What are the different strengths of inhaled corticosteroids (ICS)?

From the Guidelines

Inhaled corticosteroids should be used at the lowest effective dose to control asthma symptoms, with the option to step up to higher doses or add adjunctive therapies if symptoms persist, as the benefits of higher doses may be outweighed by the increased risk of systemic effects. The choice of inhaled corticosteroid strength should be based on asthma severity, with low-strength options including beclomethasone 40-80mcg/puff, budesonide 90-200mcg/puff, ciclesonide 80-160mcg/puff, and fluticasone propionate 44-110mcg/puff, and high-strength options including beclomethasone >200mcg/puff, budesonide >400mcg/puff, ciclesonide >160mcg/puff, and fluticasone propionate >440mcg/puff 1.

Some key points to consider when selecting an inhaled corticosteroid strength include:

• The potential for increased risk of side effects with higher doses, such as oral thrush, hoarseness, and potential systemic effects with long-term use 1
• The importance of regular reassessment of symptoms to determine if the current strength remains appropriate or if adjustments are needed 1
• The potential benefits of using a spacer device with metered-dose inhalers and rinsing the mouth after use to minimize local side effects 1
• The option to add adjunctive therapies, such as long-acting beta agonists or leukotriene modifiers, if symptoms persist despite treatment with inhaled corticosteroids 1

It is also important to note that there are no clinically meaningful differences among the various types of inhaled corticosteroids, and that the bronchoprotective effects of inhaled corticosteroids delivered via dry powder inhaler and hydrofluoroalkane-propelled metered dose inhalers are equivalent 1. Additionally, patients with mild to moderate persistent asthma treated with inhaled corticosteroids demonstrate improved symptom scores, lower exacerbation rates, and reduced symptom frequency, and have fewer hospitalizations compared to patients taking other single long-term control medications 1.

From the FDA Drug Label

DOSAGE FORMS AND STRENGTHS Inhalation suspension: 0.25 mg/2 mL and 0.5 mg/2 mL. The different strengths of inhaled corticosteroids available for budesonide inhalation suspension are 0.25 mg/2 mL and 0.5 mg/2 mL 2.

• The available strengths are used for maintenance treatment of asthma and as prophylactic therapy in children 12 months to 8 years of age.
• The dosage form is an inhalation suspension, which should be administered via compressed air driven jet nebulizers only.
• The choice of strength may depend on the patient's previous therapy and response to treatment, with the goal of using the lowest effective dose to control symptoms 2.

From the Research

Different Strengths of Inhaled Corticosteroids

• Inhaled corticosteroids (ICS) are commonly used in the treatment of asthma and chronic obstructive pulmonary disease (COPD) 3, 4, 5, 6.
• The choice of ICS strength and type depends on various factors, including the severity of the disease, patient characteristics, and preferences 7.
• Studies have compared the efficacy and safety of different ICS strengths and combinations, including budesonide/formoterol, fluticasone/salmeterol, and fluticasone/vilanterol 3, 4, 5.
• The results of these studies suggest that the effects of budesonide/formoterol on reducing exacerbations and improving quality of life may be similar to, or more marked than, those of other ICS combinations in COPD 3.
• However, the choice of ICS strength and type should be individualized based on patient needs and preferences, and healthcare providers should consider factors such as inhaler attributes, dosing regimen, and patient characteristics when selecting an ICS 7.

Comparison of ICS Combinations

• A systematic review compared the clinical effectiveness and tolerability of fluticasone propionate and budesonide, and formoterol fumarate and salmeterol xinafoate administered alone or in combination 5.
• The review found that fluticasone was associated with significantly greater improvement in lung function and better asthma symptom control than budesonide, and formoterol was associated with significantly greater improvement in lung function and better asthma symptom control than salmeterol 5.
• Another study found that budesonide/formoterol maintenance and reliever therapy reduced the risk of severe asthma exacerbations compared with conventional regimens using a short-acting beta(2)-adrenoceptor agonist alone as reliever therapy 6.

Factors Influencing ICS Choice

• The choice of ICS strength and type is influenced by many factors, including inhaler attributes, patient characteristics and preferences, dosing regimen, clinical setting, and support available for both patients and healthcare providers 7.
• Healthcare providers should consider these factors when selecting an ICS for their patients, and engage their patients in decision-making for inhaler choice to ensure adherence to treatment and correct use of the inhaler 7.