Budesonide

Budesonide 0.5mg Nebuliser Suspension

One ml of suspension contains 0.25mg budesonide.

One ampoule of 2ml suspension contains 0.5mg budesonide.

Nebuliser suspension

White to off-white suspension.

Treatment of persistent bronchial asthma in patients where use of a pressurised inhaler or dry powder formulation is unsatisfactory or inappropriate.

Very serious pseudocroup (laryngitis subglottica) in which hospitalisation is indicated.

Posology

Asthma

The dose should be given twice daily.

Administration once daily may be considered in cases of mild to moderate stable asthma.

Initial dosage:

The initial dose should be tailored to the severity of the disease and thereafter should be adjusted on an individual basis. The following doses are recommended but the minimum effective dose should always be sought:

Children aged 6 months and above:

0.25 - 1.0mg daily. For patients in maintenance therapy with oral steroids a higher initial dosage up to 2.0 mg daily should be considered.

Adults (including the elderly) and children/adolescents over 12 years of age:

0.5 - 2 mg daily. In very severe cases the dosage may be increased further.

Maintenance dose:

The maintenance dose should be adjusted to meet the requirements of the individual patient taking account of the severity of the disease and the clinical response of the patient. When the desired clinical effect has been obtained, the maintenance dose should be reduced to the minimum required for control of the symptoms.

Children aged 6 months and above:

0.25 - 1.0mg daily.

Adults (including the elderly) and children/adolescents over 12 years of age:

0.5 - 2.0mg daily. In very severe cases the dose may be further increased.

Administration once daily:

Administration once daily should be considered for children and adults with mild to moderate stable asthma and with a maintenance dose between 0.25 mg and 1 mg budesonide daily. Once-daily administration may be initiated both in patients who are not receiving corticosteroid treatment and in well-controlled patients who are already taking inhaled steroids. The dose may be given in the morning or evening. If a worsening of the asthma occurs, the daily dose should be increased by administering the dose twice daily.

Onset of effect:

An improvement of the asthma following administration of budesonide may occur within 3 days after initiation of therapy. The maximum effect will only be obtained after 2-4 weeks of treatment.

Patients in maintenance therapy with oral glucocorticosteroids:

Asthma

Budesonide nebuliser suspension may permit replacement or significant reduction in dosage of oral glucocorticosteroids while maintaining asthma control. When transferral from oral steroids to budesonide nebuliser suspension is started, the patient should be in a relatively stable phase. A high dose of budesonide nebuliser suspension is then given in combination with the previously used oral steroid dose for about 10 days.

After that, the oral steroid dose should be gradually reduced (by for example 2.5 milligrams prednisolone or the equivalent each month) to the lowest possible level.

When tapering off systemic corticosteroids some patients will experience steroid withdrawal symptoms, e.g. joint and/or muscle pain, lack of energy and depression or even a decreased lung function. Such patients must be advised to continue the inhaled budesonide therapy, but they should also be examined for any objective signs of adrenocortical insufficiency. If such signs are present, the dose of the systemic corticosteroid should be temporarily increased and then tapered off even more slowly. In periods of stress or severe asthma attacks, patients in the transition phase may require treatment with systemic corticosteroids.

Pseudocroup

In infants and children with pseudocroup, the commonly used dose is 2 mg of nebulised budesonide. This is given as a single administration, or as two 1 mg doses separated by 30 minutes. Dosing can be repeated every 12 hours for a maximum of 36 hours or until clinical improvement.

Method of administration

For inhalation use only.

Dosage schedule:

*) Should be mixed with 0.9 % saline to a volume of 2 ml.

Division of the dose and miscibility:

The contents of the single-dose container may be divided for adjustment of the dose.

Half the ampoule contents should be placed in the nebuliser cup and mixed with an equal volume of 0.9% sodium chloride solution. To ensure accurate dosing the use of a measuring syringe is recommended.

Budesonide Nebuliser Suspension may be mixed with 0.9% sodium chloride solution and with solutions for inhalation containing terbutaline, salbutamol, sodium cromoglycate or ipratropium.

