Asthma Treatment: Steroids and Other Anti-Inflammatory DrugsNebulized budesonide has been demonstrated to be effective and safe in children ages years, and, with less evidence, in infants and adults with asthma. Other investigations, with the addition of in vitro and in vivo comparison buy winstrol mexico, have shown somatropin abuse nebulized beclomethasone, fluticasone, and flunisolide are effective alternatives to nebulized budesonide in asthma and COPD. Efficient delivery of nebulized ICSs requires that the nebulizer system, the nebulized drug formulation, and the inhaling subject interact properly. The practices of mixing nebulized ICSs with nebulized steroids for asthma and using nebulized ICSs in acute settings are promising, tren x1x require further confirmations, and at present cannot be recommended. I conclude that nebulizers may be considered as an effective alternative to inhalers for delivering ICSs nebulized steroids for asthma can be recommended to asthmatic and COPD subjects who are unwilling or unable to use inhalers.
Nebulized corticosteroids in asthma and COPD. An Italian appraisal. - PubMed - NCBI
However, there are some patients with chronic severe asthma whose symptoms are inadequately controlled by high doses of inhaled corticosteroids and maximal bronchodilator therapy. Such patients require increasingly frequent courses of oral corticosteroids, often culminating in their long term use. Until recently in the UK, budesonide Pulmicort Respules, Astra Pharmaceuticals was the only corticosteroid available for nebulisation.
Fluticasone propionate Flixotide Nebules, Glaxo Wellcome was launched in late , and is being actively marketed. The evidence for the effectiveness of nebulised corticosteroids in the treatment of stable asthma is reviewed, together with a discussion of whether there is any evidence that their use allows a reduction in regular oral corticosteroid dose in patients with severe asthma.
In considering this evidence it is important to compare the side effects of nebulised corticosteroids with those of high dose inhaled corticosteroids and with those of oral corticosteroids. Studies which compare nebulised corticosteroid with oral corticosteroid in the treatment of acute exacerbations of asthma are also reviewed. It is important to consider patient preference for nebulised, inhaled or oral therapy, which is closely linked with compliance with treatment.
Finally, in such a review it is vital to consider the cost implications of any change in practice in the treatment of patients with acute and chronic asthma. There are a large number of case reports and uncontrolled studies of the effect of nebulised corticosteroids in asthma.
This review is limited to considering controlled trials where these are available but, in their absence, the evidence from uncontrolled studies is considered. There are few controlled trials assessing the effectiveness of nebulised corticosteroids in children with chronic asthma. In a double blind, randomised, crossover study Pedersen et al compared the effect of 0.
However, this study did not include a control group. Mellon et al compared the effect of four doses of nebulised budesonide 0. The first report in adults which suggested that nebulised corticosteroids were effective and had a steroid sparing effect in patients with severe asthma came in Fourteen patients successfully stopped and three patients successfully reduced their dose of oral corticosteroid.
Despite the apparently positive results from both of these studies, neither of them included a control group and, since virtually all studies attempting corticosteroid reduction in the presence of placebo have reported success, these results are difficult to interpret.
In a multicentre, randomised, double blind, parallel group study, Efthimiou et al compared two doses of nebulised fluticasone 0. Significantly more patients in the higher dose fluticasone group than in either of the other two groups managed to stop oral corticosteroid treatment. In practice it is the minority of patients with asthma who require regular oral corticosteroids, and most patients are treated successfully with inhaled corticosteroids.
A small number of patients were taking an oral corticosteroid on a regular basis and their steroid dose was not changed during the study. Of the patients who expressed a preference, more patients preferred the metered dose inhaler than the nebuliser, although this difference was not significant. The cost of nebulised budesonide was estimated to be 1. However, this study compared two different inhaled steroids and it is clear from a number of studies that fluticasone is twice as potent as budesonide at a mg for mg dose.
Bisgaard et al compared the effect of budesonide administered by nebuliser and metered dose inhaler. There was a trend towards greatest effect in the higher dose of nebuliser although this did not reach significance. This study suggested equipotency between budesonide administered by this nebuliser and the metered dose inhaler and spacer, suggesting that the superior efficacy of nebulised steroid in some studies may simply reflect the higher dose administered by nebuliser than metered dose inhaler.
