Years of Age >600–1,200 µg >1,200 µg 0.25–0.5 mg 1.0 mg 0.5 mg >0.5–1.0 mg >1.0 mg 2.0 mg 500–1,000 µg 1,000–1,250 >1,000–2,000 >1,250 µg >2,000 µg >1,500 µg >750–1,500 µg
Key: DPI, Dry power inhaler; HFA, hydrofluoroalkane; MDI, metered-dose inhaler; NA, not available (either not approved, no data available, or safety and efficacy not established for this age group)
Therapeutic Issues:  The most important determinant of appropriate dosing is the clinician’s judgment of the patient’s response to therapy. The clinician must monitor the patient’s  response on several clinical parameters and adjust the dose accordingly. Once control of asthma is achieved, the dose should be carefully titrated to the minimum dose required to maintain control.
 Preparations are not interchangeable on a µg or per puff basis. This figure presents estimated comparable daily doses. See EPR–3 Full Report 2007 for full discussion.
 Some doses may be outside package labeling, especially in the high-dose range. Budesonide nebulizer suspension is the only inhaler corticosteroid (ICS) with FDAapproved labeling for children <4 years of age.
 For children <4 years of age: The safety and efficacy of ICSs in children <1 year has not been established. Children <4 years of age generally require delivery of ICS  (budesonide and fluticasone HFA) through a face mask that should fit snugly over nose and mouth and avoid nebulizing in the eyes. Wash face after each treatment  to prevent local corticosteroid side effects. For budesonide, the dose may be administered 1–3 times daily. Budesonide suspension is compatible with Albuterol,  Ipratropium, and Levalbuterol nebulizer solutions in the same nebulizer. Use only jet nebulizers, as ultrasonic nebulizers are ineffective for suspensions. For  Fluticasone HFA, the dose should be divided 2 times daily; the low dose for children <4 years of age is higher than for children 5–11 years of age due to lower dose delivered with face mask and data on efficacy in young children.
Potential Adverse Effects of Inhaled Corticosteroids:  Cough, dysphonia, oral thrush (candidiasis).
 Spacer or valved holding chamber with non-breath-actuated MDIs and mouthwashing and spitting after inhalation decrease local side effects.
 A number of the ICSs, including Fluticasone, Budesonide, and Mometasone, are metabolized in the gastrointestinal tract and liver by CYP 3A4 isoenzymes. Potent  inhibitors of CYP 3A4, such as Ritonavir and Ketoconazole, have the potential for increasing systemic concentrations of these ICSs by increasing oral availability and  decreasing systemic clearance. Some cases of clinically significant Cushing syndrome and secondary adrenal insufficiency have been reported.
 In high doses, systemic effects may occur, although studies are not conclusive, and clinical significance of these effects has not been established (e.g., adrenal  suppression, osteoporosis, skin thinning, and easy bruising). In low-to-medium doses, suppression of growth velocity has been observed in children, but this effect may be transient, and the clinical significance has not been established.