Nebuliser:

Budesonide Nebuliser Suspension must be administered with a jet nebuliser supplied with a mouthpiece or mask. The nebuliser should be connected to an air compressor with adequate air flow (5-8 l/min), and the filling volume should be 2-4 ml.

There can be variation in the performance (dose delivered) between nebulizers, even those of the same make and model.

Note! Ultrasound nebulisers are not suitable for nebulisation of Budesonide Nebuliser Suspension and therefore cannot be recommended.

Instruction for use:

The spray container should be shaken before use.

To minimise the risk of oropharyngeal candida infection, the patient should rinse their mouth out with water after inhaling.

To prevent irritation of the facial skin the face should be washed after using the nebuliser with a mask.

The nebuliser should be cleaned after each use.

Wash the nebuliser container and mouthpiece or face-mask in warm water using a mild detergent in accordance with the manufacturer's instructions. Rinse well and dry it by connecting the nebuliser container to the compressor or the air inlet.

Budesonide is not indicated for the treatment of acute dyspnoea or status asthmaticus. These conditions should be treated with short acting β-sympathomimetics and other bronchodilators.

The transfer of patients treated with oral corticosteroids to the inhaled corticosteroid and their subsequent management requires special care. The patients should be in a reasonably stable state before initiating a high dose of inhaled corticosteroid in addition to their usual maintenance dose of systemic corticosteroid. After about 10 days, withdrawal of the systemic corticosteroid is started by reducing the daily dose gradually (by for example 2.5 milligrams prednisolone or the equivalent each month) to the lowest possible level. It may be possible to completely replace the oral corticosteroid with inhaled corticosteroid. Transferred patients whose adrenocortical function is impaired may need supplementary systemic corticosteroid during periods of stress e.g. surgery, infection or worsening asthma attacks.

Patients who have required high dose emergency corticosteroid therapy or prolonged treatment at the highest recommended dose of inhaled corticosteroids, may also be at risk of impaired adrenal function. These patients may exhibit signs and symptoms of adrenal insufficiency when exposed to severe stress. Additional systemic corticosteroid treatment should be considered during periods of stress or elective surgery.

During transfer from oral therapy to inhaled budesonide, symptoms may appear that had previously been suppressed by systemic treatment with glucocorticosteroids, for example symptoms of allergic rhinitis, eczema, muscle and joint pain. Specific treatment should be co-administered to treat these conditions.

Some patients may feel unwell in a non-specific way during the withdrawal of systemic corticosteroids despite maintenance or even improvement in respiratory function. Such patients should be encouraged to continue treatment with inhaled budesonide and withdrawal of oral corticosteroid unless there are clinical signs to indicate the contrary, for example signs which might indicate adrenal insufficiency.

As with other inhalation therapies paradoxical bronchospasm may occur, manifested by an immediate increase in wheezing and shortness of breath after dosing. Paradoxical bronchospasm responds to a rapid-acting inhaled bronchodilator and should be treated straight away. Budesonide should be discontinued immediately, the patient should be assessed and, if necessary, alternative treatment instituted.

When an acute episode of dyspnoea occurs despite a well monitored treatment, a rapid-acting inhaled bronchodilator should be used and medical reassessment should be considered. If despite maximum doses of inhaled corticosteroids, asthma symptoms are not adequately controlled, patients may require short-term treatment with systemic corticosteroids. In such cases, it is necessary to maintain the inhaled corticosteroid therapy in association with treatment by the systemic route.

Systemic effects may occur with any inhaled corticosteroid, particularly at high doses prescribed for long periods. These effects are much less likely to occur with inhalation treatment than with oral corticosteroids.

Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract, glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). It is important, therefore, that the dose of inhaled corticosteroid is titrated to the lowest dose at which effective control of asthma is maintained.

