close

Log in

Access to premium content is restricted to healthcare professionals / registered members. Login with your email address to continue.

Forgot Your Password?

Don't have an account? Sign up

By signing in or creating an account, you agree to our Terms and conditions and Privacy notice

This site is intended for Healthcare Professionals only
Back to CKS

Drugs and devices

Corticosteroids - inhaled

Last revised in July 2025

Corticosteroids are synthetic analogues of hormones produced by the adrenal cortex.Inhaled corticosteroids are glucocorticoids

Corticosteroids - inhaled: Summary

  • Corticosteroids are synthetic analogues of hormones produced by the adrenal cortex.
  • They exhibit glucocorticoid and/or mineralocorticoid properties, and the ratio of these properties influences their efficacy and therapeutic use.
  • Inhaled corticosteroids (ICS) primarily exert glucocorticoid effects and are used to manage respiratory conditions, such as asthma and chronic obstructive pulmonary disease (COPD). They reduce airway inflammation by suppressing cytokine production, decreasing microvascular permeability, and inhibiting eosinophil infiltration.
  • The ICS currently available in the UK are beclometasone dipropionate, budesonide, ciclesonide, fluticasone furoate, fluticasone propionate, and mometasone furoate. ICS are also available in combination with a long-acting beta-agonist (LABA) and as triple therapy with a LABA and a long-acting muscarinic antagonist (LAMA).
  • ICS are delivered directly to the lungs via various devices, including pressurized metered-dose inhalers (pMDIs), breath-actuated inhalers, and dry powder inhalers. 
  • When initiating an ICS:
    • The most appropriate device should be selected, considering factors such as the person's age, physical and cognitive ability, preference, and the inhaler's environmental impact.
    • Inhaler technique should be demonstrated and checked.
    • Inhalers should ideally be prescribed by brand name to ensure device consistency and support adherence.
    • A spacer device should be prescribed with pMDIs.
    • It should be noted that extra fine-particle inhalers (such as Qvar®) are more potent than traditional inhalers (such as Clenil Modulite®), and that fluticasone furoate (in Relvar Ellipta®) is more potent than fluticasone propionate (found in inhalers such as Flixotide® and Seretide®). Therefore, their doses are not interchangeable.
    • A steroid alert card should be provided if appropriate. 
  • There are no contraindications to the use of ICS. However, care should be taken in people with:
    • Active (untreated) or quiescent tuberculosis.
    • Untreated fungal, bacterial, systemic viral infections, or ocular herpes simplex.
  • Local adverse effects of ICS include oral candidiasis, throat irritation, hoarseness, steroid rash, and paradoxical bronchospasm.
  • Systemic adverse effects (such as adrenal suppression and growth retardation in children) can occur with prolonged high-dose treatment or when systemic exposure is increased by other factors, such as concurrent use of other corticosteroid preparations. 
  • To reduce the risk of adverse effects:
    • Inhaler technique should be regularly reviewed.
    • The lowest effective ICS dose should be prescribed.
    • ICS treatment should be tapered gradually when withdrawing.
    • Appropriate information and advice should be given to the person, including using a spacer with pMDIs, gargling after ICS doses, not stopping ICS suddenly, recognizing infection risk, identifying signs of adrenal suppression, carrying a steroid alert card (if needed), following sick day rules (where relevant), and attending review appointments.
  • Cytochrome P450 3A4 (CYP3A4) inhibitors may reduce the metabolism of ICS, increasing the risk of systemic adverse effects. Where possible, concurrent use with potent CYP3A4 inhibitors (such as ketoconazole, itraconazole, ritonavir, and cobicistat) should be avoided.

Have I got the right topic?

From birth onwards.

This CKS topic covers the general management of people receiving inhaled corticosteroids (ICS) in primary care.

This CKS topic does not cover the management of the specific condition for which the ICS is prescribed. It also does not include information on treatment dosages.

There are separate CKS topics on Corticosteroids - oral and Corticosteroids - topical (skin), nose, and eyes.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2025 — minor update. The sections on Actions of corticosteroids and Steroid alert cards have been revised. Broken links have been fixed.

