What are the common Inhaled Corticosteroids (ICS) medications, their typical dosages, and potential side effects?

Inhaled Corticosteroids: Medications, Dosing, and Side Effects

Common ICS Medications and Dosing

The most commonly used inhaled corticosteroids include beclomethasone, budesonide, fluticasone, mometasone, flunisolide, and triamcinolone, with dosing stratified by age and severity into low, medium, and high dose ranges. 1

Available ICS Formulations by Age Group:

Adults and Children ≥12 years:

• Beclomethasone HFA (40 or 80 mcg/puff): Low dose 80-240 mcg, Medium dose >240-480 mcg, High dose >480 mcg 1
• Budesonide DPI (90,180, or 200 mcg/inhalation): Low dose 180-600 mcg, Medium dose >600-1200 mcg, High dose >1200 mcg 1
• Fluticasone propionate HFA/MDI (44,110,220 mcg/puff): Low dose 88-264 mcg, Medium dose >264-440 mcg, High dose >440 mcg 1
• Fluticasone DPI (50,100, or 250 mcg/inhalation): Low dose 100-300 mcg, Medium dose >300-500 mcg, High dose >500 mcg 1
• Mometasone DPI (200 mcg/inhalation): Low dose 200 mcg, Medium dose 400 mcg, High dose >400 mcg 1

Children 5-11 years:

• Beclomethasone HFA: Low dose 80-160 mcg, Medium dose >160-320 mcg, High dose >320 mcg 1
• Budesonide DPI: Low dose 180-400 mcg, Medium dose >400-800 mcg, High dose >800 mcg 1
• Fluticasone HFA/MDI: Low dose 88-176 mcg, Medium dose >176-352 mcg, High dose >352 mcg 1
• Fluticasone DPI: Low dose 100-200 mcg, Medium dose >200-400 mcg, High dose >400 mcg 1

Children 0-4 years:

• Budesonide nebulizer suspension (only FDA-approved ICS for this age): Low dose 0.25-0.5 mg, Medium dose >0.5-1.0 mg 1
• Fluticasone HFA: Low dose 176 mcg, Medium dose >176-352 mcg, High dose >352 mcg (requires face mask delivery) 1

Local Side Effects

The most common local adverse effects are cough, dysphonia (hoarseness), and oral thrush (candidiasis), which occur at the site of drug deposition in the oropharynx. 1

Prevention of Local Side Effects:

• Use spacers or valved holding chambers (VHCs) with metered-dose inhalers to decrease oropharyngeal deposition and reduce risk of topical effects like thrush 1
• Rinse mouth thoroughly and spit after each inhalation to remove residual medication 1
• Wash face after each nebulizer treatment to prevent local skin effects 1
• Spacers/VHCs are particularly important as they can reduce systemic availability of ICS with higher oral absorption 1

Systemic Side Effects

Most benefits of ICS occur at low-to-medium dose ranges, while the risk of systemic adverse effects increases with dose and duration of exposure. 1

Dose-Related Systemic Effects:

High doses (≥600 mcg fluticasone equivalent) and prolonged use (>1 year) carry increased risk of systemic complications:

• Adrenal suppression and hypothalamic-pituitary-adrenal (HPA) axis dysfunction 1, 2
• Growth suppression in children (0.8-1.1 cm reduction per year), which is more sensitive than HPA-axis testing for detecting systemic exposure 1, 2
• Osteoporosis and reduced bone density, particularly with frequent oral corticosteroid courses 1
• Posterior subcapsular cataracts requiring slit-lamp examination monitoring 1
• Skin thinning and easy bruising 1
• Increased pneumonia risk, especially in COPD patients and elderly 3, 4, 5
• Major adverse cardiac events (MACE), arrhythmias, and pulmonary embolism at medium-high doses 4

Specific Risk Data from Recent Studies:

At medium daily ICS doses (201-599 mcg fluticasone equivalent), the number needed to harm over 12 months is: MACE 473, arrhythmia 567, pulmonary embolism 1221, and pneumonia 230 4

At high daily ICS doses (≥600 mcg), the number needed to harm over 12 months is: MACE 224, arrhythmia 396, pulmonary embolism 577, and pneumonia 93 4

Short-term use of low-dose ICS was not associated with adverse effects in this large observational study. 4

Drug-Specific Considerations

Fluticasone, budesonide, and mometasone are metabolized by CYP3A4 enzymes, creating potential for drug interactions with potent inhibitors like ritonavir and ketoconazole, which can increase systemic concentrations and cause Cushing syndrome or secondary adrenal insufficiency. 1

Fluticasone is more likely to cause systemic effects compared to budesonide, while newer molecules like ciclesonide may reduce systemic complications with prolonged use. 3, 6

Critical Safety Recommendations

To minimize systemic adverse effects, the following algorithm should be followed:

1. Use the lowest effective ICS dose that maintains asthma control 1, 4
2. Evaluate inhaler technique and adherence before increasing doses 1
3. Consider adding a long-acting beta-agonist (LABA) to low-medium dose ICS rather than escalating to high-dose ICS monotherapy 1
4. Monitor growth velocity routinely in children (via stadiometry) as it is more sensitive than HPA-axis testing 2
5. Consider bone densitometry and slit-lamp eye examinations for patients on high-dose ICS >1 year, especially with frequent oral corticosteroid courses 1
6. Ensure calcium and vitamin D supplementation in perimenopausal women and age-appropriate dietary intake in children 1
7. Titrate to minimum effective dose once control is achieved for 2-4 months 1

Special Population Considerations

In children <4 years, budesonide nebulizer suspension is the only FDA-approved ICS, requiring face mask delivery that fits snugly over nose and mouth. 1

In elderly patients with COPD, use ICS only when benefits outweigh risks (particularly those with frequent exacerbations), monitor for pneumonia, diabetes, cataracts, and bone fractures, and use lowest possible doses. 5, 7

The potential risks of ICS are well balanced by their benefits when used appropriately at the lowest effective dose. 1