Budesonide ?

Elkins6147

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Hi everyone, I'm looking for a little info. Is anyone out there using Budesonide Formoterol nebulized for croup, pedi asthma and COPD. If so, how do you like it? Do you find it has limited use in older pts due to their daily medications?
 

Peak

ED/Prehospital Registered Nurse
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Symbicort is not indicated for croup. We don't tend to use it for asthma in peds, certainly not to a large degree in our hospital (we only really continue it if they are on it outpatient). This varies by what various insurances will cover and the preferences of asthma/allergy and pulm.

To my understanding symbicort is not available as a nebulized solution in the US.
 

Elkins6147

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Thank you for the reply. It has been used in clinical trials in Ottawa and Baltimore at Johns Hopkins Pediatrics in the ER for mild to moderate croup with (so far) promising results. It is not, however, a standard of care but in trial. I just wonder if anyone else has been using it. I am not sure on supply. it is available packaged like albuterol elsewhere.
 

hometownmedic5

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If it's still in clinical trials at Hopkins, it's years away from an American ambulance, at least one in Massachusetts. If the FDA greenlit a magic, guaranteed to work with no side effects cure for anything, it would be ten years before OEMS would even consider reading the pamphlet.
 

rescue1

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Fomotorol and other LABAs are usually contraindicated in acute bronchospasm unless there’s some new data I haven’t seen. Symbicort is a long term control medication, not for acute exacerbations.

Inhaled steroids alone for croup make sense, but I’ve never seen them used. If a patient is sick enough to be calling an ambulance for croup they probably can get IV steroids and racemic epi though.
 

ThadeusJ

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Its more of a "control the issue" medication versus a rescue medication and traditionally not used as a first line drug for acute exacerbations. Even if the studies prove to be successful, one has to determine the cost/benefit analysis of making them pre-hospital and even then it would take years to deploy (IMO).
 

Gurby

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Fomotorol and other LABAs are usually contraindicated in acute bronchospasm unless there’s some new data I haven’t seen. Symbicort is a long term control medication, not for acute exacerbations.

Inhaled steroids alone for croup make sense, but I’ve never seen them used. If a patient is sick enough to be calling an ambulance for croup they probably can get IV steroids and racemic epi though.
Are they contraindicated, because they can act as a partial agonist and interfere with shorter acting drugs that might have stronger effect? Or are they not indicated, because there are better drugs for the acute setting?
 

rescue1

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Are they contraindicated, because they can act as a partial agonist and interfere with shorter acting drugs that might have stronger effect? Or are they not indicated, because there are better drugs for the acute setting?
My initial understanding was they are contraindicated, as LABA monotherapy was associated with decreased outcomes in acute exacerbation, though a quick search on UpToDate says that fomoterol may have a similar onset time as albuterol “but has not been sufficiently studied for routine use in acute asthma”. This is also from my M2 pharm class which means there’s a chance it’s like ten years out of date and I’m behind the times.

So who knows really. I found one study that showed that fomoterol had similar/indentical outcomes to albuterol in acute asthma so perhaps the data is changing. I’m not sure if it’s worth it to make the switch prehospitally though—I’m not sure if you can do a “continuous LABA” the way you can with albuterol for a severe attack.
 

Peak

ED/Prehospital Registered Nurse
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So I looked more into the research so far.

Essentially nebulized budesonide shows roughly the same efficacy as dexamethasone. The argument for it is that if a kid can't take PO (is vomiting, can't swallow secretions, and so on) you can give it without starting an IV or having to give it IM.

Cost depends on dosing and suppliers but budesonide is roughly $20 a dose, IV Dex is $1-2 (which is what we also give for PO since it isn't more expensive and tastes better than the pills or elixir).

My opinion is that if some kid really isn't clearing their airway because their croup is so bad they should probably have an IV anyway. I recognize that this is easier said as someone who routinely places access is small dry kids but an airway threat ideally should have access. If some kid really doesn't have vasculature and isn't sick enough for an IO then I can see some benefit.

Conversely if some kid is vomiting because of a viral component and not just post-tussive then I think we should be treating the vomiting. Especially with a airway insult we should be trying to keep the juices away from the air holes. Again this patient would probably benefit from having a line started, but keep in mind that ODT zofran works just fine if given rectally.

All of this is excludes the use of IM Dex or zofran, although I'm not a huge fan of either for a variety of reasons.
 
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