Dosing

Chronic obstructive pulmonary disease (FEV1<70% predicted normal)

Type	Age Range	Dose	Licensed
Maintenance	From 18 years	2 actuations - TWICE a DAY - inhalation

Asthma: Maintenance

Type	Age Range	Dose	Licensed
Maintenance	From 12 years to 18 years	1 actuation - ONCE a DAY - inhalation - using a metered dose device
Maintenance	From 18 years	1 actuation - ONCE a DAY - inhalation - using a metered dose device
Maintenance	From 12 years to 18 years	1 actuation - TWICE a DAY - inhalation - using a metered dose device
Maintenance	From 18 years	1 actuation - TWICE a DAY - inhalation - using a metered dose device
Maintenance	From 12 years to 18 years	2 actuations - ONCE a DAY - inhalation - using a metered dose device
Maintenance	From 18 years	2 actuations - ONCE a DAY - inhalation - using a metered dose device
Maintenance	From 12 years to 18 years	2 actuations - TWICE a DAY - inhalation - using a metered dose device
Maintenance	From 18 years	2 actuations - TWICE a DAY - inhalation - using a metered dose device
Maintenance	From 18 years	3 actuations - TWICE a DAY - inhalation - using a metered dose device
Maintenance	From 18 years	4 actuations - TWICE a DAY - inhalation - using a metered dose device

Asthma: Maintenance and reliever therapy

Type	Age Range	Dose	Licensed
Maintenance	From 12 years to 18 years	1 actuation - TWICE a DAY - an additional actuation may be taken to relieve symptoms, followed by a further actuation after a few minutes if needed - inhalation - using a metered dose device - Maximum dose 8 actuations DAILY
Maintenance	From 18 years	1 actuation - TWICE a DAY - an additional actuation may be taken to relieve symptoms, followed by a further actuation after a few minutes if needed - inhalation - using a metered dose device - Maximum dose 8 actuations DAILY
Maintenance	From 12 years to 18 years	2 actuations - ONCE a DAY - an additional actuation may be taken to relieve symptoms, followed by a further actuation after a few minutes if needed - inhalation - using a metered dose device - Maximum dose 8 actuations DAILY
Maintenance	From 18 years	2 actuations - ONCE a DAY - an additional actuation may be taken to relieve symptoms, followed by a further actuation after a few minutes if needed - inhalation - using a metered dose device - Maximum dose 8 actuations DAILY
Maintenance	From 12 years to 18 years	2 actuations - TWICE a DAY - an additional actuation may be taken to relieve symptoms, followed by a further actuation after a few minutes if needed - inhalation - using a metered dose device - Maximum dose 8 actuations DAILY
Maintenance	From 18 years	2 actuations - TWICE a DAY - an additional actuation may be taken to relieve symptoms, followed by a further actuation after a few minutes if needed - inhalation - using a metered dose device - Maximum dose 8 actuations DAILY

Asthma: Reliever therapy

Type	Age Range	Dose	Licensed
Maintenance	From 12 years	1 actuation - when required - inhalation - using a metered dose device - Maximum dose 8 actuations DAILY

Safety Advice Warnings

Adverse effects (report/action)

• Corticosteroids may cause growth retardation in children under 18 years
• During transfer from oral steroids allergic conditions may be unmasked
• High doses may affect bone metabolism
• If growth in children is slowed, consider referral to a paediatrician
• If visual disturbances occur, perform ophthalmic evaluation
• May reduce serum potassium levels
• Prolonged or high dose may lead to adrenal suppression
• Systemic effects possible with any inhaled corticosteroid

Advice concerning formulation

• Not all available brands are indicated for all uses
• Not all available brands are licensed for all age groups

Advice on Administration

• Consider use of a spacer device for suitable patients and formulations

Advice on drug withdrawal

• Do not withdraw this drug suddenly

Advice on possible excipients

• Some formulations contain lactose

Discontinue due to test or exam

• Discontinue if paradoxical bronchospasm occurs

Dose changes (other conditions)

• Dose varies with brand
• Maintain treatment at the lowest effective dose
• Not licensed for all indications in all age groups

Patient Counselling

• Advise patient to rinse mouth with water after each dose
• Advise patient to seek medical advice if asthma seems to be worsening
• Advise patient to seek medical advice if treatment is ineffective
• Advise patients to avoid chickenpox, measles etc - see doctor if exposed
• Advise visual disturbances may affect ability to drive or operate machinery
• Consider issuing Steroid Treatment/Steroid Emergency Card
• Ensure patient has a fast acting bronchodilator available
• If reliever required frequently consider alternative without corticosteroid
• Patient should seek medical advice if signs of pulmonary infection develop
• Patients may not taste/feel any medication when using dry powder inhalers
• Use regularly to maintain freedom from symptoms

Pre-treatment points to consider

• Correct electrolyte disorders before treatment
• Therapy should not be initiated during exacerbation of asthma

Recommended monitoring

• Check patient is using correct inhaler technique
• Consider monitoring ECG in patients at risk of QT prolongation
• Monitor adrenal function in stressed patients e.g.surgery/intensive care
• Monitor blood glucose closely in patients with diabetes mellitus
• Monitor for signs/symptoms of pneumonia in patients at risk
• Monitor regularly the height of children receiving prolonged treatment
• Monitor serum electrolytes
• Monitor serum potassium regularly in severe asthmatic or hypoxic patients
• Re-evaluate therapy in active or quiescent pulmonary tuberculosis