The total mass output delivered from the two devices was similar, but the fraction of small particles with the metered dose inhaler was twice that from the nebuliser. There is a great deal of available information about the side effects associated with the long term use of oral corticosteroid use.
Less is known about the side effects associated with the use of inhaled corticosteroids. It is therefore important to compare the side effects of nebulised corticosteroids with these treatments. Toogood et al in a double blind, placebo controlled, crossover study compared the potency and side effects of six weeks of oral prednisolone in a dose of 7.
The milligram equivalent potency ratio for cortisol suppression for prednisolone versus inhaled budesonide was calculated to be 7. In a 12 week study children aged six months to eight years received between 0. In another study 41 children aged 3—14 years with mild to moderate asthma were treated with albuterol, cromolyn, and nebulised budesonide 8 or fluticasone dipropionate. The body mass index BMI fell in the corticosteroid treated group, which was attributed to an improvement in ability to exercise and quality of life.
In a randomised, double blind, placebo controlled study Scarfone et al compared the effect of 1. Clinical improvement occurred earlier at two hours in the group of children who received nebulised corticosteroid.
There are few data addressing the efficacy of nebulised corticosteroids in the treatment of acute exacerbations of asthma in adults. The authors concluded that nebulised fluticasone is an effective alternative to oral prednisolone in adults in the early stages of recovery from an acute exacerbation of asthma.
There is very little evidence that nebulised corticosteroids are more effective than high dose inhaled corticosteroids in this patient group, although one placebo controlled study reported significant reductions in the regular oral corticosteroid dose with the addition of nebulised fluticasone. At least one study suggests that the superior efficacy of nebulised corticosteroid over corticosteroid delivered by metered dose inhaler relates simply to the delivery of a higher dose of corticosteroid, rather than because the nebulised preparation is more effective.
The only study which has attempted to assess patient preference suggested that nebulised budesonide was less popular than corticosteroid administered by metered dose inhaler and spacer, presumably because of the time required for nebulisation.
So what should be the present recommendation for the use of nebulised budesonide and fluticasone in the treatment of asthma? A few patients with apparently severe asthma have another cause for their symptoms and it is important to exclude vocal cord dysfunction, gastro-oesophageal reflux, or psychological disease which may be exacerbating their symptoms.
There would be significant cost implications of changing from corticosteroid delivered by inhaler to corticosteroid delivered by nebuliser. More work is required in this area. There are a small number of studies suggesting that nebulised corticosteroids may be as effective as oral corticosteroids in the treatment of acute severe exacerbations of asthma. The cost implications of a change in treatment practice for these patients would be huge and perhaps, at present, nebulised corticosteroids should be restricted to patients who are not keen or are unable to take oral corticosteroids because of side effects.
Forgot your log in details? Register a new account? Forgot your user name or password? Search for this keyword. Latest content Current issue Archive Authors About. Log in via Institution. Nebulised corticosteroids in the treatment of patients with asthma. Effectiveness of nebulised corticosteroids in stable asthma CHILDREN There are few controlled trials assessing the effectiveness of nebulised corticosteroids in children with chronic asthma.
ADULTS The first report in adults which suggested that nebulised corticosteroids were effective and had a steroid sparing effect in patients with severe asthma came in Side effects of nebulised corticosteroids There is a great deal of available information about the side effects associated with the long term use of oral corticosteroid use.
ADULTS There are few data addressing the efficacy of nebulised corticosteroids in the treatment of acute exacerbations of asthma in adults. Thorax 52 Suppl 1 S1 — 21 ,. Pedersen S , Hansen OR Dose response relationships to nebulized budesonide in children with asthma.
Eur J Clin Res 5: J Allergy Clin Immunol Eur Respir J Ann Emerg Med Curtis P Comparison of prednisolone and nebulised budesonide in acute asthma in children: Eur Respir J 8: Read the full text or download the PDF: