Alvesco (Ciclesonide) Dosing for Asthma
For adults and adolescents ≥12 years with asthma, start Alvesco at 80 mcg twice daily if previously on bronchodilators alone or inhaled corticosteroids, or 320 mcg twice daily if transitioning from oral corticosteroids, with a maximum dose of 320 mcg twice daily. 1
FDA-Approved Dosing by Prior Therapy
The FDA label provides clear stratification based on previous asthma treatment 1:
- Bronchodilators alone: Start 80 mcg twice daily (maximum 160 mcg twice daily)
- Inhaled corticosteroids: Start 80 mcg twice daily (maximum 320 mcg twice daily)
- Oral corticosteroids: Start 320 mcg twice daily (maximum 320 mcg twice daily)
Administration Guidelines
- Administer via oral inhalation twice daily 1
- Prime before first use: Actuate 3 times before using a new canister or if unused for >10 days 1
- Rinse mouth with water and spit out after each use to reduce oropharyngeal candidiasis risk 1
- Available strengths: 80 mcg/actuation (brown actuator) and 160 mcg/actuation (red actuator) 1
Dose Titration Principles
Maximum benefit may not occur for 4 weeks or longer after initiation 1. After achieving asthma stability, titrate to the lowest effective dose 1. For patients inadequately controlled after 4 weeks on the starting dose, higher doses may provide additional control, but do not exceed 320 mcg twice daily 1.
Research supports once-daily dosing efficacy at 160-640 mcg (ex-valve doses equivalent to 200-800 mcg), though FDA labeling specifies twice-daily administration 2, 3, 4. Studies demonstrate that ciclesonide 160 mcg once daily effectively maintains asthma control with cortisol levels unaffected and adverse event profiles comparable to placebo 3.
Special Considerations for Oral Corticosteroid Tapering
When transitioning patients from oral corticosteroids 1:
- Reduce prednisone gradually: No faster than 2.5 mg/day weekly, beginning after ≥1 week of Alvesco therapy
- Monitor carefully for asthma instability using objective airflow measures
- Watch for adrenal insufficiency during taper and after oral corticosteroid discontinuation
This is critical because abrupt withdrawal can precipitate adrenal crisis in patients with suppressed hypothalamic-pituitary-adrenal axis function 1.
Age Restrictions and Contraindications
Alvesco is NOT indicated for children <12 years of age 1. It is also contraindicated in 1:
- Primary treatment of status asthmaticus or acute asthma episodes requiring intensive measures
- Known hypersensitivity to ciclesonide or any ingredient (rare angioedema cases reported)
Safety Profile
Ciclesonide demonstrates favorable tolerability 2, 3, 4:
- Oropharyngeal candidiasis: Occurred in 32/3038 patients in clinical trials, with 20 cases in patients receiving ≥320 mcg daily; most cases were mild-to-moderate 1
- No cortisol suppression: Serum and 24-hour urine cortisol remained unaffected at therapeutic doses 3, 4
- No oral candidiasis reported in multiple studies 3, 5
Clinical Context
While general asthma guidelines recommend low-dose inhaled corticosteroids as Step 2 therapy for mild persistent asthma in patients ≥12 years 6, the specific Alvesco dosing must follow FDA-approved labeling. The drug's pro-drug formulation provides potent local anti-inflammatory effects with reduced systemic activity 2, 3, making it particularly suitable for patients concerned about corticosteroid side effects.