BUDESONIDE Asmavent CLASSIFICATION(S): Ther. Class: antiasthmatics, anti-inflammatories (steroidal) Pharm.

Class: corticosteroids, inhalation INDICATIONS Maintenance and prophylactic treatment of asthma May decrease requirement for or use of systemic corticosteroids and delay pulmonary damage that occurs from chronic asthma. ACTION Potent, locally acting anti-inflammatory and immune modifier. Therapeutic Effects: o Decrease frequency and severity of asthma attacks o Prevention of pulmonary damage associated with chronic asthma. PHARMACOKINETICS Absorption: budesonide39%. Action of all agents is primarily local after inhalation. Distribution: 1025% of inhaled corticosteroids is deposited in the airways if a spacer device is not used. With the use of a spacer, a greater percentage may reach the respiratory tract. All agents cross the placenta and enter breast milk in small amounts. Protein Binding: Budenoside8590% Metabolism and Excretion: metabolized by the liver after absorption from lungs, 60% excreted in urine, smaller amounts in feces Half-life: 23 hr CONTRAINDICATIONS AND PRECAUTIONS Contraindicated in: Some products contain chlorofluorocarbon (CFC) propellants, alcohol, propylene, or polyethylene glycol and should be avoided in patients with known hypersensitivity or intolerance Acute attack of asthma/status asthmaticus. Use Cautiously in: Active untreated infections Patients with diabetes or glaucoma

Patients with underlying immunosuppression (due to disease or concurrent therapy) Systemic corticosteroid therapy (should not be abruptly discontinued when inhalable therapy is started; additional corticosteroids needed in stress or trauma) Pregnancy, lactation, or children <6 yr (safety not established; prolonged or high-dose therapy may lead to complications). ADVERSE REACTIONS AND SIDE EFFECTS* *CAPITALS indicate life threatening; underlines indicate most frequent. CNS: headache EENT: dysphonia, hoarseness, oropharyngeal fungal infections, cataracts Resp: bronchospasm, cough, wheezing. GI: dry mouth, esophageal candidiasis; Budesonidedyspepsia, gastroenteritis Endo: adrenal suppression (increased dose, long-term therapy only), decreased growth (children). MS: Budesonideback pain Misc: CHURG-STRAUSS SYNDROME; flu-like syndrome. INTERACTIONS Drug-Drug: Ketoconazole decreases metabolism and increases levels of budesonide ROUTE AND DOSAGE Budesonide Inhaln (Adults): Previously controlled on bronchodilators alone12 inhalations twice daily (200 mcg/inhalation); previously controlled on other inhaled corticosteroids12 inhalations twice daily (up to 4 inhalations twice daily); previously controlled on oral corticosteroids24 inhalations twice daily (up to 4 inhalations twice daily). Inhaln (Children 6 yr): Previously controlled on bronchodilators alone12 inhalations twice daily (200 mcg/inhalation); previously controlled on other inhaled corticosteroids12 inhalations twice daily; previously controlled on oral corticosteroidsNot to exceed 2 inhalations twice daily. Inhaln (Children 12 mos8 yr): Pulmicort Respules dose formPreviously controlled on bronchodilators alone0.25 mg/day as a single dose or twice daily in divided doses; previously controlled on other inhaled corticosteroids0.5 mg/day as

a single dose or twice daily in divided doses; previously controlled on oral corticosteroids1 mg/day as a single dose or twice daily in divided doses. Individual titration is required. AVAILABILITY o Budesonide Inhalation powder: 200 mcg/metered inhalation in 200-metered-inhalation inhalerRx. Inhalation suspension (Respules): 0.25 mg/2 mlRx, 0.5 mg/2 mlRx TIME/ACTION PROFILE (improvement in symptoms) ONSET Inhalation

