ciclesonide

ciclesonide (inhalation)

Alvesco

Indications

Action

Pharmacokinetics

Time/action profile (improvement in symptoms)

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• headache (most frequent)

Ear, Eye, Nose, Throat

• candida infection of mouth and pharynx
• nasal congestion (most frequent)
• nasopharyngitis (most frequent)
• pharyngolaryngeal pain
• cataracts
• ↑ intraocular pressure

Endocrinologic

• adrenal suppression (↑ dose, long term therapy)
• ↓ growth (children)

Musculoskeletal

• arthralgia (most frequent)
• back pain (most frequent)
• ↓ bone mineral density (↑ dose, long term therapy)
• extremity pain (most frequent)

Miscellaneous

• worsening of infections

Interactions

Drug-Drug interaction

Route/Dosage

Availability

Nursing implications

Nursing assessment

• Monitor respiratory status and lung sounds. Pulmonary function tests may be assessed periodically during and for several months following a transfer from systemic to inhalation corticosteroids.
• Assess patients changing from systemic corticosteroids to inhalation corticosteroids for signs of adrenal insufficiency (anorexia, nausea, weakness, fatigue, hypotension, hypoglycemia) during initial therapy and periods of stress. If these signs appear, notify health care professional immediately; condition may be life-threatening.
• Monitor for withdrawal symptoms (fatigue, weakness, nausea, vomiting, hypotension, joint or muscular pain, lassitude, depression) during withdrawal from oral corticosteroids.
• Monitor growth rates in children receiving chronic therapy; lowest possible dose should be used.
• Monitor patients with a change in vision or with a history of ↑ intraocular pressure, glaucoma, or cataracts closely.
• Lab Test Considerations: Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal (HPA) axis suppression in chronic therapy. Children and patients using higher than recommended doses are at highest risk for HPA suppression.

Potential Nursing Diagnoses

Implementation

• When changing from oral to inhaled corticosteroids, taper oral dose slowly, no faster than prednisone 2.5 mg/day on a weekly basis, beginning after at least 1 wk of ciclesonide inhalation therapy.
• After the desired clinical effect has been obtained, attempts should be made to ↓ dose to lowest amount required to control symptoms. Gradually ↓ as long as desired effect is maintained. If symptoms return, dose may briefly return to starting dose.
• Inhalation: Allow at least 1 min between inhalations. Do not shake inhaler or use with spacer (See ).
  • If bronchospasm occurs right after ciclesonide dose, discontinue and administer short acting bronchodilator; notify health care professional.

Patient/Family Teaching

• Instruct patient to use inhaler at regular intervals as directed. If a dose is missed, omit and take next regularly scheduled dose. Advise patient not to ↑ dose or discontinue medication, even if feeling better, without consulting health care professional; gradual ↓ is required. If asthma symptoms worsen, contact health care professional. Instruct patient to read Patient Leaflet before use.
• Advise patient to follow instructions supplied. Before first-time use or if inhaler has not been used for more than 10 days, prime unit by actuating 3 times prior to dose. Do not shake inhaler. When dose indicator display window shows a red zone, 20 inhalations are left and refill is required; discard when indicator shows zero. Do not use actuator with other medications. Clean mouthpiece weekly with a clean dry tissue; do not wash or put any part of the inhaler in water.
• Advise patients using inhalation corticosteroids and bronchodilator to use bronchodilator first and to allow 5 min to elapse before administering the corticosteroid, unless otherwise directed by health care professional.
• Advise patient that inhalation corticosteroids should not be used to treat an acute asthma attack but should be continued even if other inhalation agents are used.
• Instruct patient to notify health care professional if asthma worsens or if signs of adrenal insufficiency occur.
• Patients using inhalation corticosteroids to control asthma may require systemic corticosteroids for acute attacks. Advise patient to use regular peak flow monitoring to determine respiratory status.
• Advise patient to rinse mouth with water after treatment to ↓ risk of developing local candidiasis.
• Caution patient to avoid smoking, known allergens, and other respiratory irritants.
• Advise patient to notify health care professional if sore throat or mouth occurs or if exposed to anyone with chicken pox or measles.
• Instruct patient to consult health care professional before taking other Rx, OTC, or herbal products.
• Advise female patients to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
• Instruct patient whose systemic corticosteroids have been recently reduced or withdrawn to carry a warning card indicating the need for supplemental systemic corticosteroids in the event of stress or severe asthma attack unresponsive to bronchodilators.

Evaluation/Desired Outcomes

• Management of the symptoms of chronic asthma.
• Improvement in asthma symptoms. Maximum benefit may take 4 wks or longer.

ciclesonide (nasal)

Omnaris

Zetonna

Indications

Action

Pharmacokinetics

Time/action profile

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• headache

Ear, Eye, Nose, Throat

• cataracts
• ear pain
• epistaxis
• glaucoma
• local stinging
• nasal perforation
• nasal ulceration
• nasopharyngitis

Endocrinologic

• adrenal suppression (high-dose, long term therapy only)

Miscellaneous

• angioedema (life-threatening)

Interactions

Drug-Drug interaction

Route/Dosage

Availability

Nursing implications

Nursing assessment

• Monitor degree of nasal stuffiness, amount and color of nasal discharge, and frequency of sneezing.
• Patients on long-term therapy should have periodic otolaryngologic examinations to monitor nasal mucosa and passages for infection or ulceration.
• Patients previously treated with systemic corticosteroids for prolonged periods and transferred to topical corticosteroids should be carefully monitored for acute adrenal insufficiency in response to stress.
• Lab Test Considerations: Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal (HPA) axis suppression in chronic therapy. Children and patients using higher than recommended doses are at highest risk for HPA suppression.

Potential Nursing Diagnoses

Implementation

• Intranasal: Shake bottle gently before use to ensure a consistent amount is dispensed per actuation. For initial use, prime pump by actuating 8 times. If not used for 4 consecutive days, reprime with 1 spray or until a fine mist appears. Wipe applicator tip with a clean tissue and replace dust cap after each use. Discard bottle after 120 actuations following initial priming or after 4 mo after bottle is removed from foil pouch, whichever occurs first.
  • Patients also using a topical decongestant should be given decongestant 5–15 min before corticosteroid nasal spray. If patient is unable to breathe freely through nasal passages, instruct patient to blow nose gently in advance of medication administration.

Patient/Family Teaching

• Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Medication should be used at regular intervals for best effect.
• Caution patient not to exceed maximal daily dose.
• Instruct patient in correct technique for administering nasal spray (see ). Most nasal sprays include directions with pictures. Instruct patient to read patient information sheet prior to use. Shake well before use. Warn patient that temporary nasal stinging may occur.
• Advise patients on immunosuppressive doses of cortiosteroids to avoid exposure to chickenpox or measles. If exposed, contact health care professional.
• Inform patient that glaucoma and cataracts may occur with intranasal steroids. Advise patient to have regular eye exams and to notify health care professional if changes in vision occur during use.
• Instruct patient to notify health care professional if symptoms do not improve within 1–2 wks for seasonal allergic rhinitis or 5 wks in perennial allergic rhinitis or if nasal discharge becomes purulent.

Evaluation/Desired Outcomes

• Resolution of nasal stuffiness, discharge, and sneezing in seasonal or perennial rhinitis.