The most recent recommendations for asthma treatment and
control by the National Heart, Lung, and Blood Institute (NHLBI)
emphasize preventive therapy, including the use of inhaled steroids.
The NHLBI and others have made statements suggesting that medications in
this class are interchangeable, as all inhaled steroids are equally
effective at equipotent doses.
The UK Hospital
Pharmacy has maintained a supply of five different inhaled
corticosteroids in a variety of package sizes. The Pharmacy and
Therapeutics Committee recently reviewed the class of inhaled
corticosteroids in an effort to streamline inventory while maintaining
the best care for patients. Based on current usage patterns,
formulations, and cost considerations, the following actions were taken:
-
Beclomethasone regular strength will remain on the
formulary. Only Vanceril®
will be stocked.
-
Fluticasone (Flovent®
inhalers will be stocked in 60-inhalation sizes, and only in 44 mcg
and 110 mcg strengths.
-
Flunisolide and triamcinolone inhalers have been
deleted from the formulary. Budesonide will remain nonformulary.
The NHLBI
recommendations for comparative steroid doses can be found in table 1,
and should be of assistance when converting patients to formulary
agents.
|
Table 1. Comparable Daily Doses for
Inhaled Corticosteroids
|
|
A D U L T S |
|
Drug |
Low Dose |
Medium Dose |
High Dose |
|
Beclomethasone
dipropionate |
168 – 504 mcg |
504 – 840 mcg |
>840 mcg |
|
42 mcg/puff |
(4-12 puffs – 42 mcg) |
(12-20 puffs – 42 mcg) |
(>20 puffs – 42 mcg) |
|
84 mcg/puff |
(2-6 puffs – 84 mcg) |
(6-10 puffs – 84 mcg) |
(>10 puffs – 84 mcg) |
 |
|
Budesonide
DPI: 200 mcg/dose |
200 – 400 mcg
(1-2 inhalations) |
400 – 600 mcg
(2-3 inhalations) |
>600 mcg
(>3 inhalations) |
|
|
|
Flunisolide
250 mcg/puff |
500 – 1000 mcg
(2-4 puffs) |
1000 – 2000 mcg
(4-8 puffs) |
>2000 mcg
(>8 puffs) |
|
|
|
Fluticasone |
88 – 264 mcg |
264 – 660 mcg |
>660 mcg |
|
MDI: 44, 110, 220 mcg/puff |
(2-6 puffs – 44 mcg OR 2 puffs – 110
mcg) |
(2-6 puffs – 110 mcg) |
(>6 puffs – 110 mcg OR >3 puffs – 220 mcg) |
|
DPI: 50, 100, 250 mcg/dose |
(2-6 inhalations – 50 mcg) |
(3-6 inhalations – 100 mcg) |
(>6 inhalations – 100 mcg OR
>2 inhalations – 250 mcg) |
|
|
|
Triamcinolone acetonide
100 mcg/puff |
400 – 1000 mcg
(4-10 puffs) |
1000 – 2000 mcg
(10-20 puffs) |
>2000 mcg
(>20 puffs) |
|
|
|
|
|
|
C H I L D R E N |
|
Drug |
Low Dose |
Medium Dose |
High Dose |
|
Beclomethasone dipropionate
|
84 – 336 mcg
|
336 – 672 mcg
|
>672 mcg
|
|
42 mcg/puff |
(2-8 puffs – 42 mcg) |
(8-16 puffs – 42 mcg) |
(>16 puffs – 42 mcg) |
|
84 mcg/puff |
(1-4 puffs – 84 mcg) |
(4-8 puffs – 84 mcg) |
(>8 puffs – 84 mcg) |
|
|
|
Budesonide
DPI: 200 mcg/dose
|
100 – 200 mcg
|
200 – 400 mcg
(1-2 inhalations)
|
>400 mcg
(>2 inhalations)
|
|
|
|
Flunisolide
250 mcg/puff
|
500 – 750 mcg
(2-3 puffs)
|
1000 – 1250 mcg
(4-5 puffs)
|
>1250 mcg
(>5 puffs)
|
|
|
|
Fluticasone
|
88 – 176 mcg
|
176 – 440 mcg
|
>440 mcg
|
|
MDI: 44, 110, 220 mcg/puff |
(2-4 puffs – 44 mcg) |
(4-10 puffs – 110 mcg OR 2-4 puffs – 110 mcg)
|
(>4 puffs – 110 mcg, OR >2 puffs – 220 mcg)
|
|
DPI: 50, 100, 250 mcg/dose |
(2-4 inhalations – 50 mcg) |
(2-4 inhalations – 100 mcg) |
(>4 inhalations – 100 mcg OR >2 inhalations – 250 mcg)
|
|
|
|
Triamcinolone acetonide
100 mcg/puff
|
400 – 800 mcg
(4-8 puffs)
|
800 – 1200 mcg
(8-12 puffs)
|
>1200 mcg
(>12 puffs)
|
DPI = dry powder
inhaler MDI = metered dose inhaler
|
