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Inhaled corticosteroid (prodrug) Pregnancy: Considered safe — inhaled corticosteroids preferred over uncontrolled asthma in pregnancy.

Ciclesonide

Brand names: Alvesco

Adult dose

Dose: Asthma: 80–160 mcg OD; severe disease 160 mcg BD (max 640 mcg/day).
Route: Inhalation (HFA pMDI)
Frequency: Once daily (preferred) or twice daily
Max: 640 mcg/day
Activated by esterases in airway epithelium — minimal oropharyngeal deposition; mouth rinsing not strictly required (but still good practice).

Paediatric dose

Route: Inhalation
Frequency: Once daily
≥12 yrs: adult dose. Not licensed under 12 in UK (limited data). Spacer recommended.

Clinical pearls

  • Once-daily ICS dosing improves adherence vs BD — useful for patients struggling with twice-daily regimens.
  • Prodrug — activated by airway esterases to des-ciclesonide; minimal active drug in oropharynx → lower thrush/dysphonia rates than beclometasone or fluticasone.
  • Equivalent low-dose ICS (BTS/SIGN): ciclesonide 160 mcg/day ≈ beclometasone (Clenil) 400 mcg/day ≈ fluticasone 200 mcg/day.
  • Useful when oral candidiasis or dysphonia limits other ICS — common in elderly, professional voice users.
  • Reasonable alternative if patient cannot tolerate other ICS but rarely needs to be a first-choice agent.
  • Always ensure step-up review and inhaler technique check before stepping up dose.

Contraindications

  • Hypersensitivity to ciclesonide
  • Untreated active TB or fungal pulmonary infection (relative)

Side effects

  • Lower oral candidiasis and dysphonia rates than older ICS (prodrug activation in the airways means less oropharyngeal deposition)
  • Headache, nasopharyngitis
  • Paradoxical bronchospasm (rare)
  • Adrenal suppression at high doses (less than equivalent dose of beclometasone — better systemic safety)
  • Skin thinning, easy bruising (long-term high-dose)
  • Cataracts, glaucoma (long-term)
  • Behavioural changes (rare)

Interactions

  • CYP3A4 inhibitors (ritonavir, ketoconazole, clarithromycin, itraconazole): ↑ systemic exposure — caution
  • Beta-blockers: ↑ asthma exacerbation risk

Monitoring

  • Asthma control test
  • Adrenal axis if high dose

Reference: BNFc; BNF 90; SmPC Alvesco; BTS/SIGN Asthma 158 (2019); GINA 2024. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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