Can a patient with a recent history of asthma and a current viral respiratory tract infection use budesonide (corticosteroid)?

Budesonide Use in Asthma Patients with Viral Respiratory Tract Infection

Yes, budesonide should be used in patients with asthma who develop viral respiratory tract infections, as this is specifically recommended by current guidelines and can reduce exacerbations requiring systemic corticosteroids. 1

Evidence-Based Recommendations by Patient Age

For Children Under 4 Years Old

Intermittent budesonide therapy is conditionally recommended starting at the first sign of respiratory tract infection symptoms. 1

• Administer budesonide inhalation suspension 1 mg twice daily for 7-10 days at the onset of respiratory tract infection symptoms 1, 2
• This regimen reduces exacerbations requiring systemic corticosteroids by 33% relative risk reduction 1
• Caregivers can initiate treatment at home without a provider visit when they have clear written instructions 1
• This approach is appropriate for children who have had ≥3 episodes of wheezing triggered by respiratory infections in their lifetime, or ≥2 episodes in the past year 1

Critical monitoring consideration: Growth should be carefully monitored, as conflicting data exist regarding effects on linear growth 1. One study found 5% lower gain in height/weight with fluticasone, while another found no effect on growth with budesonide 1.

For Adults and Children Over 4 Years

Continue maintenance budesonide therapy during viral respiratory infections and add short-acting beta-agonists as needed for symptom relief. 1, 3

• Budesonide is not a bronchodilator and should not be used alone for acute symptom relief 3
• Patients should contact their physician immediately if usual bronchodilator doses are insufficient 3
• Oral corticosteroids may be required during severe episodes despite continued budesonide use 3

Mechanistic Support for Use During Viral Infections

Recent research demonstrates budesonide has both antiviral and anti-inflammatory properties against rhinovirus infection:

• Post-infection addition of budesonide inhibits virus-induced TSLP and CCL26 production from airway epithelial cells 4
• Budesonide reduces viral load and IL-1β cytokine levels in infected lung tissue 5
• The antiviral effect is mediated through autophagy activation 5
• Budesonide reduces ICAM-1 expression (the rhinovirus receptor) and viral RNA within cells 6

Critical Safety Considerations

Budesonide does NOT increase susceptibility to viral infections and should be continued during respiratory infections. 3

• The FDA label cautions about immunosuppression with corticosteroids, but this primarily applies to systemic (not inhaled) corticosteroids at therapeutic doses 3
• A study of 243 asthmatic children (ages 12 months-8 years) on budesonide 0.25-1 mg daily showed 85% developed protective antibody titers to varicella vaccine, similar to 90% in non-corticosteroid treated patients 3
• No patient on budesonide developed chicken pox from vaccination 3

Important caveat: Patients on budesonide who are exposed to chicken pox or measles may require prophylaxis with VZIG or IG, particularly if not previously immunized 3

Common Pitfalls to Avoid

• Do not discontinue budesonide during viral respiratory infections - this is when it is most beneficial for preventing exacerbations 1, 4
• Do not rely on budesonide alone for acute symptom relief - always ensure patients have short-acting bronchodilators available 3
• Do not assume all wheezing in young children is asthma - proper diagnosis is essential before initiating long-term therapy 1
• Do not use budesonide as primary treatment for status asthmaticus - this is a contraindication requiring intensive measures 3

Administration Technique for Young Children

• Use a face mask that fits snugly over nose and mouth for children under 4 years 2, 7
• Rinse mouth after inhalation to prevent oral candidiasis 3
• Wash face after each treatment to prevent local side effects 7
• For nebulized budesonide, use jet nebulizer with standard flow rate compressor at 6 L/min 7