budesonide(bue des' oh nide)Inhalation:Entocort (CAN), Pulmicort Respules, Pulmicort Turbuhaler, Rhinocort Aqua, Rhinocort Turbuhaler (CAN)Oral:Entocort EC Pregnancy Category B Drug classCorticosteroid Therapeutic actionsAnti-inflammatory effect; local administration into nasal passages maximizes beneficial effects on these tissues, while decreasing the likelihood of adverse effects from systemic absorption. Indications Management of symptoms of seasonal or perennial allergic rhinitis in adults and children; nonallergic perennial rhinitis in adultsTurbuhaler Maintenance treatment of asthma as prophylactic therapy in adults and children > 6 yr and for patients requiring corticosteroids for asthmaInhalation suspension Maintenance treatment and prophylaxis therapy of asthma in children 12 mo8 yrOral Treatment of mild to moderate active Crohn's disease involving the ileum or ascending colon Contraindications and cautionsInhalation Contraindicated with hypersensitivity to drug or for relief of acute asthma or bronchospasm. Use cautiously with TB, systemic infections, lactation.Oral Contraindicated with hypersensitivity to drug, lactation. Use cautiously with TB, hypertension, diabetes mellitus, osteoporosis, peptic ulcer disease, glaucoma, cataracts, family history of diabetes or glaucoma, other conditions in which glucocorticosteroids may have unwanted effects.Nasal Contraindicated with hypersensitivity to drug, nasal infections, nasal trauma, nasal septal ulcers, recent nasal surgery. Use cautiously with lactation, TB, systemic infection. Available formsAerosol32 mcg/actuation; dry powder for inhalation200 mcg (each actuation delivers 160 mcg); inhalation suspension0.25 mg/2 mL, 0.5 mg/2 mL; capsules3 mg DosagesNasal inhalationADULTS AND PATIENTS > 6 YRInitial dose, 64 mcg/day given as 1 spray in each nostril morning and evening. After desired clinical effect is achieved, reduce dose to the smallest dose possible to maintain the control of symptoms. Generally takes 37 days to achieve maximum clinical effect. Pulmicort TurbuhalerADULTSPreviously on inhaled corticosteroids: Initially, 200400 mcg twice daily, maximum dose, 800 mcg bid (4 inhalations).Previously on bronchodilators alone: 200400 mcg bid.Previously on oral corticosteroids: 400800 mcg bid.PEDIATRIC PATIENTSChildren > 6 yr previously on inhaled corticosteroids: 200 mcg bid.Children > 6 yr previously on bronchodilators alone: 200 mcg bid.Children > 6 yr previously on oral corticosteroids: 400 mcg bid. RespulesPEDIATRIC PATIENTS 12 MO8 YR0.251 mg once daily or in two divided doses of Respules, using jet nebulizer.OralADULTS9 mg/day PO taken in the morning for up to 8 wk. Recurrent episodes may be retreated for 8-wk periods.PEDIATRIC PATIENTSSafety and efficacy not established.PATIENTS WITH HEPATIC IMPAIRMENTMonitor patients very closely for signs of hypercorticism; reduced dosage should be considered with these patients. PharmacokineticsRouteOnsetPeakDurationIntranasal, inhaledImmediateRapid812 hrOralSlow0.510 hrUnknownMetabolism: Hepatic; T1/2: 23.6 hr (oral); T1/2: 2.8 hr (inhalation)Distribution: Crosses placenta; may enter breast milkExcretion: Urine Adverse effects CNS: Headache, dizziness, lethargy, fatigue, paresthesias, nervousness Dermatologic: Rash, edema, pruritus, alopecia Endocrine: HPA suppression, Cushing's syndrome with overdosage and systemic absorption GI: Nausea, dyspepsia, dry mouth Local: Nasal irritation, fungal infection Respiratory: Epistaxis, rebound congestion, pharyngitis, cough Other: Chest pain, asthenia, moon face, acne, bruising, back pain InteractionsOral useDrug-drug Increased risk of corticosteroid toxic effects if combined with ketoconazole, itraconazole, ritonavir, indinavir, saquinavir, erythromycin, or other known CYP3A4 inhibitors; if drugs must be used together, decrease dosage of budesonide and monitor patient closelyDrug-food Risk of increased toxic effects if combined with grapefruit juice; avoid this combination. Nursing considerationsAssessment History: Untreated local nasal infections, nasal trauma, septal ulcers, recent nasal surgery, lactation Physical: BP, P, auscultation; R, adventitious sounds; examination of nares InterventionsInhalation WARNING: Taper systemic steroids carefully during transfer to inhalational steroids; deaths from adrenal insufficiency have occurred. Arrange for use of decongestant nose drops to facilitate penetration if edema, excessive secretions are present. Prime unit before use for Pulmicort Turbuhaler; have patient rinse mouth after each use. Use aerosol within 6 mo of opening. Shake well before each use. Store Respules upright and protected from light; gently shake before use; open envelopes should be discarded after 2 wk. Oral Make sure patient does not cut, crush, or chew capsules; they must be swallowed whole. Administer the drug once each day, in the morning; do not administer with grapefruit juice. Encourage patient to complete full 8 wk of drug therapy. WARNING: Monitor patient for signs of hypercorticismacne, bruising, moon face, swollen ankles, hirsutism, skin striae, buffalo humpwhich could indicate need to decrease dosage. Teaching pointsInhalation Do not use more often than prescribed; do not stop without consulting your health care provider. It may take several days to achieve good effects; do not stop if effects are not immediate. Use decongestant nose drops first if nasal passages are blocked. Prime unit before use for Pulmicort Turbuhaler; rinse mouth after each use. Store Respules upright, protect from light; discard open envelopes after 2 wk; gently shake before use. You may experience these side effects: Local irritation (use your device correctly), dry mouth (suck sugarless lozenges). Report sore mouth, sore throat, worsening of symptoms, severe sneezing, exposure to chickenpox or measles, eye infections. Oral Take the drug once a day in the morning. Do not cut, crush, or chew the capsules, they must be swallowed whole. If you miss a day, take the capsules as soon as you remember them. Take the next day's capsules at the regular time. Do not take more than three capsules in a day. Take the full course of the drug therapy (8 wk in most cases). Do not take this drug with grapefruit juice; avoid grapefruit juice entirely while using this drug. Store Respules upright, protected from light; discard open envelopes after 2 wk. Shake before use. You may experience these side effects: Dizziness, headache (avoid driving or operating dangerous machinery if these effects occur); nausea, flatulence (frequent small meals may help; try to maintain your fluid and food intake). Report chest pain, ankle swelling, respiratory infections, increased bruising.