Table 1.
ICS type and doses associated with increased adrenal suppression risk*
| Corticosteroid | Dose associated with increased AS risk † (µg/day) Canadian/European dosing |
Dose associated with increased AS risk† (µg/day) American dosing |
| Beclomethasone dipropionate HFA26 | >400 | >320 |
| Budesonide DPI8 26 Budesonide and formoterol |
≥800 | ≥800 |
| Ciclesonide‡ | >400 | >320 |
| Fluticasone propionate1 8 11 Fluticasone and salmeterol |
≥500 | ≥440 (HFA) ≥500 (DPI) |
| Fluticasone furoate DPI27 | ≥100 | ≥100 |
| Mometasone DPI28 Mometasone formoterol |
≥800 | ≥800 |
*Doses associated with increased risk of AS are based on the best available literature. Where no specific evidence for AS risk in paediatrics was available, doses cited are from adult studies with the exception of ciclesonide. Because of lack of clear thresholds for increased risk, we recommend that high-dose therapy (as defined by national or international guidelines)20–22 prompts the clinician to consider patients to be at increased risk recognising that AS is possible even with low to moderate dosing.
†In the USA, inhaler dose is based on the amount leaving the mouthpiece, rather than the amount leaving the canister; this accounts for differences in listed (but not actual) doses.
‡While ciclesonide has been demonstrated to have reduced risk of systemic side effects, cases of AS have been reported with high doses.33
§Fluticasone furoate (Arnuity Ellipta and Breo Ellipta) contains a new potent ICS. 100 µg daily is equivalent to 500 µg daily of fluticasone. This formulation has a high potential risk for AS.27
AS, adrenal suppression; DPI, dry-powder inhaler; HFA, hydrofluoroalkane; ICS, inhaled corticosteroids.