UK Clinical Pharmacy Association

Beclometasone

Brands of Corticosteroids - inhaled, nebulised and intranasal

This list is not exhaustive.

Inhaled

  • Beclometasone: Clenil®, Qvar®, Kelhale®, Soprobec®
  • Budesonide: Pulmicort®
  • Ciclesonide: Alvesco®
  • Fluticasone: Flixotide®
  • Mometasone: Asmanex®

Inhaled combination products

  • AirFluSal®
  • Atectura®
  • DuoResp®
  • Enerzair®
  • Flutiform®
  • Fobumix®
  • Fostair®
  • Luforbec®
  • Relvar®
  • Sereflo®
  • Seretide®
  • Sirdupla®
  • Symbicort®
  • Trelegy®
  • Trimbow®
  • Trixeo®

Intranasal

  • Beclometasone: Beconase®, Betnesol®
  • Budesonide: Benacort®, Rhinocort®
  • Fluticasone: Avamys®, Flixonase®
  • Mometasone: Nasonex®
  • Trimacinolone: Nasacort®

Intranasal combination products

  • Betnesol N®
  • Dymista®

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 numerous inhaled and intranasal preparations which contain corticosteroids, either as single agents or in combination products with antimuscarinics and/or long-acting beta2 adrenoceptor agonists – all of these can be continued pre-operatively. Check active ingredients of currently available preparations in the British National Formulary and see also Antimuscarinics - inhaled and nebulised drug records and Long-acting beta2 adrenoceptor agonist - oral and inhaled drug records, if applicable.

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 (for beclometasone 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, see Corticosteroids - systemic drug records.

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 interactions listed in Corticosteroids- systemic drug records – 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 interactions listed in Corticosteroids - systemic drug records – 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. For guidance on replacement, where clinically indicated, see Corticosteroids - systemic drug records.

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

Liu MM, Reidy AB, Saatee S et al. Perioperative Steroid Management: Approaches Based on Current Evidence. Anesthesiology. 2017; 127:166-172

Freudzon L. Perioperative steroid therapy: where’s the evidence? Curr Opin Anaesthesiol. 2018; 31(1):39-42

Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. https://bnf.nice.org.uk/ [Accessed on 5th August 2020]

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]

Summary of Product Characteristics – Seretide 250 Evohaler. GlaxoSmithKline UK. Accessed via www.medicines.org.uk 05/08/2020 [date of revision of the text November 2019]

Summary of Product Characteristics – Benacort 64 micrograms Nasal Spray. McNeil Products Ltd. Accessed via www.medicines.org.uk 05/08/2020 [date of revision of the text July 2018] 

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

Broersen LAH, Pereira AM, Jorgensen JOL et al. Adrenal insufficiency in corticosteroids use: systematic review and meta-analysis. JCEM 2015; 100(6):2171-2180