Influence on growth

It is recommended that the height of children receiving prolonged treatment with inhaled corticosteroids is regularly monitored. If growth is slowed, therapy should be re-evaluated with the aim of reducing the dose of inhaled corticosteroid. The benefits of the corticosteroid therapy and the possible risks of growth suppression must be carefully weighed. In addition, consideration should be given to referring the patient to a paediatric respiratory specialist.

Patients who have previously been dependent on oral corticosteroids may, as a result of prolonged systemic corticosteroid therapy, experience effects of impaired adrenal function. Recovery may take a considerable amount of time after cessation of oral corticosteroid therapy and hence oral steroid-dependent patients transferred to budesonide may remain at risk from impaired adrenocortical function for some considerable time. In such circumstances hypothalamic pituitary adrenocortical (HPA) axis function should be monitored regularly.

Oral candidiasis may occur during the therapy with inhaled corticosteroids.).

Exacerbation of clinical symptoms of asthma may be due to acute respiratory tract bacterial infections and treatment with appropriate antibiotics may be required. Such patients may need to increase the dose of inhaled budesonide and a short course of oral corticosteroids may be required. A rapid-acting inhaled bronchodilator should be used as “rescue” medication to relieve acute asthma symptoms.

Special care and adequate specific therapeutic control of patients with active and quiescent pulmonary tuberculosis is necessary before commencing treatment with inhaled budesonide. Similarly patients with fungal, viral or other infections of the airways require close observation and special care and should use budesonide only if they are also receiving adequate treatment for such infections.

In patients with excessive mucous secretion in the respiratory tract, short-term therapy with oral corticosteroids may be necessary.

In patients with severe hepatic dysfunction, treatment with inhaled budesonide can result in a reduced elimination rate and hence enhanced systemic availability. Possible systemic effects may then result and therefore HPA axis function in these patients should be monitored at regular intervals.

Concomitant treatment with ketoconazole, HIV protease inhibitors or other potent CYP3A4 inhibitors should be avoided. If this is not possible the time interval between administration of the two drugs should be as long as possible.

Recent epidemiological studies show that there is an increased incidence of pneumonia in patients with Chronic Obstructive Pulmonary Disease (COPD) treated with inhaled corticosteroids, with an adjusted odds ratio of 1.7 (Reference). Care should be exercised in prescribing budesonide for those patients whose respiratory disease might have a component of COPD.

Visual disturbance

Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.

Budesonide Nebuliser Suspension should be used with a jet nebuliser device. An ultrasonic nebuliser should not be used as this is not appropriate for nebuliser suspensions.

Budesonide Nebuliser Suspension can increase the efficacy of inhaled beta-2-sympathomimetics.

Co-treatment with CYP3A inhibitors, including cobicistat-containing products, is expected to increase the risk of systemic side-effects. The combination should be avoided unless the benefit outweighs the increased risk of systemic corticosteroid side-effects, in which case patients should be monitored for systemic corticosteroid side-effects.

Other potent CYP3A4 inhibitors such as erythromycin, clarithromycin, ritonavir and saquinavir are also likely to markedly increase plasma concentrations of budesonide.

Cimetidine had a weak but clinically insignificant inhibiting effect on hepatic metabolism of budesonide.

Raised plasma concentrations of and enhanced effects of corticosteroids have been observed in women also treated with oestrogens and contraceptive steroids, but no effect has been observed with budesonide and concomitant intake of low dose combination oral contraceptives.

The suppressive effect on adrenal function is additive if used concomitantly with systemic or intranasal steroids.

Because adrenal function may be suppressed, an ACTH stimulation test for diagnosing pituitary insufficiency might show false results (low values).

Pregnancy

Most results from prospective epidemiological studies and world-wide post-marketing data have not been able to detect an increased risk for adverse effects for the foetus and newborn child from the use of inhaled budesonide during pregnancy. It is important for both foetus and mother to maintain an adequate asthma treatment during pregnancy. As with other drugs administered during pregnancy, the benefit of the administration of budesonide for the mother should be weighed against the risks to the foetus.

Breastfeeding

Budesonide is excreted in breast milk. However, at therapeutic doses of budesonide no effects on the suckling child are anticipated. Budesonide can be used during breast feeding.

