Budesonide (inhalation)
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Deepika Beereddy, MBBS [2]
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Black Box Warning
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See full prescribing information for complete Boxed Warning.
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Overview
Budesonide (inhalation) is an adrenal cortex hormone that is FDA approved for the treatment of asthma, crohn's disease, allergic and non-allergic rhinitis, active ulcerative colitis (mild to moderate). There is a Black Box Warning for this drug as shown here. Common adverse reactions include diarrhea, nausea, arthralgia, headache, epistaxis, nasal stinging/burning, respiratory tract infection, sinusitis.
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
Asthma
- Dosing Information
- Initial dose: 360 mcg via oral inhalation twice daily;180 mcg twice daily initially may be sufficient in some patients
- Maximum dose: 720 mcg twice daily
Crohn's disease
- Dosing Information
- Induction of Remission:
- Recommended dose: 9 mg orally once daily in the morning for up to 8 weeks; a repeat 8-week course may be given for recurring episodes; taper off oral prednisolone while concurrently initiating budesonide
- Maintenance of Remission:
- Recommended dose: 6 mg orally once daily for up to 3 months; after 3 months, taper to complete cessation (use beyond 3 months has not shown substantial clinical benefit)
Rhinitis, allergic and non-allergic
- Dosing Information
- Recommended dose: 64 mcg (one 32-mcg spray/nostril) once daily; titrate to minimum effective dose; may be able to reduce dose once symptoms are controlled
- Maximum dose: 256 mcg/day (4 sprays/nostril once daily)
Ulcerative colitis (Mild to Moderate), Active
- Dosing Information
- Recommended dose (Uceris(TM)): 9 mg orally once daily in the morning for up to 8 weeks
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Budesonide in adult patients.
Non–Guideline-Supported Use
Nasal polyp
- Dosing Information
- Dose: 128 mcg intranasally once daily over 8 weeks or 400 mcg/day intranasally in 2 divided doses over 8 to 12 weeks
Ulcerative colitis, distal
- Dosing information
- Effective dose: 100 to 125 mL of a suspension containing 2 mg/100 mL once daily at bedtime (study dosage)or 2 mg (100 mL) as a rectal enema once daily at night for 4 to 8 weeks (Canadian manufacturer dosage)
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
Asthma
- Dosing Information
- Inhaler:
- Recommended dose, 6 years or older: Initiate at 180 mcg via oral inhalation twice daily; 360 mcg twice daily may be required initially in some patients
- Maximum dose: 360 mcg twice daily
- Nebulization:
- Recommended dose, 1 to 8 years: Based on previous therapy as follows
Rhinitis, allergic and non-allergic
- Dosing information
- Nasal route:
- Recommended dose (6 years or older): 64 mcg (one 32-mcg spray/nostril) once daily; titrate to minimum effective dose; may be able to reduce dose once symptoms are controlled
- Maximum dose: under 12 years, 128 mcg/day (2 sprays/nostril once daily); 12 years or older, 256 mcg/day (4 sprays/nostril once daily)
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Budesonide in pediatric patients.
Non–Guideline-Supported Use
Condition1
- Dosing Information
- Dosage
Condition2
There is limited information regarding Off-Label Non–Guideline-Supported Use of Budesonide (inhalation) in pediatric patients.
Contraindications
The use of budesonide inhalation suspension is contraindicated in the following conditions:
- Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
- Hypersensitivity to budesonide or any of the ingredients of budesonide inhalation suspension
Warnings
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See full prescribing information for complete Boxed Warning.
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Local Effects
- In clinical trials with budesonide inhalation suspension, localized infections with Candida albicans occurred in the mouth and pharynx in some patients. The incidences of localized infections of Candida albicans were similar between the placebo and budesonide inhalation suspension treatment groups. If these infections develop, they may require treatment with appropriate local or systemic antifungal therapy and/or discontinuance of treatment with budesonide inhalation suspension. Patients should rinse the mouth after inhalation of budesonide inhalation suspension.
Deterioration of Disease and Acute Asthma Episodes
- Budesonide inhalation suspension is not a bronchodilator and is not indicated for the rapid relief of acute bronchospasm or other acute episodes of asthma.
- Patients should be instructed to contact their physician immediately if episodes of asthma not responsive to their usual doses of bronchodilators occur during the course of treatment with budesonide inhalation suspension. During such episodes, patients may require therapy with oral corticosteroids.