Previous changes

April 2025 — reviewed. A literature search was conducted in March 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last version of this topic. No major changes to recommendations have been made.

December 2023 — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.

May 2020 — reviewed. A literature search was conducted in May 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic.

April 2020 — minor update. Advice on using inhaled corticosteroids (ICS) during the COVID-19 pandemic has been added in line with the National Institute for Health and Care Excellence (NICE) guidelines COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD) [NICE, 2020] and COVID-19 rapid guideline: severe asthma [NICE, 2020]. 

July to September 2015 — reviewed. A literature search was conducted in June 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last version of this topic. There have been no major changes to the recommendations.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

November 2011 — minor update. Based on the updated Summary of Product Characteristics (SPC) for Symbicort Turbohaler®, the section on Drug interactions has been updated to include a possible interaction between budesonide and potent cytochrome P450 inhibitors. 

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

September 2010 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has reminded prescribers that psychological and behavioural adverse effects may occur with ICS. 

April to August 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2025.

New policies

No new national policies or guidelines since 1 March 2025.

New safety alerts

No new safety alerts issued since 1 March 2025.

Changes in product availability

No changes in product availability since 1 March 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Ensure that people receiving inhaled corticosteroids in primary care are properly managed.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP were found during the review of this topic.

NICE quality standards

Chronic obstructive pulmonary disease in adults:

  • People with COPD who are prescribed an inhaler have their inhaler technique assessed when starting or changing treatment and then at least annually during treatment.

[NICE, 2023]

Background information

What are corticosteroids?

  • Corticosteroids are synthetic analogues of hormones produced by the adrenal cortex.
    • They are used to treat a wide range of conditions, including:
      • Respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD).
      • Autoimmune diseases, such as rheumatoid arthritis and inflammatory bowel disease.
      • Endocrine disorders, such as Addison’s disease.
      • Skin disorders, such as eczema and dermatitis.
      • Nasal conditions, such as allergic rhinitis and nasal polyps.
      • Eye conditions, such as uveitis and post-operative inflammation.

[Ritter, 2020]

 

How do corticosteroids work?

  • Corticosteroids mimic the effects of hormones naturally produced by the adrenal cortex, exhibiting glucocorticoid and/or mineralocorticoid properties. 
    • The ratio of glucocorticoid to mineralocorticoid properties varies between corticosteroids and influences their efficacy and therapeutic use.
    • Glucocorticoid effects include metabolic, anti-inflammatory, immunosuppressive, anti-proliferative, vasoconstrictive, and regulatory actions. For more information, see the section on Actions of corticosteroids in the CKS topic on Corticosteroids - oral.
    • Mineralocorticoid effects include increased sodium and water retention, and increased potassium and hydrogen ion loss. 
  • Inhaled corticosteroids primarily exert glucocorticoid effects, reducing airway inflammation by:
    • Suppressing cytokine production.
    • Decreasing microvascular permeability.
    • Inhibiting eosinophil infiltration.

[Atack, 2018; Brown, 2018; Ritter, 2020]

Which inhaled corticosteroids are available in the UK?

  • The inhaled corticosteroids (ICS) available in the UK are:
    • Beclometasone dipropionate.
    • Budesonide.
    • Ciclesonide.
    • Fluticasone furoate. 
    • Fluticasone propionate.
    • Mometasone furoate.
  • ICS are also available in combination with a long-acting beta-agonist (LABA) and as triple therapy with both a LABA and a long-acting muscarinic antagonist (LAMA).
    • ICS/LABA inhalers available in the UK include: 
      • Beclometasone dipropionate and formoterol.
      • Budesonide and formoterol.
      • Fluticasone furoate and vilanterol.
      • Fluticasone propionate and formoterol.
      • Fluticasone propionate and salmeterol.
      • Mometasone furoate and indacaterol.
    • ICS/LABA/LAMA inhalers available in the UK include:
      • Beclometasone dipropionate, formoterol, and glycopyrronium.
      • Budesonide, formoterol, and glycopyrronium.
      • Fluticasone furoate, vilanterol, and umeclidinium.
      • Mometasone furoate, indacaterol, and glycopyrronium.
  • ICS can be delivered via a range of devices, including pressurized metered-dose inhalers, breath-actuated inhalers, and dry powder inhalers.
    • For detailed information on the ICS products available in the UK, see the RightBreathe website (www.rightbreathe.com). 

