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Wednesday, July 23, 2025

Beclometasone inhalers


Beclometasone inhalers contain beclometasone dipropionate, a synthetic corticosteroid used as a controller medication in asthma and chronic obstructive pulmonary disease (COPD). These inhalers work by reducing airway inflammation, preventing bronchial hyperresponsiveness, and improving overall respiratory function when used regularly. Beclometasone is a preventer, not a reliever—it does not provide immediate symptom relief but must be used daily to maintain control.

Brand Names

Beclometasone inhalers are marketed under various names, as monotherapy or in combination with other agents:

Monotherapy Inhalers (ICS only)

  • Beclazone®

  • Beconase Inhaler® (not to be confused with nasal spray)

  • Qvar®

  • Clenil Modulite®

  • Beclomet Easyhaler®

  • Becloforte® (discontinued in many regions)

Combination Inhalers

  • Fostair® (beclometasone + formoterol)

  • Trimbow® (beclometasone + formoterol + glycopyrronium)

  • Fostair NEXThaler® (dry powder inhaler)

Mechanism of Action

Beclometasone acts as an inhaled corticosteroid (ICS) by:

  • Binding to glucocorticoid receptors in bronchial epithelial cells

  • Inhibiting inflammatory cytokines, chemokines, prostaglandins, and leukotrienes

  • Reducing recruitment and activation of eosinophils, mast cells, macrophages

  • Suppressing mucus hypersecretion and vascular permeability

This leads to:

  • Reduced airway edema

  • Decreased bronchial inflammation

  • Restoration of airway calibre

  • Lower frequency of asthma exacerbations

Indications

Primary Indications:

  • Persistent asthma (mild to severe): As a daily preventer

  • COPD: In selected patients (typically in triple therapy)

Off-label/Secondary Uses:

  • Eosinophilic bronchitis

  • Exercise-induced bronchospasm (as prevention)

  • Allergic bronchopulmonary aspergillosis (ABPA) (in conjunction with antifungals)

Available Formulations and Devices

Inhaler Types:

  • pMDI: Pressurized metered-dose inhaler (Clenil Modulite, Qvar)

  • DPI: Dry powder inhaler (Easyhaler, Fostair NEXThaler)

  • BA-MDI: Breath-actuated metered-dose inhaler (Autohaler)

Particle Size Differences:

  • Clenil Modulite®: Standard-particle beclometasone

  • Qvar®: Extra-fine particle inhaler → deeper lung penetration, lower dose required

Dosage and Administration

Dosing varies by preparation:

  • Standard particle (e.g., Clenil Modulite):

    • Low dose: 100–200 mcg/day

    • Medium dose: 200–400 mcg/day

    • High dose: >400 mcg/day

  • Extra-fine particle (e.g., Qvar):

    • Lower doses needed for similar efficacy

    • E.g., 50 mcg per actuation = ~100 mcg standard-particle ICS equivalent

Asthma Dosage in Adults:

  • Typically 100–400 mcg twice daily, adjusted based on control

  • May be increased up to 800 mcg/day in severe cases (step 4 per GINA guidelines)

Children (≥5 years):

  • Starting dose: 50–100 mcg twice daily

  • Maximum: 200 mcg twice daily

Administration Tips:

  • Rinse mouth and spit after each dose to reduce risk of oral candidiasis

  • Use spacer device with pMDI to enhance delivery and reduce oropharyngeal deposition

  • Shake well before each actuation (for pMDIs)

  • Breathe in slowly and deeply for pMDI; sharply and deeply for DPI

Contraindications

  • Hypersensitivity to beclometasone or formulation excipients

  • Acute asthma attack or status asthmaticus (relievers like salbutamol should be used instead)

Precautions

  • Not for acute relief; must be used regularly for prevention

  • Avoid abrupt withdrawal; taper slowly if discontinuing after long-term use

  • Monitor for signs of systemic steroid effects in high doses

  • Assess for adrenal suppression in long-term high-dose use

  • May mask infection in the respiratory tract

Side Effects

Local (Common):

  • Oral candidiasis (thrush)

  • Dysphonia (hoarseness)

  • Cough or throat irritation

Systemic (Dose-Dependent, Rare):

  • Adrenal suppression

  • Growth retardation in children (long-term use)

  • Bone mineral density loss

  • Glaucoma and cataracts

  • Skin thinning or easy bruising

Regular use of spacer devices, mouth rinsing, and lowest effective dose helps minimize these risks.

Drug Interactions

Systemic interactions are rare due to low bioavailability, but caution is warranted with:

  • Strong CYP3A4 inhibitors (e.g., ritonavir, ketoconazole): May increase systemic steroid exposure

  • Other ICS or oral corticosteroids: Increased cumulative effect and systemic toxicity

  • Live vaccines: Systemic immunosuppression unlikely, but theoretical risk with very high ICS doses

No significant interaction with bronchodilators, but optimal efficacy is achieved when used with LABAs in combination.

Special Populations

Pregnancy:

  • Considered safe for use in pregnancy when needed for asthma control

  • Poorly controlled asthma poses greater risk to fetus than ICS use

Lactation:

  • Compatible; systemic absorption is minimal

  • Avoid spraying near breast area

Children:

  • Approved for use in children ≥5 years

  • Monitor growth velocity annually during long-term therapy

Comparative Notes with Other Inhaled Corticosteroids

  • Compared to budesonide and fluticasone, beclometasone is equally effective at equivalent doses for most patients.

  • Qvar® (extra-fine) achieves deep lung penetration, so lower doses can be used vs. standard-particle ICS.

  • Budesonide has a faster onset of action, while fluticasone has slightly higher receptor affinity.

  • Mometasone and ciclesonide offer lower systemic bioavailability, advantageous in high-dose therapy.

  • Trimbow® (beclometasone/formoterol/glycopyrronium) is reserved for moderate to severe COPD patients.

Patient Counseling Points

  • Emphasize daily use, even when symptoms are controlled

  • Instruct on correct inhaler technique—demonstrate with a placebo device if possible

  • Always rinse mouth and spit after use to prevent thrush

  • Inform patients to report:

    • White patches in mouth

    • Hoarseness

    • Persistent cough or wheeze

    • Visual changes (e.g., blurred vision—risk of cataracts/glaucoma)

  • Remind that this is not a rescue inhaler

  • Store the inhaler at room temperature, away from heat and moisture

  • Track dose counter if present; discard when empty

Storage and Stability

  • Store at 15–25°C

  • Keep away from direct sunlight

  • Do not freeze

  • Discard after labelled number of doses (e.g., 120 or 200 actuations)

Clinical Guidelines and Use

GINA (Global Initiative for Asthma):

  • Recommends ICS-containing regimen for all persistent asthma

  • Beclometasone is a core part of stepwise asthma therapy

NICE (UK) and GOLD (for COPD):

  • Clenil Modulite, Qvar, and Fostair recommended for asthma and COPD control

  • Triple therapy inhalers (e.g., Trimbow®) now recommended for select COPD patients with exacerbation history




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