Hypersensitivity Reactions Including Anaphylaxis
- Hypersensitivity reactions including anaphylaxis, rash, contact dermatitis, urticaria, angioedema, and bronchospasm have been reported with use of budesonide inhalation suspension. Discontinue budesonide inhalation suspension if such reactions occur.
Immunosuppression
- Patients who are on drugs that suppress the immune system are more susceptible to infection than healthy individuals. Chicken pox and measles, for example, can have a more serious or even fatal course in susceptible children or adults using corticosteroids. In children or adults who have not had these diseases, or been properly immunized, particular care should be taken to avoid exposure. How the dose, route, and duration of corticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed to chicken pox, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information.) If chicken pox develops, treatment with antiviral agents may be considered.
- The clinical course of chicken pox or measles infection in patients on inhaled corticosteroids has not been studied. However, a clinical study has examined the immune responsiveness of asthma patients 12 months to 8 years of age who were treated with budesonide inhalation suspension. An open-label non-randomized clinical study examined the immune responsiveness of varicella vaccine in 243 asthma patients 12 months to 8 years of age who were treated with budesonide inhalation suspension 0.25 mg to 1 mg daily (n=151) or noncorticosteroid asthma therapy (n=92) (ie, beta2-agonists, leukotriene receptor antagonists, cromones). The percentage of patients developing a seroprotective antibody titer of ≥5.0 (gpELISA value) in response to the vaccination was similar in patients treated with budesonide inhalation suspension (85%) compared to patients treated with non-corticosteroid asthma therapy (90%). No patient treated with budesonide inhalation suspension developed chicken pox as a result of vaccination.
- Inhaled corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infection of the respiratory tract, untreated systemic fungal, bacterial, viral, or parasitic infections; or ocular herpes simplex.
Transferring Patients from Systemic Corticosteroid Therapy
- Particular care is needed for patients who are transferred from systemically active corticosteroids to inhaled corticosteroids because deaths due to adrenal insufficiency have occurred in asthmatic patients during and after transfer from systemic corticosteroids to less systemically available inhaled corticosteroids. After withdrawal from systemic corticosteroids, a number of months are required for recovery of hypothalamic-pituitary-adrenal (HPA)-axis function.
- Patients who have been previously maintained on 20 mg or more per day of prednisone (or its equivalent) may be most susceptible, particularly when their systemic corticosteroids have been almost completely withdrawn.
- During this period of HPA-axis suppression, patients may exhibit signs and symptoms of adrenal insufficiency when exposed to trauma, surgery, infection (particularly gastroenteritis) or other conditions associated with severe electrolyte loss. Although budesonide inhalation suspension may provide control of asthma symptoms during these episodes, in recommended doses it supplies less than normal physiological amounts of glucocorticosteroid systemically and does NOT provide the mineralocorticoid activity that is necessary for coping with these emergencies.
- During periods of stress or a severe asthma attack, patients who have been withdrawn from systemic corticosteroids should be instructed to resume oral corticosteroids (in large doses) immediately and to contact their physicians for further instructions. These patients should also be instructed to carry a medical identification card indicating that they may need supplementary systemic corticosteroids during periods of stress or a severe asthma attack.
- Patients requiring oral corticosteroids should be weaned slowly from systemic corticosteroid use after transferring to budesonide inhalation suspension. Initially, budesonide inhalation suspension should be used concurrently with the patient’s usual maintenance dose of systemic corticosteroid. After approximately one week, gradual withdrawal of the systemic corticosteroid may be initiated by reducing the daily or alternate daily dose. Further incremental reductions may be made after an interval of one or two weeks, depending on the response of the patient. Generally, these decrements should not exceed 25% of the prednisone dose or its equivalent. A slow rate of withdrawal is strongly recommended.
- Lung function (FEV1 or AM PEF), beta-agonist use, and asthma symptoms should be carefully monitored during withdrawal of oral corticosteroids. In addition to monitoring asthma signs and symptoms, patients should be observed for signs and symptoms of adrenal insufficiency such as fatigue, lassitude, weakness, nausea and vomiting, and hypotension.
- Transfer of patients from systemic corticosteroid therapy to budesonide inhalation suspension may unmask allergic or other immunologic conditions previously suppressed by the systemic corticosteroid therapy, e.g., rhinitis, conjunctivitis, eosinophilic conditions, eczema, and arthritis.
- During withdrawal from oral corticosteroids, patients may experience symptoms of systemically active corticosteroid withdrawal (e.g., joint and/or muscular pain, lassitude, depression) despite maintenance or even improvement of respiratory function.