Management

Scenario: Corticosteroids - inhaled

From birth onwards.

What contraindications and cautions are associated with inhaled corticosteroids?

  • There are no contraindications to the use of inhaled corticosteroids (ICS).
  • Prescribe ICS with caution to:
    • People with: 
      • Active (untreated) or quiescent tuberculosis.
      • Untreated fungal, bacterial, systemic viral infections, or ocular herpes simplex.
    • Pregnant or breastfeeding women.
  • Be aware of factors that increase systemic exposure to corticosteroids, and therefore the risk of systemic adverse effects, such as:
    • Age — younger (and smaller) children may be at greater risk of systemic adverse effects from ICS because they receive relatively higher doses per kilogram of body weight.
    • Steroid properties — ICS differ in potency and systemic bioavailability. For example, Clenil Modulite® has moderate potency with low systemic exposure, while Qvar® has higher lung deposition and systemic exposure. 
    • Treatment dosage and duration — higher doses and longer or more frequent use increase systemic exposure.
    • Concurrent corticosteroid treatment — systemic exposure increases when ICS are combined with other corticosteroid preparations (for example, oral or intranasal).
    • Concurrent use of an enzyme inhibitor — cytochrome P450 3A4 (CYP3A4) inhibitors, such as ritonavir, itraconazole, and ketoconazole, reduce steroid metabolism and increase systemic corticosteroid levels.

Basis for recommendation

These recommendations are largely based on the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], the British National Formulary (BNF) [BNF, 2025], and the manufacturers' Summaries of Product Characteristics (SPCs) for Clenil Modulite® [EMC, 2023a], Qvar® [EMC, 2024], and Asmanex® [EMC, 2025].

What should I consider when initiating an inhaled corticosteroid?

  • When initiating an inhaled corticosteroid (ICS):
    • Select the most appropriate device, considering factors such as the person's age, physical and cognitive ability, preference, and the device's environmental impact. For more information, see the section on Choosing an inhaler device.
    • Ensure that the person and/or their parents/carers know how to use the device. Demonstration videos are available on the Asthma + Lung UK website (www.asthmaandlung.org.uk).
    • Check individual manufacturers' Summaries of Product Characteristics (SPCs) for licensing, prescribing, and dosing information. Be aware that:
      • Different products and dosages are licensed for different age groups.
      • Inhalers with extrafine particles (such as Qvar®, Kelhale®, Luforbec®, and Fostair®) are more potent than, and not interchangeable with, traditional (non-extrafine particle) inhalers. For example, Qvar® and Kelhale® inhalers are approximately twice as potent as Clenil Modulite® and Soprobec®.
      • Fluticasone furoate (in Relvar Ellipta®) is more potent than, and not interchangeable with, fluticasone propionate (found in inhalers such as Flixotide® and Seretide®).
    • Prescribe inhalers by brand name to ensure device consistency and support adherence. This is especially important for products like Qvar® and Clenil Modulite®, which are not interchangeable due to differences in potency.
    • Consider the need for a steroid alert card.
    • Provide clear information and advice to ensure safe use and reduce the risk of adverse effects.

Steroid alert cards for inhaled corticosteroids

There are two types of steroid alert cards: the Steroid Treatment Card (Blue) and the Steroid Emergency Card (Red). 

