Recommended Dosing for Corticosteroid Inhalers in Asthma Treatment
The recommended dosing for corticosteroid inhalers in asthma treatment follows a stepwise approach based on asthma severity, with low-dose inhaled corticosteroids (ICS) being the preferred initial therapy for persistent asthma, administered twice daily for most formulations. 1
Dosing Guidelines by Age Group
Adults and Children ≥12 Years:
Low daily dose ranges 1:
- Fluticasone HFA/MDI: 88-264 mcg/day
- Budesonide DPI: 180-600 mcg/day
- Mometasone DPI: 200 mcg/day
Medium daily dose ranges 1:
- Fluticasone HFA/MDI: >264-440 mcg/day
- Budesonide DPI: >600-1200 mcg/day
- Mometasone DPI: 400 mcg/day
High daily dose ranges 1:
- Fluticasone HFA/MDI: >440 mcg/day
- Budesonide DPI: >1200 mcg/day
- Mometasone DPI: >400 mcg/day
Children 5-11 Years:
Low daily dose ranges 1:
- Fluticasone HFA/MDI: 88-176 mcg/day
- Budesonide DPI: 180-400 mcg/day
Medium daily dose ranges 1:
- Fluticasone HFA/MDI: >176-352 mcg/day
- Budesonide DPI: >400-800 mcg/day
High daily dose ranges 1:
- Fluticasone HFA/MDI: >352 mcg/day
- Budesonide DPI: >800 mcg/day
Children 0-4 Years:
- For budesonide inhalation suspension (the only FDA-approved ICS for this age group) 1, 2, 3:
- Low daily dose: 0.25-0.5 mg total daily dose (0.125-0.25 mg twice daily)
- Medium daily dose: >0.5-1.0 mg total daily dose (>0.25-0.5 mg twice daily)
- High daily dose: >1.0-2.0 mg total daily dose (>0.5-1.0 mg twice daily)
Administration Frequency
- Most ICS formulations should be administered twice daily 1, 3
- Budesonide inhalation suspension should be administered twice daily, especially for children under 4 years 2, 3
- Some newer formulations of fluticasone furoate may be administered once daily in the evening 4
Stepwise Approach to Dosing
Step 1: Short-acting beta agonist as needed (no ICS) 1
Step 2: Low-dose ICS is the preferred initial controller therapy 1
- This dose achieves 80-90% of maximum therapeutic benefit 5
Step 3: Options include 1:
- Low-dose ICS plus long-acting beta agonist (LABA)
- OR Medium-dose ICS
Step 4: Medium-dose ICS plus LABA 1
Step 5: High-dose ICS plus LABA 1
Step 6: High-dose ICS plus LABA plus oral corticosteroid 1
Dose Adjustment Considerations
- After achieving asthma control for at least 3 months, gradually step down to the lowest effective dose 1
- Use of short-acting beta agonist more than twice weekly (except for exercise) indicates inadequate control and need to step up treatment 1
- Research suggests limited additional benefit with doses above medium range for most patients with mild to moderate asthma 6, 7
Administration Techniques and Precautions
- For MDIs: Use spacer or valved holding chamber and rinse mouth after use to reduce local side effects 1
- For young children: Use face mask that fits snugly over nose and mouth 1, 2
- Wash face after each treatment to prevent local side effects 1, 2
Potential Adverse Effects
- Common local effects: Cough, dysphonia, oral thrush (candidiasis) 1
- Higher doses (800-1000 mcg/day) significantly increase risk of hoarseness and oral candidiasis 6, 7
- Systemic effects are rare at low-to-medium doses but may include adrenal suppression, growth velocity reduction in children, and bone mineral density effects at higher doses 1
Important Clinical Considerations
- Fluticasone is approximately twice as potent as budesonide or beclomethasone on a mcg-to-mcg basis 8
- Preparations are not interchangeable on a mcg or per-puff basis 1
- Once control is achieved, titrate to the lowest effective dose 3
- For oral steroid-dependent asthmatics, higher doses of ICS may help reduce oral steroid requirements 6, 7