Hypercorticism and Adrenal Suppression
- Budesonide inhalation suspension, will often help control asthma symptoms with less suppression of HPA function than therapeutically equivalent oral doses of prednisone. Since individual sensitivity to effects on cortisol production exists, physicians should consider this information when prescribing budesonide inhalation suspension. Because of the possibility of systemic absorption of inhaled corticosteroids, patients treated with budesonide inhalation suspension should be observed carefully for any evidence of systemic corticosteroid effects. Particular care should be taken in observing patients post-operatively or during periods of stress for evidence of inadequate adrenal response. It is possible that systemic corticosteroid effects such as hypercorticism, and adrenal suppression (including adrenal crisis) may appear in a small number of patients, particularly when budesonide is administered at higher than recommended doses over prolonged periods of time. If such effects occur, the dosage of budesonide inhalation suspension should be reduced slowly, consistent with accepted procedures for tapering of systemic corticosteroids and for management of asthma.
Reduction in Bone Mineral Density
- Decreases in bone mineral density (BMD) have been observed with long-term administration of products containing inhaled corticosteroids. The clinical significance of small changes in BMD with regard to long-term outcomes is unknown. Patients with major risk factors for decreased bone mineral content, such as prolonged immobilization, family history of osteoporosis, poor nutrition, or chronic use of drugs that can reduce bone mass (e.g., anticonvulsants and corticosteroids), should be monitored and treated with established standards of care.
Effects on Growth
- Orally inhaled corticosteroids, including budesonide, may cause a reduction in growth velocity when administered to pediatric patients. Monitor the growth of pediatric patients receiving budesonide inhalation suspension routinely (e.g., via stadiometry). To minimize the systemic effects of orally inhaled corticosteroids, including budesonide inhalation suspension, each patient should be titrated to his/her lowest effective dose.
Glaucoma and Cataracts
- Glaucoma, increased intraocular pressure, and cataracts have been reported following the long-term administration of inhaled corticosteroids, including budesonide. Therefore, close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts.
Paradoxical Bronchospasm and Upper Airway Symptoms
- As with other inhaled asthma medications, bronchospasm, with an immediate increase in wheezing, may occur after dosing. If acute bronchospasm occurs following dosing with budesonide inhalation suspension, it should be treated immediately with a fast-acting inhaled bronchodilator. Treatment with budesonide inhalation suspension should be discontinued and alternate therapy instituted.
Eosinophilic Conditions and Churg-Strauss Syndrome
- In rare cases, patients on inhaled corticosteroids may present with systemic eosinophilic conditions. Some of these patients have clinical features of vasculitis consistent with Churg-Strauss syndrome, a condition that is often treated with systemic corticosteroids therapy. These events usually, but not always, have been associated with the reduction and/or withdrawal of oral corticosteroid therapy following the introduction of inhaled corticosteroids. Healthcare providers should be alert to eosinophilia, vasculitis rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. A causal relationship between budesonide and these underlying conditions has not been established.
Drug Interactions with Strong Cytochrome P450 3A4 Inhibitors
- Caution should be exercised when considering the coadministration of budesonide inhalation suspension with ketoconazole, and other known strong CYP3A4 inhibitors (e.g., ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, saquinavir, telithromycin) because adverse effects related to increased systemic exposure to budesonide may occur.
Adverse Reactions
Clinical Trials Experience
ystemic and inhaled corticosteroid use may result in the following:
- Candida albicans infection.
- Hypersensitivity reactions including anaphylaxis.
- Immunosuppression.
- Hypercorticism and adrenal suppression.
- Reduction in bone mineral density.
- Growth effects in pediatric patients.
- Glaucoma, increased intraocular pressure and cataracts.
- Eosinophilic conditions and Churg-Strauss syndrome.
Clinical Trials Experience
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
- The incidence of common adverse reactions is based on three double-blind, placebo-controlled, randomized U.S. clinical trials in which 945 patients, 12 months to 8 years of age, (98 patients ≥12 months and <2 years of age; 225 patients ≥2 and <4 years of age; and 622 patients ≥4 and ≤8 years of age) were treated with budesonide inhalation suspension (0.25 to 1 mg total daily dose for 12 weeks) or vehicle placebo. The incidence and nature of adverse events reported for budesonide inhalation suspension was comparable to that reported for placebo. The following table shows the incidence of adverse events in U.S. controlled clinical trials, regardless of relationship to treatment, in patients previously receiving bronchodilators and/or inhaled corticosteroids. This population included a total of 605 male and 340 female patients and 78.4% were Caucasian, 13.8% African American, 5.5% Hispanic and 2.3% Other.
