:1) 1

Combination Therapy

• Combining ICS with LABAs increases efficacy in moderate-to-severe asthma 7
• Adding a LABA to budesonide (800 mcg) led to a 63% reduction in severe exacerbations compared to a 49% reduction with budesonide alone 7
• LABAs should never be used as monotherapy for asthma and should always be prescribed with an ICS 1, 7

Clinical Pearls

• ICS are the cornerstone of therapy for persistent asthma of all severities 1, 5
• The most important factor in ICS effectiveness is regular use and proper inhaler technique 1
• Consider device selection based on patient age, ability to use the device correctly, and personal preference 1
• For patients with poor inhaler technique, consider using a spacer/holding chamber or nebulizer 4