Corticosteroids (Inhaled, Nebulised and Intranasal)


Inhaled: Beclometasone (Clenil®, Qvar®, Kelhale®, Soprobec®), Budesonide (Pulmicort®), Ciclesonide (Alvesco®), Fluticasone (Flixotide®), Mometasone (Asmanex®)

Inhaled combination products include AirFluSal®, Atectura®, DuoResp®, Enerzair®, Flutiform®, Fobumix®, Fostair®, Luforbec®, Relvar®, Sereflo®, Seretide®, Sirdupla®, Symbicort®, Trelegy®, Trimbow®, Trixeo® although this list is not exhaustive

Intranasal: Beclometasone (Beconase®, Betnesol®), Budesonide (Benacort®, Rhinocort®), Fluticasone (Avamys®, Flixonase®), Mometasone (Nasonex®), Trimacinolone (Nasacort®)

Intranasal combination products include Betnesol N®, Dymista®

[For patients taking oral corticosteroids - see Corticosteroids (Systemic) monograph]

  Issues for Surgery


For suppression of inflammatory and allergic disorders (including asthma, chronic obstructive pulmonary disease [COPD], allergic rhinitis) – increased risk of disease relapse if omitted.

Potential increased risk of acute adrenal insufficiency (e.g. severe hypotension, tiredness and weakness, confusion, psychosis, tachycardia) if omitted – see Further Information.


  Advice in the Perioperative period


Elective and Emergency Surgery
Continue1 (including combination products).  

There are numerous inhaled and intranasal preparations which contain corticosteroids, either as single agents or in combination products with antimuscarinics and / or long-acting beta2 adrenoceptor agonists – all of these can be continued pre-operatively.  Check active ingredients of currently available preparations in the British National Formulary and see also Inhaled Antimuscarinics monograph and Long-acting Beta2 Adrenoceptor Agonist monograph if applicable.

Advise patients who do not use their inhaled corticosteroids as prescribed to use regularly to optimise disease control prior to anaesthesia.

Advise patients taking regular inhaled or intranasal corticosteroids that their corticosteroid medication should not be abruptly stopped1,2.

Confirm the brand, device and strength with the patient (for beclometasone see Further Information).


Perioperative Considerations
Perioperative corticosteroid replacement is not routinely recommended for patients on inhaled or intranasal corticosteroids due to the lower incidence of adrenal suppression associated with these administration routes – see Further Information.

For patients taking systemic corticosteroids in addition to inhaled / intranasal corticosteroids see Corticosteroids (Systemic) monograph.   


Post-operative Advice
Inhaled preparations
Restart post-operatively, at usual dose, as soon as next dose is due1,2.

If patients are unable to resume their usual inhaled corticosteroid medication post-operatively, supplementation with nebulised or systemic corticosteroids may be considered if clinically indicated, particularly if there are concerns regarding adrenal suppression – see Further Information.

Intranasal preparations
Restart post-operatively, at usual dose, as soon as next dose is due1,2 except for patients undergoing nasal surgery where restarting should be delayed until healing has occurred3 unless specifically advised otherwise by ENT Surgeon.


  Interaction(s) with Common Anaesthetic Agents


None anticipated with inhaled / intranasal use3,4,5,6; however, bear in mind the possibility of systemic absorption and thus the relevance of interactions listed in Corticosteroids (Systemic) monograph – see Further Information.


  Interaction(s) with other Common Medicines used in the Perioperative Period


None anticipated with inhaled / intranasal use3,4,5,6; however, bear in mind the possibility of systemic absorption and thus the relevance of interactions listed in Corticosteroids (Systemic) monograph – see Further Information.


  Further Information


Systemic Absorption
Although not intended it is possible that inhaled or intranasal administration of corticosteroids may result in systemic absorption, particularly if high doses are used or with prolonged treatment3. Risk of systemic absorption is considered greater with nasal drops than nasal sprays as they are more likely to be administered incorrectly3.

Adrenal Suppression, Perioperative Stress and Corticosteroid Replacement
Whilst adrenal insufficiency is most common in patients taking systemic corticosteroids there is evidence that this can occur with chronic corticosteroid administration via other routes7,8. High doses and prolonged treatment duration results in increased systemic absorption and therefore risk of adrenal insufficiency; however, there is no dose, administration route or treatment duration for which the risk of adrenal insufficiency can safely be excluded8. Meta-analysis indicates incidence of adrenal insufficiency is lower in patients prescribed intranasal (4.2%) and inhaled (7.8%) corticosteroids compared to oral (48.7%) and intra-articular (52.2%) corticosteroids, although this incidence is likely to be higher in individuals receiving corticosteroids by multiple routes8.

The possibility of adrenal insufficiency should be considered in individuals taking inhaled or intranasal corticosteroids who fail to improve as anticipated post-operatively. Current evidence on the necessity of administering perioperative stress-dose steroids for patients with suspected secondary adrenal insufficiency is inadequate to either support or refute this practice1,2, however, if adrenal insufficiency is suspected, corticosteroid replacement appears to carry minimal risk compared with the risk of adrenal crisis1. For guidance on replacement, where clinically indicated, see Corticosteroids (Systemic) monograph.

Prescribing Information
Beclometasone inhalers should be prescribed by brand name as differences in particle size, and therefore potency, mean Qvar®, Kelhale®, Soprobec® and Clenil Modulite® preparations are not interchangeable3.

 

  References


  1. Liu MM, Reidy AB, Saatee S et al. Perioperative Steroid Management: Approaches Based on Current Evidence. Anesthesiology. 2017; 127:166-172
  2. Freudzon L. Perioperative steroid therapy: where’s the evidence? Curr Opin Anaesthesiol. 2018; 31(1):39-42
  3. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. https://bnf.nice.org.uk/ [Accessed on 5th August 2020]
  4. Interactions of Corticosteroids. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://about.medicinescomplete.com [Accessed 5th August 2020]

  5. Summary of Product Characteristics – Seretide 250 Evohaler. GlaxoSmithKline UK. Accessed via www.medicines.org.uk 05/08/2020 [date of revision of the text November 2019]

  6. Summary of Product Characteristics – Benacort 64 micrograms Nasal Spray. McNeil Products Ltd. Accessed via www.medicines.org.uk  05/08/2020 [date of revision of the text July 2018] 

  7. Wlodarczyk JH, Gibson PG, Caeser M. Impact of Inhaled corticosteroids on cortisol suppression in adults with asthma: a quantitative review. Ann Allergy Asthma Immunol. 2008; 100(1):23-30

  8. Broersen LAH, Pereira AM, Jorgensen JOL et al. Adrenal insufficiency in corticosteroids use: systematic review and meta-analysis. JCEM 2015; 100(6):2171-2180[For patients taking oral corticosteroids - see Corticosteroids (Systemic) monograph]