  • The Steroid Treatment Card (Blue) provides treatment details (prescriber, dosage, and duration) and guidance on reducing steroid risks.
  • The Steroid Emergency Card (Red) helps healthcare staff identify adults with adrenal insufficiency and provides guidance on emergency treatment during acute illness, trauma, surgery, or other significant stress.
    • It should be given to adults with adrenal insufficiency and steroid dependence for whom missed doses, illness, or surgery puts them at risk of adrenal crisis, such as those with Addison’s disease, congenital adrenal hyperplasia, and hypothalamo-pituitary damage from tumours or surgery.
    • People on prolonged and/or high-dose corticosteroid treatment for other conditions may also develop adrenal insufficiency due to suppression of the hypothalamic–pituitary–adrenal (HPA) axis and become steroid dependent. For more information, see the section on Adrenal insufficiency in the CKS topic on Corticosteroids - oral.
    • A joint guideline by the Society for Endocrinology (SfE) Steroid Emergency Card working group and Specialist Pharmacy Services (SPS) recommends issuing a Steroid Emergency Card to adults prescribed:
      • More than 1000 micrograms of beclomethasone per day, more than 500 micrograms of fluticasone per day, or an equivalent dose of another glucocorticoid, and for 12 months after stopping.
      • Specified doses of ICS in combination with any other form of glucocorticoid treatment — see the guideline for ICS dose details.
    • The  SfE/SPS guideline also recommends providing both a Steroid Emergency Card and sick day rules advice to:
      • People with respiratory disease (such as asthma) who are on high-dose ICS and have had repeated courses of oral steroids (3 or more courses over the past 6 months).
      • People receiving intra-articular or intramuscular glucocorticoid injections in combination with other glucocorticoid preparations (for example, inhaled).
      • People taking CYP3A4 inhibitors (such as ritonavir, itraconazole, and ketoconazole) in combination with other glucocorticoid preparations (except for small amounts of mild or moderate topical glucocorticoids, which should be assessed on a case-by-case basis).
    • The Steroid Emergency Card can be ordered from PCSE online. A printable version is available on the SfE website (www.endocrinology.org).
  • For children with adrenal insufficiency and steroid dependence, the British Society for Paediatric Endocrinology and Diabetes (BSPED) has developed an Adrenal Insufficiency Card, which includes a management summary for the emergency treatment of adrenal crisis and sick day dosing. 

Basis for recommendation

These recommendations are largely based on the joint British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) [BTS/NICE/SIGN, 2024], the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], and what CKS considers to be good clinical practice.

What devices are available for inhaled corticosteroids?

