How many puffs of Anora (beclomethasone) are recommended for asthma management?

Beclomethasone (Anora) Dosing for Asthma Management

For chronic asthma management, beclomethasone should be administered as 200-400 mcg twice daily (total daily dose 400-800 mcg), with twice-daily dosing superior to once-daily regimens for maintaining asthma control. 1, 2

Standard Maintenance Dosing

Adults and Children >5 Years

• Low dose: 200-400 mcg total daily, divided twice daily 1
• Medium dose: 400-800 mcg total daily, divided twice daily 1, 3
• High dose: Up to 2000 mcg daily equivalent may be used for severe persistent asthma 1

Twice-daily administration (morning and evening) is more effective than once-daily dosing for controlling symptoms and maintaining peak expiratory flow rates, particularly morning PEF 2, 4. While once-daily dosing in the late afternoon (15:00-16:00) shows promise for suppressing nocturnal symptoms and overnight eosinophil peaks 5, the established standard remains twice-daily dosing for optimal control 2.

Children <5 Years

• Higher doses per actuation may be needed due to lower delivery efficiency with face masks 1
• Specific dosing should account for delivery device limitations in this age group 1

Acute Exacerbation Dosing

During acute severe asthma, beclomethasone is NOT the primary treatment—systemic corticosteroids and bronchodilators take priority. 1

For acute management:

• Immediate: Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 1
• Bronchodilator: Salbutamol 5 mg or terbutaline 10 mg via nebulizer, OR 2 puffs via MDI with spacer repeated 10-20 times 1
• Continue high-dose systemic steroids (prednisolone 30-60 mg daily) until recovery 1

Dosing Frequency Considerations

If symptoms are not controlled on twice-daily dosing, increase to four times daily at the same total daily dose before escalating the total dose. 1 This approach maximizes topical anti-inflammatory effect while minimizing systemic exposure.

Timing Optimization

Recent evidence suggests afternoon dosing (15:00-16:00) may provide superior overnight symptom control compared to morning or twice-daily regimens, with better suppression of nocturnal FEV1 dip and blood eosinophil peaks 5. However, this requires validation in real-world settings before replacing standard twice-daily dosing 5.

Dose Escalation Strategy

When inadequate control persists:

1. First: Verify proper inhaler technique and compliance 1
2. Second: Increase frequency to 4 times daily (same total dose) 1
3. Third: Increase total daily dose up to 2000 mcg beclomethasone equivalent 1
4. Fourth: Consider adding long-acting β2-agonist (salmeterol 50-100 mcg twice daily) rather than further increasing inhaled steroid dose 1

Adding a long-acting β2-agonist to low-dose inhaled corticosteroids (400 mcg beclomethasone) is more effective than doubling the steroid dose for improving symptoms, lung function, and reducing exacerbations 1.

Dose Reduction Strategy

After 1-3 months of stability, reduce dose by 25-50% at each step. 1 Never reduce during periods of instability or increased symptoms 1.

Critical Pitfalls to Avoid

• Never use beclomethasone as monotherapy for acute exacerbations—it will not prevent death 1, 6
• Do not substitute inhaled steroids for systemic steroids during acute attacks—add systemic steroids immediately 1, 3
• Patients transferring from oral steroids require 9-12 months of monitoring for adrenal insufficiency during stress, trauma, or severe infections 3
• Spacer devices must be used with MDIs to reduce oropharyngeal candidiasis (dose-related, more common in women) 1, 3
• Mouth rinsing and spitting after inhalation reduces local side effects 1

Device-Specific Delivery

• MDI with spacer: 2 puffs (typically 100-250 mcg per puff depending on formulation) 1
• Concentrated aerosol: 250 mcg per puff allows once or twice daily dosing 2
• For acute use with spacer: 2 puffs repeated 10-20 times delivers equivalent to nebulized therapy 1