Brands of beclometasone
This list is not intended to be exhaustive.
Inhaled: Clenil®, Qvar®, Kelhale®, Soprobec®
Inhaled (combination products, with beta-2 adrenoceptor agonists): Fostair®, Luforbec®
Inhaled (combination products, with beta-2 adrenoceptor agonists and antimuscarinic): Trimbow®
Intranasal: Beconase®, Betnesol®
Intranasal (combination product): Betnesol N
Issues for surgery
For suppression of inflammatory and allergic disorders (including asthma, chronic obstructive pulmonary disease [COPD], allergic rhinitis) – increased risk of disease relapse if omitted.
Potential increased risk of acute adrenal insufficiency (e.g. severe hypotension, tiredness and weakness, confusion, psychosis, tachycardia) if omitted – see Further information.
Advice in the perioperative period
Elective and emergency surgery
Continue (including combination products).
There are a number of inhaled and intranasal preparations which contain beclometasone, either as single agents or in combination products with antimuscarinics and / or long-acting beta-2 adrenoceptor agonists – all of these can be continued pre-operatively. Check active ingredients of currently available preparations in the British National Formulary.
Advise patients who do not use their inhaled corticosteroids as prescribed to use regularly to optimise disease control prior to anaesthesia.
Advise patients taking regular inhaled or intranasal corticosteroids that their corticosteroid medication should not be abruptly stopped.
Confirm the brand, device and strength with the patient (see Further information).
Perioperative considerations
Perioperative corticosteroid replacement is not routinely recommended for patients on inhaled or intranasal corticosteroids due to the lower incidence of adrenal suppression associated with these administration routes – see Further information.
For patients taking systemic corticosteroids in addition to inhaled / intranasal corticosteroids, refer to relevant monograph for systemic preparation.
Post-operative advice
Inhaled preparations
Restart post-operatively, at usual dose, as soon as next dose is due.
If patients are unable to resume their usual inhaled corticosteroid medication post-operatively, supplementation with nebulised or systemic corticosteroids may be considered if clinically indicated, particularly if there are concerns regarding adrenal suppression – see Further information.
Intranasal preparations
Restart post-operatively, at usual dose, as soon as next dose is due, except for patients undergoing nasal surgery where restarting should be delayed until healing has occurred, unless specifically advised otherwise by ENT surgeon.
Interactions with common anaesthetic agents
None anticipated with inhaled / intranasal use; however, bear in mind the possibility of systemic absorption and thus the relevance of potential interactions - see Further information.
Interactions with other common medicines used in the perioperative period
None anticipated with inhaled / intranasal use; however, bear in mind the possibility of systemic absorption and thus the relevance of potential interactions - see Further information.
Further information
Systemic absorption
Although not intended it is possible that inhaled or intranasal administration of corticosteroids may result in systemic absorption, particularly if high doses are used or with prolonged treatment. Risk of systemic absorption is considered greater with nasal drops than nasal sprays as they are more likely to be administered incorrectly.
Adrenal suppression, perioperative stress and corticosteroid replacement
Whilst adrenal insufficiency is most common in patients taking systemic corticosteroids there is evidence that this can occur with chronic corticosteroid administration via other routes. High doses and prolonged treatment duration results in increased systemic absorption and therefore risk of adrenal insufficiency; however, there is no dose, administration route or treatment duration for which the risk of adrenal insufficiency can safely be excluded. Meta-analysis indicates incidence of adrenal insufficiency is lower in patients prescribed intranasal (4.2%) and inhaled (7.8%) corticosteroids compared to oral (48.7%) and intra-articular (52.2%) corticosteroids, although this incidence is likely to be higher in individuals receiving corticosteroids by multiple routes.
The possibility of adrenal insufficiency should be considered in individuals taking inhaled or intranasal corticosteroids who fail to improve as anticipated post-operatively. Current evidence on the necessity of administering perioperative stress-dose steroids for patients with suspected secondary adrenal insufficiency is inadequate to either support or refute this practice; however, if adrenal insufficiency is suspected, corticosteroid replacement appears to carry minimal risk compared with the risk of adrenal crisis.
Prescribing information
Beclometasone inhalers should be prescribed by brand name as differences in particle size, and therefore potency, mean Qvar®, Kelhale®, Soprobec® and Clenil Modulite® preparations are not interchangeable.
References
Broersen LAH, Pereira AM, Jorgensen JOL et al. Adrenal insufficiency in corticosteroids use: systematic review and meta-analysis. JCEM 2015; 100(6):2171-2180
Freudzon L. Perioperative steroid therapy: where’s the evidence? Curr Opin Anaesthesiol. 2018; 31(1):39-42
Interactions of Corticosteroids. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://about.medicinescomplete.com [Accessed 5th August 2020]
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. https://bnf.nice.org.uk/ [Accessed on 5th August 2020]
Liu MM, Reidy AB, Saatee S et al. Perioperative Steroid Management: Approaches Based on Current Evidence. Anesthesiology. 2017; 127:166-172
Wlodarczyk JH, Gibson PG, Caeser M. Impact of Inhaled corticosteroids on cortisol suppression in adults with asthma: a quantitative review. Ann Allergy Asthma Immunol. 2008; 100(1):23-30