What to Know About Pulmicort (Budesonide)

Pulmicort (budesonide) is an inhaled corticosteroid used for long-term control and prevention of asthma symptoms. This medication is used on a daily schedule to reduce airway inflammation that leads to bronchospasms and hyperresponsiveness.

Available as an inhaled powder for adults and older children (Pulmicort Flexhaler) and a nebulized solution for babies and younger children (Pulmicort Respules), Pulmicort can be used on its own or with a long-acting bronchodilator to prevent asthma attacks.

Pulmicort and less costly generic formulations are only available by prescription.

Uses

Pulmicort is one of several inhaled corticosteroids (also known as steroids) that your healthcare provider may prescribe.

As with other corticosteroid drugs, Pulmicort reduces inflammation by suppressing an overactive immune response. By acting directly on the smooth muscles of the airways, hyperresponsiveness can be reduced along with your reaction to asthma triggers.

Pulmicort is not used to treat acute asthma symptoms. For immediate asthma relief, short-acting beta-agonists (SABAs) like albuterol are considered the gold standard rescue medication.

Combinations

Pulmicort is often used in combination with an inhaled bronchodilator called a long-acting beta-agonist (LABA). Although some experts recommend starting with an inhaled steroid and adding a LABA later if control is not achieved, other authorities like the Global Initiative for Asthma (GINA) recommend starting treatment with both an inhaled steroid and a LABA.

Budesonide is also found in the combination inhaler Symbicort, which pairs the inhaled steroid with the inhaled LABA formoterol.

Off-Label Uses

Pulmicort is not approved to treat chronic obstructive pulmonary disease (COPD) but is sometimes used off-label with or without a LABA to improve breathing in people with severe respiratory obstruction due to COPD.

Because of the suppressive action it exerts on certain immune cells, Pulmicort is sometimes used off-label to treat eosinophilic esophagitis, an allergic inflammatory disease of the esophagus (food pipe).

Pulmicort Respules are also occasionally used off-label for managing symptoms of severe chronic rhinosinusitis (inflammation of the sinuses and nasal passages) that isn't relieved with more conservative treatments.

Before Using

Pulmicort Flexihaler and Pulmicort Respules are usually prescribed only after a rescue inhaler has not been effective for controlling asthma symptoms. If you use a rescue inhaler more than twice weekly, the American Academy of Allergy, Asthma & Immunology (AAAAI) recommends adding a daily inhaled steroid to your treatment plan.

Prior to starting therapy, your pulmonologist (lung specialist) will typically perform tests to classify the severity of your asthma as either mild-intermittent, mild-persistent, moderate-persistent, or severe-persistent. An inhaled steroid is usually started when the disease is classified as mild-persistent.

As the disease progresses, the dose of the inhaled steroid may be increased, and/or other drugs may be added to the treatment plan.

Precautions and Considerations

Pulmicort should never be used by anyone with a known or suspected allergy to budesonide. This includes people who have experienced a hypersensitive reaction to Symbicort.

Long-term use of corticosteroids can affect the eyes, bones, and the production of certain hormones. Although inhaled steroids have less impact on the body than oral steroids, inhalants like Pulmicort should be used with caution in people with certain pre-existing conditions:

• Adrenal insufficiency (also known as Addison's disease)
• Cataracts or glaucoma
• Osteopenia (bone mineral loss) or osteoporosis (porous bones)

Pulmicort may cause a worsening of symptoms in people with these conditions. This is especially true for elderly adults who are more likely to have these conditions.

Animal studies suggest a potential for fetal harm when using Pulmicort while pregnant, but no well-controlled studies in humans are available. The benefits of treatment may outweigh the risks.

If you are pregnant, planning to become pregnant, or breastfeeding, speak with your healthcare provider to fully understand the pros and cons of using Pulmicort during pregnancy and lactation.

Dosage

Pulmicort is available in two different formulations. Each is approved for different age groups with different dosages and delivery systems. Once treatment is started, it may take one to two weeks before the full benefits are noticeable.

