ICS - Inhaled Corticosteroids

Question 1

Benefits of ICS?

Answer 1

• Most effective controllers for asthma
• Most effective anti-inflammatory agents used in asthma therapy –> decrease inflammatory numbers & their activation pathways
• Reduce eosinophils in airways & sputum, and #s of activated T-cells & surface mast cells in airway mucosa

Question 2

MOA of corticosteroids

Answer 2

• Involves several effects on the inflammatory process
• Major effect of corticosteroids is to switch off the transcription of multiple activated genes that encode inflammatory proteins (cytokines, chemokines, adhesion molecules, and inflammatory enzymes)

Question 3

Background info on ICS

Answer 3

• Usually given 2x daily
• Rapidly improve sx of asthma & lung function improves over several days
• Effective in preventing asthma sx (EIA & nocturnal exacerbation), but also prevent severe asthma exacerbation.
• Reduce AHR, but max improvement may take several mos of therapy
• Early trx appears to prevent irreversible changes in airway function that occur w/ chronic asthma
• Withdrawal results in slow deterioration of asthma control. indicating that they suppress inflammation and sx, but do not cure underlying condition
• Now given as 1st line therapy for pts w/ persistent asthma, but if they do not control sx at low doses, then add LABA

Question 4

How ICS enter systemic circulation

Answer 4

MDI –> 10-20% inhaled into lungs and then enters systemic circulation
–> 80-90% enters the GI tract –> liver (inactivation “first pass”) –> systemic circulation

Question 5

Beclomethasone

Answer 5

• Indication: Maintenance trx for asthma and as prophylactic therapy in pts 5 yrs and older.
• Used in trx of asthma in pts who require oral coritcosteroid therapy to reduce or eliminate the need for systemic corticosteroids
• CAUTION: Care is needed in pts who are transferred from systemically active corticosteroids bc deaths d/t adrenal insufficiency have occurred in asthmatic pts during and after transfer from systemic corticosteroids to less systemically active inhaled corticosteroids.

***After withdrawal, a number of mos are required for recovery of hypothalamic pituitary adrenal (HPA) function

Question 6

Budesonide

Answer 6

• Maintenance trx of asthma as prophylactic therapy in adult and pediatric pts 6+
• DO NOT use as primary trx of status asthmaticus or other acute episodes of asthma where intensive measures are required.
• CI: Severe HS to milk proteins

Question 7

Ciclesonide

Answer 7

• Indicated for maintenance trx of asthma as prophylactic therapy in adults and adolescent pts 12+.
• Not indicated for relief of acute bronchospasm
• Do not use in presence of Candida albicans infection of mouth & pharynx, TB, fungal, bacterial, viral or parasitic infxn.

Question 8

Flunisolide

Answer 8

• For maintenace trx of asthma as prophylactic therapy in adults and pts 6+.
• For asthma pts requiring oral corticosteroid therapy, where adding Flunisolide therapy may reduce or eliminate need for oral corticosteroids
• CI in pts for primary trx of status asthmaticus or other acute episodes of asthma where intensive measures are indicated

Question 9

Fluticasone

Answer 9

• Maintenance trx of asthma as prophylactic therapy in pts 4+
• Not indicated for relief of acute bronchospasm
• CI: Candida albicans infxn of mouth & pharynx may occur. Monitor pts periodically. Advise the pt to rinse their mouth w/ water w/o swallowing after inhalation to help decrease risk.

Question 10

Mometasone

Answer 10

• Maintenance trx of asthma as prophylactic therapy in pts 4+.
• CI in pts for primary trx of status asthmaticus or other acute episodes of asthma where intensive measures are indicated.
• CI in pts w/ known HS to milk proteins

Question 11

Triamcinolone

Answer 11

• Maintenance trx of asthma as prophylactic therapy.
• For asthma pts who require systemic corticosteroid administration, where adding this agent may reduce or eliminate the need for systemic corticosteroids.
• Not indicated for relief of acute bronchospasm
• CI in pts for primary trx of status asthmaticus or other acute episodes of asthma where intensive measures are indicated.
• CAUTION: Care is needed in pts who are transferred from systemically active corticosteroids bc deaths d/t adrenal insufficiency have occurred in asthmatic pts during and after transfer from systemic corticosteroids to less systemically active inhaled corticosteroids.

Question 12

When to use oral steroids?

Answer 12

Used in combination w/ short acting beta agonists to trx moderate to severe asthma flare-ups.
- more likely to cause side effects than inhaled steroids

Question 13

Prednisone

Answer 13

• Oral steroid
• Used as anti-inflammatory or immunosuppressive agent for certain allergic, dermatologic, GI, hematologic, ophthalmologic, nervous system, renal, respiratory, rheumatologic, specific infectious dz or conditions, and organ transplantation.
• Used for trx of certain endocrine conditions and for palliation of certain neoplastic conditions.
• CI: May lead to HPA axis suppression. Monitor pt’s for Cushing’s syndrome and hyperglycemia w/ chronic use and taper doses gradually for withdrawal after chronic use.