Maintenance treatment with inhaled budesonide (200 or 400 micrograms twice daily) in asthmatic nursing women results in negligible systemic exposure to budesonide in breast-fed infants.

In a pharmacokinetic study, the estimated daily infant dose was 0.3% of the daily maternal dose for both dose levels, and the average plasma concentration in infants was estimated to be 1/600th of the concentrations observed in maternal plasma, assuming complete infant oral bioavailability. Budesonide concentrations in infant plasma samples were all less than the limit of quantification.

Based on data from inhaled budesonide and the fact that budesonide exhibits linear PK properties within the therapeutic dosage intervals after nasal, inhaled, oral and rectal administrations, at therapeutic doses of budesonide, exposure to the suckling child is anticipated to be low.

Inhaled budesonide has no or negligible influence on the ability to drive and use machines.

Tabulated list of adverse reactions

The following definitions apply to the incidence of undesirable effects: Very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1,000 to <1/100); rare (>1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).

* refer to Description of selected adverse reactions: facial skin irritation, cataract, anxiety, depression below

** refer to Paediatric population, below

Description of selected adverse reactions

Facial irritation, as an example of a hypersensitivity reaction, has occurred in some cases when a nebuliser with a face mask has been used. To prevent irritation the facial skin should be washed with water after use of the face mask.

In-placebo controlled studies, cataract was also uncommonly reported in the placebo group.

Clinical trials with 13,119 patients on inhaled budesonide and 7,278 patients on placebo have been pooled. The frequency of anxiety was 0.52% on inhaled budesonide and 0.63% on placebo; that of depression was 0.67% on inhaled budesonide and 1.15% on placebo.

There is an increased risk of pneumonia in patients with newly diagnosed COPD starting treatment with inhaled corticosteroids. However a weighted assessment of 8 pooled clinical trials involving 464³ COPD patients treated with budesonide and 3,643 patients randomized to non-ICS treatments did not demonstrate an increased risk for pneumonia. The results from the first 7 of these 8 trials have been published as a meta-analysis.

Treatment with inhaled budesonide may result in candida infection in the oropharynx. Experience has shown that candida infection occurs less often when inhalation is performed before meals and/or when the mouth is rinsed after inhalation. In most cases this condition responds to topical anti-fungal therapy without discontinuing treatment with inhaled budesonide.

Coughing can usually be prevented by inhaling a beta-2 agonist (e.g. terbutaline) 5-10 minutes before administration of Budesonide 0.5mg Nebuliser Suspension.

Occasionally, signs or symptoms of systemic glucocorticosteroid-side effects may occur with inhaled glucocorticosteroids, probably depending on dose, exposure time, concomitant and previous corticosteroid exposure, and individual sensitivity. These may include adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract and glaucoma, and susceptibility to infections. The ability to adapt to stress may be impaired. The systemic effects described, however, are much less likely to occur with inhaled budesonide than with oral corticosteroids.

Paediatric population

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme; website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Symptoms:

Acute overdose with budesonide usually does not constitute a clinical problem. The only harmful effect after a large amount of sprays during a short period is a suppression of the cortex function.

If it is a matter of chronic use of very high doses, effects such as a degree of cortex atrophy in addition to adrenocortical suppression may occur.

Treatment:

Acute overdosage: There is no need for acute measures. The treatment with budesonide should be continued with the lowest possible effective maintenance dose, and the adrenocortical function will repair itself automatically within 1-2 days.

Chronic overdosage: The patient should be treated as a steroid dependent and be transferred to a suitable maintenance dose with a systemic steroid, for example prednisolone. When the condition is stabilized, the patient should continue the treatment with the inhalation of budesonide at the recommended dose.

Pharmacotherapeutic group: Other drugs for obstructive airways diseases, inhalant, Glucocorticoids

ATC code: R03 BA 02

Budesonide is a glucocorticosteroid with a powerful local anti-inflammatory action.

