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Asthma - Management
What dose of inhaled corticosteroid?
- Use the lowest dose of inhaled corticosteroid (ICS) that maintains effective control of asthma.
- Start ICS at a dose appropriate to the severity of symptoms [SIGN and BTS, 2009]:
- Suitable starting doses for beclometasone-CFC free as Clenil Modulite® are:
- Age > 12 years: 200 micrograms twice daily.
- Age 5–12 years: 100 micrograms twice daily.
- Age < 5 years: 100 micrograms twice daily; higher doses may be required to ensure adequate drug delivery.
- If beclometasone CFC-free is started as Qvar® use half the dose listed above (licensed only for age > 12 years).
- Table 1 and Table 2 show comparable total daily doses of ICS.
- Higher doses of ICS may be needed in people who smoke. At low doses, smokers with mild persistent asthma are less sensitive than non-smokers to the therapeutic effects of ICS treatment. This disparity is reduced at high doses of ICS [Tomlinson et al, 2005].
- Treatment with ICS should initially be twice a day (except ciclesonide, which is licensed for once-a-day use) [SIGN and BTS, 2009]:
- Most ICS are slightly more effective when used twice rather than once a day, but people with milder disease may use them once a day. There is little evidence of benefit for administration more frequently than twice a day.
- Once-daily inhalation of ICS at the same total daily dose, within the product license, may be considered if good control is established.
- Prescribe CFC-free beclometasone inhalers by brand name (Clenil Modulite® or Qvar®) [MHRA, 2006a]. They are not equivalent and must not be interchanged.
- When changing from a CFC pMDI to a CFC-free pMDI [BNF 53, 2007; SIGN and BTS, 2009]:
- Clenil Modulite® may be substituted for beclometasone CFC pMDI at 1:1 dosing.
- Qvar® may be substituted for beclometasone CFC pMDI at 1:2 dosing if asthma is well controlled, but consider 1:1 dosing if asthma is poorly controlled. Monitor the person closely to ensure that adequate control is maintained.
- CFC-free budesonide may be substituted for budesonide CFC pMDI at 1:1 dosing.
Clarification / Additional information
- Comparable doses of inhaled corticosteroids are shown in Table 1 (adults and children > 12 years of age) and Table 2 (children).
- Beclometasone inhalers that contain chlorofluorocarbons (CFC) have been phased out and are no longer available.
Table 1. Recommended daily doses of inhaled corticosteroid delivered by pressurized metered-dose inhaler (pMDI) for adults and children aged 12 years of age or older. Dosage adjustment may be necessary for alternative devices.
Table 2. Recommended daily doses of inhaled corticosteroid delivered by pressurized metered-dose inhaler (pMDI) for children < 12 years of age. Dosage adjustment may be necessary for alternative devices.
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