PEAK 14 wk

DURATION unknown

within 24 hr

Improvement in pulmonary function; decreased airway responsiveness may take longer. 2-8 days for budenoside respule. NURSING IMPLICATIONS ASSESSMENT Monitor respiratory status and lung sounds. Pulmonary function tests may be assessed periodically during and for several months after a transfer from systemic to inhalation corticosteroids. Assess patients changing from systemic corticosteroids to inhalation corticosteroids for signs of adrenal insufficiency (anorexia, nausea, weakness, fatigue, hypotension, hypoglycemia) during initial therapy and periods of stress. If these signs appear, notify physician or other health care professional immediately; condition may be life-threatening. Monitor for withdrawal symptoms (joint or muscular pain, lassitude, depression) during withdrawal from oral corticosteroids. Lab Test Considerations: Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal (HPA) axis suppression in chronic therapy. Children and patients using higher than recommended doses are at highest risk for HPA suppression. o May cause increased serum and urine glucose concentrations if significant absorption occurs. o Monitor growth rate in children; use lowest possible dose. POTENTIAL NURSING DIAGNOSES

 Airway clearance, ineffective (Indications). Infection, risk for (Side Effects). Knowledge deficit, related to medication regimen (Patient/Family Teaching). IMPLEMENTATION General Info: After the desired clinical effect has been obtained, attempts should be made to decrease dose to lowest amount required to control symptoms. Gradually decrease dose every 24 wk as long as desired effect is maintained. If symptoms return, dose may briefly return to starting dose. o When switching from other beclomethasone inhalers containing CFCs to QVAR, start at 1/2 the dose of the CFC inhaler, because of smaller particle size and increased delivery Inhaln: Allow at least 1 min between inhalations of aerosol medication. PATIENT/FAMILY TEACHING General Info: Advise patient to take medication exactly as directed. If a dose is missed, take as soon as remembered unless almost time for next dose. Advise patient not to discontinue medication without consulting health care professional; gradual decrease is required. Advise patients using inhalation corticosteroids and bronchodilator to use bronchodilator first and to allow 5 min to elapse before administering the corticosteroid, unless otherwise directed by health care professional. Advise patient that inhalation corticosteroids should not be used to treat an acute asthma attack but should be continued even if other inhalation agents are used. Patients using inhalation corticosteroids to control asthma may require systemic corticosteroids for acute attacks. Advise patient to use regular peak flow monitoring to determine respiratory status. Caution patient to avoid smoking, known allergens, and other respiratory irritants. Advise patient to notify physician if sore throat or sore mouth occurs. Instruct patient whose systemic corticosteroids have been recently reduced or withdrawn to carry a warning card indicating the need for supplemental systemic corticosteroids in the event of stress or severe asthma attack unresponsive to bronchodilators. Metered-Dose Inhaler: Instruct patient in the proper use of the metered-dose inhaler. Most inhalers require priming before first use. There are 3 methods of using a metered-dose inhaler. Shake inhaler well. (1) Take a drink of water to moisten the throat; place the inhaler mouthpiece 2 finger-widths away from mouth; tilt head back slightly; while activating inhaler, take a slow, deep breath for 35 sec, hold the breath for 10 sec, and breathe out slowly. (2) Exhale, close lips firmly around

mouthpiece, administer during 2nd half of inhalation, and hold breath for as long as possible to ensure deep instillation of medication. (3) Use a spacer. Consult health care professional to determine method desired before instruction. Allow 12 min between inhalations. Rinse mouth with water or mouthwash after each use to minimize fungal infections, dry mouth, and hoarseness. Wash inhalation assembly at least daily in warm running water. Pulmicort Turbuhaler (budesonide): Advise patient to follow instructions supplied. Before first-time use, prime unit by turning cover and lifting off; hold upright with mouthpiece up and twist brown grip fully to right, then to left; repeat. To administer dose, hold upright, twist brown grip fully to right, then to left, listening for click. Turn head away from inhaler and exhale (do not blow into inhaler). Do not shake. Place mouthpiece between lips and inhale forcefully. Repeat procedure if 2nd dose required. Replace cover; rinse mouth with water (do not swallow). Flovent Rotadisk: Advise patient to follow instructions for the administration of the contents of each blister via breathactivated Diskhaler device. EVALUATION Effectiveness of therapy can be demonstrated by: Management of the symptoms of chronic asthma Prevention of pulmonary damage that results from chronic asthma.