What is the recommended dosage for Pulmicort (Budesonide) Flexhaler 180 MCG (micrograms)/1 Actuation Inhalation Powder for a patient with asthma or chronic obstructive pulmonary disease (COPD)?

Pulmicort Flexhaler 180 MCG Dosing for Asthma

For asthma management, Pulmicort (budesonide) Flexhaler 180 MCG should be dosed based on disease severity: children 5-11 years require 180-400 mcg daily for low-dose therapy, >400-800 mcg daily for medium-dose, and >800 mcg daily for high-dose; adults require 180-600 mcg daily for low-dose, >600-1200 mcg daily for medium-dose, and >1200 mcg daily for high-dose therapy. 1

Dosing by Age and Severity

Children (5-11 years)

• Low daily dose: 180-400 mcg (1-2 inhalations of 180 mcg once or twice daily) 1
• Medium daily dose: >400-800 mcg (2-4 inhalations of 180 mcg divided twice daily) 1
• High daily dose: >800 mcg (>4 inhalations of 180 mcg divided twice daily) 1

Adults (≥12 years)

• Low daily dose: 180-600 mcg (1-3 inhalations of 180 mcg once or twice daily) 1
• Medium daily dose: >600-1200 mcg (3-6 inhalations of 180 mcg divided twice daily) 1
• High daily dose: >1200 mcg (>6 inhalations of 180 mcg divided twice daily) 1

Key Dosing Principles

The clinician must monitor response on multiple clinical parameters and adjust the dose accordingly—once asthma control is achieved, carefully titrate to the minimum dose required to maintain control. 1

Frequency of Administration

• Budesonide may be administered once or twice daily depending on disease severity and control 1, 2, 3
• Twice-daily dosing is preferred for medium and high doses to optimize efficacy 1
• Once-daily dosing may be sufficient for maintenance in well-controlled patients on low doses 2, 3

Important Clinical Considerations

Preparations are not interchangeable on a mcg-per-puff basis between different delivery devices. 1

• The 180 mcg Flexhaler delivers budesonide as a dry powder inhaler (DPI), which requires adequate inspiratory flow 1
• Patients must demonstrate proper inhaler technique before prescribing and technique should be rechecked before modifying treatment 1
• After inhalation, patients should rinse mouth and spit to decrease local side effects (oral thrush, dysphonia) 1

Monitoring and Adjustment

• Assess response using FEV1, peak flow, symptom control, and rescue medication use 1, 3
• After achieving 1-3 months of stability, consider stepwise reduction by 25-50% at each step 1
• Maximum benefit occurs with early intervention—ideally within 2 years of disease recognition 4

COPD Considerations

Pulmicort Flexhaler is NOT routinely recommended for COPD management, as inhaled corticosteroids show limited benefit in this population. 1

• Only 10-20% of COPD patients demonstrate significant spirometric response to corticosteroids 1
• If used in COPD, a trial period (oral prednisolone 30 mg daily for 2 weeks or inhaled steroid equivalent to beclomethasone 500 mcg twice daily for 6 weeks) should demonstrate objective improvement (FEV1 increase ≥200 mL and ≥15% over baseline) before continuing 1
• In COPD responders, doses of 800 mcg/day budesonide have shown benefit 5

Common Pitfalls to Avoid

• Do not exceed recommended doses without specialist consultation, as high doses (>1000 mcg/day) may increase risk of systemic effects including adrenal suppression and osteoporosis 1
• Do not use as rescue medication—budesonide is a controller medication requiring regular use for efficacy 1
• Do not assume all inhaled corticosteroids are equivalent—budesonide at 400 mcg is roughly equivalent to beclomethasone 200 mcg or fluticasone 100-200 mcg 6