Table 1 - Adverse Reactions occurring at an incidence of ≥3% in at least one active treatment group where the incidence was higher with budesonide inhalation suspension than placebo
- The information below includes all adverse reactions by system organ class with an incidence of 1 to < 3%, in at least one budesonide inhalation suspension treatment group where the incidence was higher with budesonide inhalation suspension than with placebo, regardless of relationship to treatment.
- Blood and lymphatic system disorders: cervical lymphadenopathy
- Ear and labyrinth disorders:earache
- General disorders and administration site conditions: fatigue, flu-like disorder
- Immune system disorders: allergic reaction
- Infections and infestations: eye infection, herpes simplex, external ear infection, infection
- Injury, poisoning and procedural complication: fracture
- Metabolism and nutrition disorders: anorexia
- Musculoskeletal and connective tissue disorders: myalgia
- Nervous system disorders: hyperkinesia
- Psychiatric disorders: emotional lability
- Respiratory, thoracic, and mediastinal disorders: chest pain, dysphonia, stridorSkin and subcutaneous tissue disorders: contact dermatitis, eczema, pustular rash, pruritus, purpura
- The incidence of reported adverse events was similar between the 447 budesonide inhalation suspension-treated (mean total daily dose 0.5 to 1 mg) and 223 conventional therapy-treated pediatric asthma patients followed for one year in three open-label studies.
Postmarketing Experience
- The following adverse reactions have been reported during post-approval use of budesonide inhalation suspension. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Some of these adverse reactions may also have been observed in clinical studies with budesonide inhalation suspension.
- Endocrine disorders: symptoms of hypocorticism and hypercorticism.
- Eye disorders: cataracts, glaucoma, increased intraocular pressure.
- General disorders and administration site conditions: fever, pain
- Immune system disorders: immediate and delayed hypersensitivity reactions including, anaphylaxis, angioedema, bronchospasm, rash, contact dermatitis, and urticaria.
- Infection and Infestation: sinusitis, pharyngitis, bronchitis
- Musculoskeletal and connective tissue disorders: avascular necrosis of the femoral head, osteoporosis, growth suppression
- Nervous system disorders: headache
- Psychiatric disorders: psychiatric symptoms including psychosis, depression, aggressive reactions, irritability, nervousness, restlessness, and anxiety
- Respiratory, thoracic, and mediastinal disorders: cough, dysphonia and throat irritation
- Skin and subcutaneous tissue disorders: skin bruising, facial skin irritation
- Cases of growth suppression have been reported for inhaled corticosteroids including post-marketing reports for budesonide inhalation suspension.
Drug Interactions
Inhibitors of Cytochrome P4503A4
- The main route of metabolism of corticosteroids, including budesonide, is via cytochrome P450 (CYP) isoenzyme 3A4 (CYP3A4). After oral administration of ketoconazole, a strong inhibitor of CYP3A4, the mean plasma concentration of orally administered budesonide increased. Concomitant administration of a CYP3A4 inhibitor may inhibit the metabolism of, and increase the systemic exposure to, budesonide. Caution should be exercised when considering the coadministration of budesonide with long-term ketoconazole and other known strong CYP3A4 inhibitors (e.g., ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, saquinavir, telithromycin).
Use in Specific Populations
Pregnancy
- Studies of pregnant women, have not shown that inhaled budesonide increases the risk of abnormalities when administered during pregnancy. The results from a large population-based prospective cohort epidemiological study reviewing data from three Swedish registries covering approximately 99% of the pregnancies from 1995-1997 (ie, Swedish Medical Birth Registry; Registry of Congenital Malformations; Child Cardiology Registry) indicate no increased risk for congenital malformations from the use of inhaled budesonide during early pregnancy. Congenital malformations were studied in 2014 infants born to mothers reporting the use of inhaled budesonide for asthma in early pregnancy (usually 10-12 weeks after the last menstrual period), the period when most major organ malformations occur. The rate of recorded congenital malformations was similar compared to the general population rate (3.8% vs. 3.5%, respectively). In addition, after exposure to inhaled budesonide, the number of infants born with orofacial clefts was similar to the expected number in the normal population (4 children vs. 3.3, respectively).
- These same data were utilized in a second study bringing the total to 2534 infants whose mothers were exposed to inhaled budesonide. In this study, the rate of congenital malformations among infants whose mothers were exposed to inhaled budesonide during early pregnancy was not different from the rate for all newborn babies during the same period (3.6%).
