BNF for Children 2011-2012

BNFC 2011–2012 3.2 Corticosteroids 147generally be exceeded; however, if a higher dose isrequired it should be initiated and supervised by arespiratory paediatrician. The use of high doses of aninhaled corticosteroid can minimise the requirement foran oral corticosteroid.Cautions of inhaled corticosteroids Systemic therapymay be required during periods of stress, such asduring severe infections, or when airways obstruction ormucus prevent drug access to smaller airways; interactions:Appendix 1 (corticosteroids).Paradoxical bronchospasm The potential for paradoxicalbronchospasm (calling for discontinuation and alternativetherapy) should be borne in mind—mild bronchospasmmay be prevented by inhalation of a shortactingbeta 2 agonist beforehand (or by transfer from anaerosol inhalation to a dry powder inhalation if suitable).CFC-free inhalers Chlorofluorocarbon (CFC) propellantsin pressurised aerosol inhalers have been replacedby hydrofluoroalkane (HFA) propellants.Doses for corticosteroid CFC-free inhalers may be differentfrom traditional CFC-containing inhalers and maydiffer between brands, see MHRA/CHM advice below.MHRA/CHM advice (July 2008)Beclometasone dipropionate CFC-free pressurisedmetered-dose inhalers (Qvar c and Clenil Modulitec ) are not interchangeable and should beprescribed by brand name; Qvar c has extra-fineparticles, is more potent than traditional beclometasonedipropionate CFC-containing inhalers, and isapproximately twice as potent as Clenil Modulite c .Side-effects of inhaled corticosteroids Inhaledcorticosteroids have considerably fewer systemiceffects than oral corticosteroids, but adverse effectshave been reported.High doses of inhaled corticosteroids (see Managementof Chronic Asthma table, p. 135) used for prolongedperiods can induce adrenal suppression. Inhaled corticosteroidshave occasionally been associated with adrenalcrisis and coma in children; excessive doses shouldbe avoided. Children using high doses of inhaled corticosteroidsshould be under the supervision of a paediatricianfor the duration of the treatment; they should begiven a ‘steroid card’ (section 6.3.2) and specific writtenadvice to consider corticosteroid replacement during anepisode of stress, such as a severe intercurrent illness oran operation.In adults, bone mineral density is sometimes reducedfollowing long-term inhalation of higher doses of corticosteroids,predisposing patients to osteoporosis (section6.6). It is, therefore, sensible to ensure that the doseof an inhaled corticosteroid is no higher than necessaryto keep a child’s asthma under good control.Growth restriction associated with systemic corticosteroidtherapy does not seem to occur with recommendeddoses of inhaled corticosteroids; although initialgrowth velocity may be reduced, there appears to beno effect on achieving normal adult height. However,the height of children receiving prolonged treatmentwith inhaled corticosteroid should be monitored; ifgrowth is slowed, referral to a paediatrician should beconsidered.Hoarseness and candidiasis of the mouth or throat havebeen reported, usually only with high doses (see alsobelow). Hypersensitivity reactions (including rash andangioedema) have been reported rarely. Other sideeffectsthat have very rarely been reported includeparadoxical bronchospasm, anxiety, depression, sleepdisturbances, and behavioural changes including hyperactivity,irritability, and aggression (particularly in children);skin thinning and bruising have also beenreported.Candidiasis The risk of oral candidiasis can be reducedby using a spacer device with the corticosteroid inhaler;rinsing the mouth with water (or cleaning the child’steeth) after inhalation of a dose may also be helpful.Antifungal oral suspension or oral gel (section 12.3.2)can be used to treat oral candidiasis while continuingcorticosteroid therapy.Oral An acute attack of asthma should be treated with ashort course (3–5 days) of oral corticosteroid, see Managementof Acute Asthma, p. 134. The dose can usuallybe stopped abruptly but it should be reduced graduallyin children under 12 years who have taken corticosteroidsfor more than 14 days. Tapering is not needed inchildren 12–18 years provided that the child receives aninhaled corticosteroid in an adequate dose (apart fromthose on maintenance oral corticosteroid treatment orwhere oral corticosteroids are required for 3 or moreweeks); see also Withdrawal of Corticosteroids, section6.3.2.In chronic continuing asthma, when the response toother drugs has been inadequate, longer term administrationof an oral corticosteroid may be necessary; insuch cases high doses of an inhaled corticosteroidshould be continued to minimise oral corticosteroidrequirements.An oral corticosteroid should normally be taken as asingle dose in the morning to reduce the disturbance tocircadian cortisol secretion. Dosage should always betitrated to the lowest dose that controls symptoms.Some clinicians use alternate-day dosing of an oralcorticosteroid.Parenteral For the use of hydrocortisone injection inthe emergency treatment of acute severe asthma, seeManagement of Acute Asthma, p. 134.BECLOMETASONE DIPROPIONATE(Beclomethasone Dipropionate)Cautions see notes abovePregnancy see p. 133Breast-feeding see p. 133Side-effects see notes aboveLicensed use Becodisk c -400, Clenil Modulite c -200and -250, and Qvar c are not licensed for use inchildren under 12 yearsIndication and doseProphylaxis of asthmaSee Management of Chronic Asthma table, p. 135Important for Asmabec Clickhaler c , Becodisks c , andQvar c doses, see under preparations belowBeclometasone (Non-proprietary) ADry powder for inhalation, beclometasonedipropionate 100 micrograms/metered inhalation, netprice 100-dose unit = £5.36; 200 micrograms/metered inhalation, 100-dose unit = £9.89, 200-dose3 Respiratory system