  • Pressurized metered-dose inhalers (pMDIs)
    • pMDIs deliver corticosteroids in aerosol form using a propellant (typically hydrofluoroalkane). The medicine is contained in a pressurised canister and is released when the user presses down on the canister.
    • A slow and steady inhalation is needed while pressing the canister to release the medicine. 
    • Adequate dexterity and hand–breath coordination are necessary for effective drug delivery during actuation. 
    • A spacer device should be used for better drug delivery.
    • Information on the pMDIs available in the UK can be found on the RightBreathe website (www.rightbreathe.com).
  • Breath-actuated MDIs (BA-MDIs)
    • BA-MDIs deliver corticosteroids in aerosol form using a propellant (typically hydrofluoroalkane). The medicine is contained in a pressurised canister and is released when the user inhales through the mouthpiece.
    • A slow and steady inhalation triggers the release of the medicine. 
    • A minimum inspiratory effort is required to generate enough flow for effective drug delivery.
    • No coordination between actuation and inhalation is needed, making BA-MDIs more suitable for people with limited dexterity or coordination.
    • A spacer device is not needed.
    • Information on the BA-MDIs available in the UK can be found on the RightBreathe website (www.rightbreathe.com).
  • Dry powder inhalers (DPIs)
    • DPIs deliver corticosteroids in powder form without the use of a propellant. The medicine is contained in a dry powder reservoir and is released when the user inhales through the mouthpiece.
    • A quick, deep breath is needed to activate the device and deliver the medicine. 
    • A strong inspiratory effort is needed for effective drug delivery.
    • No coordination between actuation and inhalation is required, making DPIs suitable for people with limited dexterity or coordination.
    • A spacer device is not needed.
    • Information on the DPIs available in the UK can be found on the RightBreathe website (www.rightbreathe.com).
  • Nebulisers
    • Nebulisers deliver corticosteroids in aerosol droplets without using a propellant.
    • They use oxygen, compressed air, or ultrasonic power to break up liquid medicines and deliver a therapeutic dose of aerosol particles directly to the lungs. 
    • The medicine is usually administered via a mouthpiece or facemask; each treatment lasts about 5–10 minutes. A mouthpiece is preferred to reduce local adverse effects from corticosteroid exposure to the skin and eyes.
    • Nebulisers do not require coordination or specific inhalation techniques, making them useful for people who are very young, unwell, or have poor inhaler technique. They are typically reserved for situations where inhaled treatment via other devices is inadequate.
    • Patient information on nebulisers is available on the Asthma + Lung UK website (www.asthmaandlung.org.uk).
  • Spacers
    • Spacers are plastic devices designed for use with pMDIs. They typically have a mouthpiece at one end and an opening at the other where the pMDI is inserted.
    • They help improve drug delivery by allowing the medicine to be inhaled more effectively into the lungs. 
    • Several types are available, including the Volumatic® (larger than most) and AeroChamber®; some spacers come with a mouthpiece while others are fitted with a mask, often used for young children or those who struggle with mouthpieces.
    • Spacers are recommended with pMDIs because they: 
      • Remove the need for coordination between actuation of the pMDI and inhalation. 
      • Slow down the drug particles and allow more time for the propellant to evaporate so that more of the drug can be inhaled and deposited in the lungs.
      • Reduce the amount of drug deposited in the oropharynx, thereby reducing local adverse effects and systemic absorption. 
    • They are particularly beneficial for: 
      • Children who need high doses of inhaled corticosteroids (ICS).
      • People with a poor inhaler technique.
      • People who are prone to candidiasis with ICS.
    • Spacers are not interchangeable and must be compatible with the pMDI being used. Compatibility information is available on the RightBreathe website (www.rightbreathe.com).

Basis for recommendation

This information is taken from the Asthma + Lung UK website (www.asthmaandlung.org.uk), the RightBreathe website (www.rightbreathe.com), and the British National Formulary (BNF) [BNF, 2025].

What should I consider when choosing a device for an inhaled corticosteroid?

  • Indication and age
  • Physical and cognitive ability
    • Choose a device that the person can use easily, considering factors such as age, dexterity, comorbidities (such as impaired vision, arthritis, and cognitive impairment), and inspiratory flow.
      • For children under 3 years old, the preferred device is a pressurized metered-dose inhaler (pMDI) with a spacer and face mask.
      • For children aged 3–5 years, the preferred device is pMDI with spacer and a mouthpiece (if they can demonstrate good technique). 
      • For people with arthritis, the preferred device usually requires minimal finger strength and has a simple activation mechanism, such as a breath-actuated metered-dose inhaler (BA-MDIs).
      • A minimum inspiratory flow rate is required for BA-MDIs and dry powder inhalers.
  • Preference and convenience
    • Consider the person's preference for (and willingness to use) a particular device.
    • Consider the suitability of the device to their lifestyle, including portability and convenience. 
  • Concurrent inhaler devices
    • Consider other inhalers the person is using.
    • Where possible, prescribe combination inhalers to reduce the number of devices prescribed and improve adherence.
    • If more than one inhaler is indicated, prescribe devices with the same inhalation technique. 
  • Inhaler cost and availability
    • Choose a device that is cost-effective and available on the local formulary.
    • When choosing the device, consider the total daily dose required and the product price per dose.
  • Environmental impact
    • pMDIs contain propellants that are potent greenhouse gases contributing to climate change. They make up 70% of inhalers prescribed in the UK and account for about 3% of the NHS carbon footprint.
    • Where possible and appropriate:
      • Prescribe devices with a lower carbon footprint, such as DPIs. 
      • Consider combination inhalers to reduce the environmental impact of multiple inhalers. 
      • Prescribe inhalers that deliver the required dose using fewer puffs. For example, Clenil Modulite® 200 micrograms (one puff twice daily) instead of Clenil Modulite® 100 micrograms (two puffs twice daily). 
      • Encourage people to return used or expired inhalers to a local pharmacy for safe and environmentally friendly disposal.
    • An Inhaler carbon footprint comparison tool is available on the PrescQIPP website (www.prescqipp.info).
    • A Patient Decision Aid on Asthma inhalers and climate change is available on the National Institute for Health and Care Excellence (NICE) website (www.nice.org.uk).

