Budesonide

Advice to GPs on Health Pathways

COVID-19 modifying therapy: • Budesonide Budesonide Studies have shown inhaled budesonide (Pulmicort) has a modest benefit in reducing illness duration and need for admission.

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If budesonide is available, consider offering it to patients within 14 days of onset of COVID-19 symptoms who aren't taking other inhaled or systemic corticosteroids, and are either aged 65 years or older or have any of the following: •

Diabetes

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Heart disease and/or hypertension

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Asthma or lung disease

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Immunocompromised

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Mild hepatic impairment

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Stroke or other neurological problem

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Obesity

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Prescribe a dose of 800 microgram twice daily for up to 14 days.

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Be aware, due to world-wide demand, supply may become a problem.

Only supply one inhaler per patient. Consider clinical review if further inhalers are requested.

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Provide patient information about the Pulmicort turbuhaler (includes instructional video).

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Do not start inhaled budesonide/formoterol (Symbicort) in place of budesonide (Pulmicort) for this indication. The unnecessary LABA is likely to induce unwanted side effects.

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Patients already using an inhaled corticosteroid for a different indication (either alone or in combination with long acting beta agonist [LABA]) should continue to use their regular medication and not switch to budesonide.

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Ask about allergies before providing any medications.

Medicines and COVID-19 | Christchurch Medicines Information Service

There is weak evidence to support using systemic or inhaled corticosteroids to treat patients with milder COVID-19.

Patients should continue prescribed systemic or inhaled corticosteroids for usual chronic indications e.g. giant cell arteritis, asthma or COPD.

Inhaled corticosteroids A multicentre, open-label, RCT included 1856 community patients with new onset COVID-19 ≥65 years old or ≥50 years old with comorbidities (e.g. diabetes and hypertension). Treatment with inhaled budesonide 800 mcg twice daily (up to 14 days) reduced the time to self-reported recovery by 3 days compared to usual care (12 versus 15 days). No reduction in the risk of hospitalisation or death at 28 days was found. See, PRINCIPLE trial.

A parallel group, open-label, RCT included 139 community patients (> 18 years) with new onset COVID-19. Treatment with inhaled budesonide 800 mcg twice daily (average of 7 days) reduced the number of patients who required urgent medical evaluation or hospitalisation (1 versus 14 %) at 28 days compared to usual care. Self-reported recovery was 1 day shorter in the budesonide group compared to usual care (7 versus 8 days). See, STOIC trial.

A double-blind, placebo-controlled, RCT included 400 community patients (≥12 years) with new onset COVID-19. Treatment with inhaled ciclesonide 320 mcg twice daily (for 30 days) did not reduce the time to self-reported recovery compared to placebo (19 days for both groups). However, the secondary outcome of the number of patients requiring a subsequent emergency department visit or hospitalisation was lower in the ciclesonide group (1 versus 5.4%) compared to placebo (OR 0.18; 95% CI 0.04-0.85; P =0.03). In vitro data suggests that ciclesonide inhibits SARS-CoV-2 replication. This action appears unique to ciclesonide and not to all corticosteroids. See, RCT. No mortality benefit was found in these trials and they have several limitations including relying on the self-reporting of outcomes. Further clinical trials are required to determine the role of inhaled corticosteroids in COVID-19.