Dosing

Asthma - prophylaxis

Type	Age Range	Dose	Licensed
Maintenance	From 16 years	1 actuation - TWICE a DAY - inhalation
Maintenance	From 16 years	2 actuations - TWICE a DAY - inhalation
Maintenance	From 16 years	3 actuations - TWICE a DAY - inhalation
Maintenance	From 16 years	4 actuations - TWICE a DAY - inhalation

Safety Advice Warnings

Adverse effects (report/action)

• During transfer from oral steroids allergic conditions may be unmasked
• High doses may cause adrenal suppression/bone metabolism changes
• If growth in children is slowed, consider referral to a paediatrician
• Systemic effects possible with any inhaled corticosteroid

Advice concerning formulation

• Not all strengths are suitable for use in children under 16 years

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)

• Maintain treatment at the lowest effective dose

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
• Consider issuing Steroid Treatment/Steroid Emergency Card
• Ensure patient has a fast acting bronchodilator available
• Patient should seek medical advice if signs of pulmonary infection develop
• Use regularly to maintain freedom from symptoms

Pre-treatment points to consider

• Stabilise patient prior to transfer from systemic steroids

Recommended monitoring

• Check patient is using correct inhaler technique
• Consider adrenal suppression when transferring from systemic steroid
• Monitor adrenal function in stressed patients e.g.surgery/intensive care
• Monitor for signs/symptoms of pneumonia in patients at risk
• Monitor regularly the height of children receiving prolonged treatment
• Re-evaluate therapy in active or quiescent pulmonary tuberculosis

Safety/advice in other condition

• Not to be used to relieve an acute asthmatic attack
• Systemic corticosteroids may be needed during elective surgery
• Systemic corticosteroids may be needed during periods of stress

Drug Interactions

With	Risk	Severity
RITONAVIR	Increased risk of systemic corticosteroid adverse effects	High Risk: Avoid combination. Risk outweighs benefits.
(ATAZANAVIR WITH COBICISTAT)	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
(INDINAVIR)	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
(NELFINAVIR)	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
(SAQUINAVIR)	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
(TELITHROMYCIN)	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
CLARITHROMYCIN	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
COBICISTAT	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
DARUNAVIR WITH COBICISTAT	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
DARUNAVIR, COBICISTAT, EMTRICITABINE AND TENOFOVIR ALAFENAMIDE	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
ELVITEGRAVIR, COBICISTAT, EMTRICITABINE AND TENOFOVIR ALAFENAMIDE	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
ELVITEGRAVIR, COBICISTAT, EMTRICITABINE AND TENOFOVIR DISOPROXIL	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
IDELALISIB	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
ITRACONAZOLE	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
KETOCONAZOLE	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
NEFAZODONE	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
OMBITASVIR, PARITAPREVIR AND RITONAVIR	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
POSACONAZOLE	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
RIBOCICLIB	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
TIPRANAVIR	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
VORICONAZOLE	Increased risk of systemic corticosteroid adverse effects	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
(AMPRENAVIR / FOSAMPRENAVIR)	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
APREPITANT / FOSAPREPITANT	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ATAZANAVIR	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CICLOSPORIN	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CIMETIDINE	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CIPROFLOXACIN	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CRIZOTINIB	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DARUNAVIR	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DILTIAZEM	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DRONEDARONE	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ERYTHROMYCIN	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
FLUCONAZOLE	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
IMATINIB	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ISAVUCONAZOLE	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
MICONAZOLE (ORAL AND PARENTERAL)	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
MIFEPRISTONE	Corticosteroid effect may be reduced for 3 to 4 days after treatment	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
NETUPITANT	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
NILOTINIB	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
NIRMATRELVIR AND RITONAVIR	plasma level may be increased by	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
STIRIPENTOL	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
VERAPAMIL	Increased risk of systemic corticosteroid adverse effects	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
(BOCEPREVIR)	plasma level may be increased by	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
(DACLATASVIR)	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
(SIMEPREVIR)	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
(TELAPREVIR)	plasma level may be increased by	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ALPRAZOLAM	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
AMIODARONE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
AMLODIPINE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ATORVASTATIN	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
AZITHROMYCIN	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
BICALUTAMIDE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
CILOSTAZOL	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
COMBINED ORAL CONTRACEPTIVES	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ELBASVIR WITH GRAZOPREVIR	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
EVEROLIMUS	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
FLUVOXAMINE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ISONIAZID	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
IVACAFTOR	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
LACIDIPINE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
LINAGLIPTIN	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
LOMITAPIDE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
PALBOCICLIB	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
PAZOPANIB	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
PEPPERMINT OIL	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
PROPIVERINE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
RANOLAZINE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
TACROLIMUS (ORAL AND PARENTERAL)	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
TERIFLUNOMIDE	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
TOLVAPTAN	Increased risk of systemic corticosteroid adverse effects	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.

Precautions

• Adrenal insufficiency
• Breastfeeding
• Children aged 4 to 16 years
• Diabetes mellitus
• Galactosaemia
• Glucose-galactose malabsorption syndrome
• Lactose intolerance
• Major risk factors for decreased bone mineral content
• Pregnancy
• Pulmonary tuberculosis

Contraindications

• Children under 4 years

Side Effects

• Adrenal suppression
• Aggression
• Anaphylactic reaction
• Angioedema
• Anxiety
• Arthralgia
• Behavioural disturbances
• Bronchospasm (paradoxical)
• Candidiasis (mouth or throat)
• Cataracts
• Contusion
• Cushing's syndrome
• Cushingoid facies
• Cutaneous reactions
• Decrease in bone mineral density
• Depression
• Dyspepsia
• Dysphonia
• Dyspnoea
• Glaucoma
• Growth retardation (children)
• Hoarseness
• Hyperactivity
• Hyperglycaemia
• Hypersensitivity reactions
• Irritability
• Pneumonia
• Sleep disturbances
• Systemic steroid effects