Mechanism of action

The precise mechanism of action of glucocorticosteroids in the treatment of asthma is not fully understood. Anti-inflammatory effects (including T-cells, eosinophilic cells and mast cells) such as inhibition of the release of inflammatory mediators and inhibition of cytokine-mediated immune response, are probably important. The strength of budesonide, measured as affinity for glucocorticoid receptors, is approximately 15 times stronger than that of prednisolone.

Clinical efficacy and safety

A clinical trial with asthma patients in which inhaled and oral budesonide was compared with placebo, showed statistically significant effects of inhaled budesonide, but not of oral budesonide. The therapeutic effect of normally used doses of inhaled budesonide may therefore chiefly be explained by a direct effect on the airways.

Budesonide has demonstrated an anti-anaphylactic and anti-inflammatory effect in challenge tests in experimental animals and in patients. This effect has manifested itself as reduced bronchial obstruction in both the immediate and the later allergic reaction.

It was also demonstrated that budesonide reduces the airways' reactivity to histamine and metacholine in hyperreactive patients. Treatment with inhaled budesonide has been used to effectively prevent exercise-induced asthma.

Influence on plasma cortisol concentration:

Studies in healthy volunteers with inhaled budesonide have shown dose-related effect on plasma and urinary cortisol. At recommended doses, inhaled budesonide causes significantly less effect on adrenal function than prednisone 10 mg, as shown by ACTH test. No clinically relevant changes in the plasma cortisol values or response to ACTH stimulation were observed when budesonide was given in doses up to 1600 µg daily for 3 months to adults and up to 800 µg daily to children. Long-term monitoring for up to 52 weeks confirmed that the HPA axis was not suppressed.

Paediatric population

Clinical - asthma

The efficacy of budesonide nebuliser suspension has been evaluated in a large number of studies, and it has been shown that budesonide nebuliser suspension is effective both in adults and children as once- or twice-daily medication for prophylactic treatment of persistent asthma. Some examples of representative studies are given below.

Clinical - croup

A number of studies in children with croup have compared budesonide nebuliser suspension with placebo. Examples of representative studies evaluating the use of budesonide for the treatment of children with croup are given below.

Efficacy in children with mild to moderate croup

A randomized, double-blind placebo-controlled trial in 87 children (aged 7 months to 9 years), admitted to hospital with a clinical diagnosis of croup, was conducted to determine whether budesonide nebuliser suspension improves croup symptom scores or shortens the duration of stay in hospital. An initial dose of budesonide nebuliser suspension (2 mg) or placebo was given followed by either budesonide 1 mg or placebo every 12 hours. Budesonide nebuliser suspension statistically significantly improved croup score at 12 and 24 hours and at 2 hours in patients with an initial croup symptom score above 3. There was also a 33% reduction in the length of stay.

Efficacy in children with moderate to severe croup

A randomized, double-blind, placebo-controlled study compared the efficacy of budesonide nebuliser suspension and placebo in the treatment of croup in 83 infants and children (aged 6 months to 8 years) admitted to hospital for croup. Patients received either budesonide 2 mg nebuliser suspension or placebo every 12 h for a maximum of 36 h or until discharge from hospital. The total croup symptom score was assessed at 0, 2, 6, 12, 24, 36 and 48 hours after the initial dose. At 2 hours, both the budesonide nebuliser suspension and placebo groups showed a similar improvement in croup symptom score, with no statistically significant difference between the groups. By 6 hours, the croup symptom score in the budesonide nebuliser suspension group was statistically significantly improved compared with the placebo group, and this improvement versus placebo was similarly evident at 12 and 24 hours.

Both asthma and inhaled glucocorticosteroids may affect the growth in length. The effect of Budesonide Nebuliser Suspension on the growth in length was studied in 519 children (from 8 months to 9 years) in three prospective, randomised, open, non-blinded studies. The studies did not show any significant difference in the growth in length of children treated either with Budesonide Nebuliser Suspension or with conventional asthma therapy. Two studies (N = 239 and 72 patients, respectively) showed 7 mm and 8 mm greater growth after one year of treatment with Budesonide Nebuliser Suspension compared with traditional asthma therapy (not statistically significant), while one study (N = 208) showed a growth in length that after one year was 8 mm smaller in the Budesonide Nebuliser Suspension group than in the group of conventional asthma treatment (statistically significant difference).