Safety/advice in other condition

• Caution in transfer from oral steroids in adrenal insufficiency
• Systemic corticosteroids may be needed during elective surgery
• Systemic corticosteroids may be needed during periods of stress

Drug Interactions

With	Risk	Severity
(LEVACETYLMETHADOL)	Hypokalaemia with high dose beta-agonist increases risk of arrhythmias	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
ATOMOXETINE	May increase risk of cardiac effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
DOMPERIDONE	Predisposing factors may increase risk of arrhythmias	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
METHACHOLINE	Methacholine effect reduced; review dosing, see product literature	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
SOTALOL	Effect antagonised/ predisposing factors increase risk of arrhythmias	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
(ASTEMIZOLE)	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
(HALOFANTRINE)	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
(MOBOCERTINIB)	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
(RETIGABINE)	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
(SODIUM STIBOGLUCONATE)	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
AJMALINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
AMIFAMPRIDINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
AMIODARONE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ANAGRELIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ARSENIC TRIOXIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ARTEMETHER AND LUMEFANTRINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
AVAPRITINIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
AZITHROMYCIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CHLOROQUINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CILOSTAZOL	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CIPROFLOXACIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CITALOPRAM / ESCITALOPRAM	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CLARITHROMYCIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
COCAINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DELAMANID	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DISOPYRAMIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DONEPEZIL	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DRONEDARONE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DROPERIDOL	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ENTRECTINIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ERYTHROMYCIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ETELCALCETIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
FLECAINIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
FLUCONAZOLE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
GLASDEGIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
HALOPERIDOL	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
HYDROXYCHLOROQUINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
HYDROXYZINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
IBUTILIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
INOTUZUMAB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
IVABRADINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
IVOSIDENIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
LEVOFLOXACIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
MELPERONE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
METHADONE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
MOXIFLOXACIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ONDANSETRON	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
OSILODROSTAT	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
OSIMERTINIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
OXALIPLATIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
PAPAVERINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
PENTAMIDINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
PHENOTHIAZINES (QT 1)	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
PIMOZIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
PIPERAQUINE AND ARTENIMOL	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
PRALSETINIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
PROPOFOL	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
QUINIDINE / HYDROQUINIDINE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
QUIZARTINIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
SELPERCATINIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
SERTINDOLE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
SEVOFLURANE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
SULPIRIDE	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
TERLIPRESSIN	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
VANDETANIB	Predisposing factors may increase risk of arrhythmias	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ACE INHIBITORS WITH THIAZIDE DIURETICS	Increased risk of hypokalaemia with high doses of beta agonist	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ACETAZOLAMIDE	Increased risk of hypokalaemia with high doses of beta agonist	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ANGIOTENSIN II INHIBITORS AND THIAZIDE DIURETICS	Increased risk of hypokalaemia with high doses of beta agonist	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
BETA BLOCKER EYE DROPS	May antagonise effect of each other	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
BETA BLOCKERS	May antagonise effect of each other	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
BETA BLOCKERS AND THIAZIDE DIURETICS	May antagonise effect of each other	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
LOOP DIURETICS	Increased risk of hypokalaemia with high doses of beta agonist	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
THEOPHYLLINE	Increased risk of hypokalaemia with high doses of beta agonist	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
THIAZIDE DIURETICS	Increased risk of hypokalaemia with high doses of beta agonist	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.

Precautions

• Adrenal insufficiency
• Arterial aneurysm
• Breastfeeding
• Children aged 6 to 18 years
• Diabetes mellitus
• Electrolyte imbalance
• Family history of long QT syndrome
• Galactosaemia
• Glucose-galactose malabsorption syndrome
• Hepatic cirrhosis
• History of torsade de pointes
• Hypertrophic obstructive cardiomyopathy
• Hypokalaemia
• Idiopathic subvalvular aortic stenosis
• Ischaemic heart disease
• Lactose intolerance
• Major risk factors for decreased bone mineral content
• Phaeochromocytoma
• Pregnancy
• Pulmonary tuberculosis
• Severe cardiac failure
• Severe cardiovascular disorder
• Severe hypertension
• Tachyarrhythmia
• Thyrotoxicosis

Contraindications

• Children under 6 years
• Long QT syndrome
• Torsade de pointes

Side Effects

• Adrenal suppression
• Aggression
• Anaphylactic reaction
• Angina
• Angioedema
• Anxiety
• Atrial fibrillation
• Behavioural disturbances
• Blood pressure changes
• Blurred vision
• Bronchospasm (paradoxical)
• Bruising
• Candidiasis (mouth or throat)
• Cardiac arrhythmias
• Cataracts
• Cough
• Cushing's syndrome
• Decrease in bone mineral density
• Depression
• Dermatitis
• Dizziness
• Dysphonia
• Exanthema
• Extrasystoles
• Glaucoma
• Headache
• Hoarseness
• Hyperglycaemia
• Hypersensitivity reactions
• Hypokalaemia
• Increase in blood levels of free fatty acids
• Increase in blood levels of glycerol
• Increase in blood levels of insulin
• Increase in blood levels of ketones
• Muscle cramps
• Nausea
• Palpitations
• Pneumonia
• Prolongation of QT interval
• Pruritus
• Psychomotor hyperactivity
• Sleep disturbances
• Suppression of growth in children and adolescents
• Supraventricular tachycardia
• Tachycardia
• Taste disturbances
• Throat discomfort
• Tremor
• Urticaria
• Visual disturbances