- Despite the animal findings, it would appear that the possibility of fetal harm is remote if the drug is used during pregnancy. Nevertheless, because the studies in humans cannot rule out the possibility of harm, budesonide inhalation suspension should be used during pregnancy only if clearly needed.
- As with other corticosteroids, budesonide was teratogenic and embryocidal in rabbits and rats. Budesonide produced fetal loss, decreased pup weights, and skeletal abnormalities at a subcutaneous dose in rabbits that was approximately 0.4 times the maximum recommended daily inhalation dose in adults on a mcg/m2 basis and at subcutaneous dose that was approximately 4 times the maximum recommended daily inhalation dose in adults on a mcg/m2 basis. In another study in rats, no teratogenic or embryocidal effects were seen at inhalation doses up to approximately 2 times the maximum recommended daily inhalation dose in adults on a mcg/m2 basis.
- Experience with oral corticosteroids since their introduction in pharmacologic, as opposed to physiologic, doses suggests that rodents are more prone to teratogenic effects from corticosteroids than humans.
- Non-teratogenic Effects:
- Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully observed.
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Budesonide (inhalation) in women who are pregnant.
Labor and Delivery
There is no FDA guidance on use of Budesonide (inhalation) during labor and delivery.
Nursing Mothers
- Budesonide, like other corticosteroids, is secreted in human milk. Data with budesonide delivered via dry powder inhaler indicates that the total daily oral dose of budesonide in breast milk to the infant is approximately 0.3% to 1% of the dose inhaled by the mother. No studies have been conduct in breastfeeding women with budesonide inhalation suspension; however, the dose of budesonide available to the infant in breast milk, as a percentage of the maternal dose, would be expected to be similar. Budesonide inhalation suspension should be used in nursing women only if clinically appropriate. Prescribers should weigh the known benefits of breastfeeding for the mother and the infant against the potential risks of minimal budesonide exposure in the infant.
Pediatric Use
There is no FDA guidance on the use of Budesonide (inhalation) in pediatric settings.
Geriatic Use
There is no FDA guidance on the use of Budesonide (inhalation) in geriatric settings.
Gender
There is no FDA guidance on the use of Budesonide (inhalation) with respect to specific gender populations.
Race
There is no FDA guidance on the use of Budesonide (inhalation) with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Budesonide (inhalation) in patients with renal impairment.
Hepatic Impairment
There is no FDA guidance on the use of Budesonide (inhalation) in patients with hepatic impairment.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Budesonide (inhalation) in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Budesonide (inhalation) in patients who are immunocompromised.
Administration and Monitoring
Administration
There is limited information regarding Budesonide (inhalation) Administration in the drug label.
Monitoring
There is limited information regarding Budesonide (inhalation) Monitoring in the drug label.
IV Compatibility
There is limited information regarding the compatibility of Budesonide (inhalation) and IV administrations.
Overdosage
There is limited information regarding Budesonide (inhalation) overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.
Pharmacology
There is limited information regarding Budesonide (inhalation) Pharmacology in the drug label.
Mechanism of Action
There is limited information regarding Budesonide (inhalation) Mechanism of Action in the drug label.
Structure
There is limited information regarding Budesonide (inhalation) Structure in the drug label.
Pharmacodynamics
There is limited information regarding Budesonide (inhalation) Pharmacodynamics in the drug label.
Pharmacokinetics
There is limited information regarding Budesonide (inhalation) Pharmacokinetics in the drug label.
Nonclinical Toxicology
There is limited information regarding Budesonide (inhalation) Nonclinical Toxicology in the drug label.
Clinical Studies
There is limited information regarding Budesonide (inhalation) Clinical Studies in the drug label.
How Supplied
There is limited information regarding Budesonide (inhalation) How Supplied in the drug label.
Storage
There is limited information regarding Budesonide (inhalation) Storage in the drug label.
Images
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Patient Counseling Information
There is limited information regarding Budesonide (inhalation) Patient Counseling Information in the drug label.
Precautions with Alcohol
Alcohol-Budesonide interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
Brand Names
There is limited information regarding Budesonide (inhalation) Brand Names in the drug label.
Look-Alike Drug Names
There is limited information regarding Budesonide (inhalation) Look-Alike Drug Names in the drug label.
Drug Shortage Status
Price
References
The contents of this FDA label are provided by the National Library of Medicine.