Absorption

In adults the systemic availability of budesonide following administration of Budesonide Nebuliser Suspension via a jet nebuliser is approximately 15% of the nominal dose and 40% to 70% of the dose delivered to the patients. A minor fraction of the systemically available drug comes from swallowed drug. The maximal plasma concentration, occurring about 10 to 30 min after start of nebulisation is approximately 4 nmol/L after a single dose of 2 mg.

Distribution

Budesonide has a volume of distribution of approximately 3 L/kg. Plasma protein binding averages 85 - 90%.

Biotransformation

Budesonide undergoes an extensive degree (~90%) of biotransformation on first passage through the liver to metabolites of low glucocorticosteroid activity. The glucocorticosteroid activity of the major metabolites, 6β-hydroxybudesonide and 16α-hydroxyprednisolone, is less than 1 % of that of budesonide. The metabolism of budesonide is primarily mediated by CYP3A, a subfamily of cytochrome P450.

Elimination

The metabolites of budesonide are excreted as such or in conjugated form mainly via the kidneys. No unchanged budesonide has been detected in the urine. Budesonide has high systemic clearance (approximately 1.2 L/min) in healthy adults, and the terminal half-life of budesonide after iv dosing averages 2-3 hours.

Linearity

The kinetics of budesonide are dose-proportional at clinically relevant doses.

Paediatric population

Budesonide has a systemic clearance of approximately 0.5 L/min in 4-6 years old asthmatic children. Per kg body weight children have a clearance which is approximately 50% greater than in adults. The terminal half-life of budesonide after inhalation is approximately 2.3 hours in asthmatic children. This is about the same as in healthy adults. In 4-6 years old asthmatic children, the systemic availability of budesonide following administration of Budesonide Nebuliser Suspension via a jet nebuliser (Pari LC Jet Plus® with Pari Master® compressor) is approximately 6% of the nominal dose and 26% of the dose delivered to the patients. The systemic availability in children is about half of that in healthy adults. The maximal plasma concentration, occurring approximately 20 min after start of nebulisation is approximately 2.4 nmol/L in 4-6 years old asthmatic children after a 1 mg dose. The exposure (Cmax and AUC) of budesonide following administration of a single 1 mg dose by nebulisation to 4-6 year old children is comparable to that in healthy adults given the same delivered dose by the same nebuliser system.

Preclinical data revealed no special hazard for humans in the therapeutic dose range based on studies of chronic toxicity, genotoxicity and carcinogenicity.

Glucocorticoids, including budesonide, have produced teratogenic effects in animals, including cleft palate and skeletal abnormalities. Similar effects are considered unlikely to occur in humans at the recommended dose levels.

Disodium edetate

Sodium chloride

Polysorbate 80

Citric acid

Sodium citrate

Water for injection

3 years.

After first opening of the foil sachet, the ampoule may be stored unopened for three months.

Use ampoule within 12 hours of opening.

Store in the original package in order to protect from light and moisture.

Low density polyethylene ampoule containing 2ml nebuliser suspension.

Pack sizes: Tri-laminate foil sachets containing 5, 20, 24, 40 (2 x 20) and 60 ampoules (in strips of 4, 5, 8, 10 or 12 ampoules).

Not all pack sizes may be marketed.

Budesonide nebuliser suspension can be mixed with 0.9% saline and with solutions of terbutaline, salbutamol, sodium chromoglycate, or ipratropium bromide.

For single use only. Any unused solution should be discarded

Breath Limited

Whiddon Valley

Barnstaple

North Devon

EX32 8NS

United Kingdom

PL: 18023/0007

26-10-2005 / 24-02-2009

16.09.2017