Pulmicort Flexihaler

Pulmicort Flexhaler, approved for use in adults and children 6 and over, is a dry powder inhaler (DPI) that comes in a palm-sized canister. With each twist of the device, a pre-measured dose is delivered to a well in the mouthpiece. You simply "suck in" the dose to draw budesonide into your lungs.

Pulmicort Flexihaler comes in two doses: 90 micrograms (mcg) and 180 mcg. The 90-mcg version delivers 60 doses, while the 180-mcg unit delivers 120 doses. The recommended dose varies by age.

Pulmicort Respules

Pulmicort Respules, approved for children from 12 months to 8 years, are pre-measured ampules containing 2 milliliters (mL) of budesonide in solution. The liquid is placed into a jet nebulizer, which uses an air compressor and filters to transform the solution into a fine, inhalable mist.

Pulmicort Respules comes in three doses: 0.25 milligram (mg). 0.5 mg, and 1.0 mg. The recommended dose varies based on whether the child has been previously exposed to a SABA, a LABA, another inhaled steroid, or an oral steroid. SABAs are almost always used in first-line therapy followed by inhaled steroids, LABAs, and oral steroids.

It is always recommended to start with the lowest possible dose and to only increase if control is not achieved. Do not increase or decrease doses without first speaking to your healthcare provider.

How to Take and Store

Neither Pulmicort formulation is inherently "better" than the other. Pulmicort Respules are recommended for younger children because they do not have the lung capacity or strength to inhale dry powders efficiently.

When using any formulation, proper technique is required to get the right amount of the drug into the lungs.

To use Pulmicort Flexihaler:

1. Remove the inhaler from its box and packaging.
2. Twist off the white plastic cover.
3. Position the inhaler so that the mouthpiece is pointed upward.
4. Hold the inhaler in the middle with one hand and the colored grip at the bottom with the other. Do not hold the mouthpiece.
5. To load a dose, twist the grip as far as you can in one direction, then turn it back in the opposite direction until you hear a click. It doesn't matter which direction your start with. Do not shake the inhaler.
6. Turn your head away from the inhaler and exhale fully to empty your lungs.
7. Place the mouthpiece in your mouth and tighten your lips to form a seal.
8. Breathe in forcefully and deeply. This will draw the powder into your lungs; you likely won't feel this happening.
9. Remove the mouthpiece and slowly exhale.
10. If an additional dose is needed, repeat steps 4 through 9.
11. Wipe the mouthpiece with a tissue.
12. Replace the white plastic cover, twisting to close.
13. Rinse your mouth thoroughly with water. Do not swallow the water.

To use Pulmicort Respules:

1. Have your jet nebulizer assembled and ready.
2. Remove the strip of five 2-mL plastic ampules from the foil packet.
3. Twist off one coin-shaped ampule.
4. Holding the square twist cap, gently swirl the ampule in a circular motion to distribute budesonide evenly.
5. Holding the ampule upright with the cap positioned on top, twist off the cap.
6. Pour the contents into the nebulizer cup and gently squeeze to extract all of the fluid.
7. Place the nebulizer mask on the child's face and then turn on the nebulizer compressor.
8. Let the child breathe gently until all of the atomized solution is inhaled. This can take between five and 10 minutes.
9. Turn off the compressor.
10. Remove the mask, and wash the child's face.
11. Rinse the child's mouth with water. Teach the child not to swallow the water.
12. Throw away the ampule.

Both Pulimcort Flexihaler and Pulmicort Respules can be stored safely in a dry place at room temperature, ideally between 68 degrees F and 77 degrees F. Do not use past the expiration date. Keep the medications and any used ampules out of the reach of children and pets.

Side Effects

Although Pulmicort is generally well-tolerated, side effects may occur. Most tend to be mild and decrease over time. If side effects persist or worsen, let your healthcare provider know.

