What is the recommended use and dosage of budesonide (Pulmicort) neb (nebulizer) for patients with asthma or chronic obstructive pulmonary disease (COPD)?

Budesonide Nebulizer Dosage and Usage Guidelines for Asthma and COPD

Budesonide inhalation suspension (Pulmicort) is indicated for maintenance treatment of asthma in patients aged 12 months to 8 years at doses of 0.25-0.5 mg twice daily, while its use in COPD is less established but may be considered at 2-8 mg daily in divided doses for acute exacerbations. 1

Dosing for Asthma

Children (12 months to 8 years)

• Starting dose based on previous therapy: 1
  • Patients on bronchodilators alone: 0.5 mg once daily or 0.25 mg twice daily
  • Patients on inhaled corticosteroids: 0.5 mg once daily or 0.25 mg twice daily, up to 0.5 mg twice daily
  • Patients on oral corticosteroids: 0.5 mg twice daily
• For symptomatic children not responding to non-steroidal therapy, a starting dose of 0.25 mg once daily may be considered 1
• Once asthma stability is achieved, the dose should be titrated downward 1

Adults with Asthma

• Budesonide inhalation suspension has been used at doses up to 8 mg/day in adults with persistent asthma 2
• Once-daily administration may be effective for maintenance therapy in adults with mild-to-moderate asthma once control has been achieved 3

Dosing for COPD

Acute Exacerbations

• While not FDA-approved specifically for COPD, studies have shown efficacy of nebulized budesonide in acute COPD exacerbations 4
• High-dose nebulized budesonide (8 mg/day) administered as either 2 mg every 6 hours or 4 mg every 12 hours has shown better improvement in pulmonary function compared to lower doses (4 mg/day) 5
• Nebulized budesonide 2 mg every 6 hours has demonstrated comparable efficacy to oral prednisolone in improving airflow in patients with acute COPD exacerbations 4

Administration Guidelines

• For inhalation use via compressed air-driven jet nebulizers only (not for use with ultrasonic devices) 1
• Not for injection 1
• A gas flow rate of 6-8 L/min is usually used to nebulize 50% of the particles to 2-5 μm diameter to aid deposition into the small airways 6
• The volume of fluid in the nebulizer chamber is usually 2.0-4.5 mL 6

Important Clinical Considerations

• Not indicated for relief of acute bronchospasm - budesonide is a maintenance therapy, not a rescue medication 1
• Patients should rinse their mouth after nebulization to prevent oral candidiasis 6
• Monitor for potential adverse effects including respiratory infection, rhinitis, coughing, otitis media, and oral candidiasis 1, 2
• Long-term use requires monitoring for potential effects on growth in pediatric patients and bone mineral density 1
• In patients with acute severe asthma, nebulized β-agonists (such as salbutamol 5 mg or terbutaline 10 mg) should be used as first-line therapy, with consideration of adding ipratropium bromide (500 μg) 6

Specific Situations

• For patients with steroid-dependent asthma, nebulized budesonide may allow reduction in maintenance doses of oral corticosteroids 6
• In COPD, nebulized budesonide may be an alternative to oral prednisolone in the treatment of non-acidotic exacerbations 4
• Nebulized budesonide has less systemic activity than oral prednisolone, as indicated by a lower incidence of hyperglycemia 4

Practical Administration Tips

• The mouth should be rinsed out after nebulizing steroids to prevent development of oral thrush 6
• Patients should be instructed to sit upright during nebulization for optimal delivery 6
• Before prescribing home nebulizer treatment, patients should be taught how to use, clean, and assemble the device 6

Nebulized budesonide represents an effective option for delivering inhaled corticosteroids, particularly for patients who are unwilling or unable to use standard inhalers 7.