Common

The side effects of Pulmicort Flexihaler and Pulmicort Respules are similar, although they occur more frequently with the nebulized solution.

Common side effects of Pulmicort Flexihaler and Pulmicort Respules (in order of frequency) are as follows:

*Around 35% of children who use Pulmicort Respules can be expected to develop one or more respiratory infections during treatment.

Severe

While generally considered safe, Pulmicort may cause severe symptoms in some people. These tend to occur with the long-term use of the drug or in people with pre-existing cataracts, glaucoma, osteopenia, osteoarthritis, or adrenal gland dysfunction.

Call your healthcare provider if you experience any of the following while using Pulmicort:

• Vision problems (including blurred vision, eye pain, or vision loss)
• Bone fractures
• Persistent fatigue or weakness
• Irregular or missed periods
• Confusion or disorientation
• High fever

In rare instances, Pulmicort can cause a potentially life-threatening, whole-body allergy called anaphylaxis. Anaphylaxis should always be regarded as a medical emergency. If left untreated, it can lead to shock, coma, respiratory or cardiac failure, and death.

Warnings and Interactions

Pulmicort, like other corticosteroid drugs, works by suppressing the immune system. Although beneficial to the treatment of asthma, the immunosuppressive effect can leave a person vulnerable to certain infections, like colds and other upper respiratory infections.

The consequences of immunosuppression in young children, whose immune systems are not fully developed, can be imminently more severe, particularly if they're exposed to childhood diseases like measles or chickenpox. To prevent serious illness, childhood vaccination recommendations should be adhered to and every effort should be made to avoid contact with other children with measles or chickenpox.

Oral candidiasis (thrush) is a common side effect of Pulmicort and one that can often be avoided by rinsing your mouth after every treatment. If oral thrush does occur, stop treatment and call your healthcare provider. An antifungal drug will likely be needed to resolve the infection.

If you develop a lower respiratory infection like pneumonia, you will also be advised to stop treatment temporarily. Seek appropriate care and ask your healthcare provider when it is safe to start Pulmicort again. This is especially important for older adults.

Children using Pulmicort Respules will frequently develop conjunctivitis (pink eye) due to a poorly fitted nebulizer mask, as any medication that seeps out during treatment can irritate the eye. To prevent this, use an appropriate size mask for the child's age, and wash the child's face after treatment to avoid the spread of medication from the face to the eye.

Interactions

Pulmicort is metabolized by a liver enzyme known as cytochrome P450 (CYP450). Other drugs that utilize CYP450 for metabolization can end up "competing" with Pulmicort for access to the enzyme. Competitive interactions can cause adverse drops or increases in the blood concentration of one or both drugs.

Among the drugs of concern are:

• Anticoagulants like warfarin
• Calcium channel blockers like Verelan (verapamil)
• Chemotherapy drugs like cyclophosphamide
• Epilepsy drugs like Tegretol (carbamazepine)
• Heart rhythm medications like Pacerone (amiodarone)
• Hormonal contraceptives like ethinyl estradiol
• Immunosuppressive drugs like cyclosporine
• Macrolide antibiotics like clarithromycin
• Opioid drugs like fentanyl and Oxycontin (oxycodone)
• St. John's wort (Hypericum perforatum)
• Tuberculosis medications like rifampin

In some cases, a dose adjustment, drug substitution, or separation of doses by one or several hours may be needed. To avoid interactions, advise your healthcare provider about any drug or supplement you are taking, whether prescription or non-prescription.

A Word From Verywell

The single most important factor in achieving control of persistent asthma is the consistent use of inhaled steroids like Pulmicort. Studies have shown that between 37% and 78% of people with asthma do not use their inhaled steroids as prescribed.

If you find have difficulty adhering to your treatment plan, let your healthcare provider know. Discuss any concerns you have, such as concerns about side effects, with your healthcare provider. In some cases, there may be equally effective treatments that are easier to use or that don't cause side effects for you.