Basis for recommendation

These recommendations are largely based on the joint British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) [BTS/NICE/SIGN, 2024], the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], and what CKS considers to be good clinical practice. In addition

  • The information on preferred devices in children is based on the GINA guideline [GINA, 2024].
  • The information on the environmental impact of pressurized metered-dose inhalers is taken from the Asthma + Lung UK website (www.asthmaandlung.org.uk).

Can I prescribe inhaled corticosteroids to a woman who is pregnant or breastfeeding?

  • Pregnancy
    • Inhaled corticosteroids (ICS) can be used as normal at any stage in pregnancy.
  • Breastfeeding
    • ICS can be used by women who are breastfeeding.

Basis for recommendation

Pregnancy
  • Expert opinion in the joint British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) is that inhaled corticosteroids (ICS) can be used as normal during pregnancy [BTS/NICE/SIGN, 2024].
  • The UK Teratology Information Service (UKTIS) advises that exposure to ICS at any stage in pregnancy would not be regarded as medical grounds for termination of pregnancy or any additional fetal monitoring. However, other risk factors may be present in individual cases which may independently increase the risk of adverse pregnancy outcomes. Therefore, clinicians should consider such factors when performing case-specific risk assessments [UKTIS, 2023]. 
Breastfeeding
  • Expert opinion in the joint BTS, NICE, and SIGN guideline is that ICS can be used as normal during breastfeeding [BTS/NICE/SIGN, 2024].
  • Expert opinion in the LactMed® database is that the amounts of ICS absorbed into the maternal bloodstream and excreted into breastmilk are probably too small to affect a breastfed infant [LactMed, 2024].

What are the adverse effects of inhaled corticosteroids?

  • Local adverse effects of inhaled corticosteroids (ICS) include:
    • Candidiasis of the mouth and throat — an antifungal oral suspension or oral gel can be used to treat oral candidiasis without discontinuing ICS treatment.
    • Hoarseness, throat irritation, and cough.
    • Steroid rash (reddening and atrophy) — may develop on the nose and around the mouth if ICS is administered through a face mask or nebulizer.
    • Paradoxical bronchospasm (an immediate increase in wheezing after dosing). 
      • Mild bronchospasm may be prevented by using a short-acting beta-agonist before the ICS or by switching from a pressurized metered-dose inhaler (pMDI) to a dry powder inhaler (as the propellants in pMDIs or incorrect technique may contribute to irritation and bronchospasm).
      • If paradoxical bronchospasm is severe, discontinue the ICS and seek specialist advice.
  • Systemic adverse effects can occur with prolonged high-dose treatment, or when systemic exposure is increased by other factors, such as concurrent use of other corticosteroid preparations.
    • Systemic effects include:
      • Easy bruising.
      • Adrenal suppression.
      • Cushing's syndrome.
      • Osteoporosis.
      • Blurred vision or other visual disturbances (often secondary to cataract or glaucoma, and, rarely, central serous chorioretinopathy).
      • Growth retardation (in children and adolescents).
      • Rarely, psychological or behavioural effects, such as psychomotor hyperactivity, sleep disorders, anxiety, depression, or aggression (particularly in children).
    • For more information on the systematic adverse effects of corticosteroids, see the section on Adverse effects in the CKS topic on Corticosteroids - oral.

Basis for recommendation

These recommendations are largely based on the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], the British National Formulary (BNF) [BNF, 2025], and the manufacturers' Summaries of Product Characteristics (SPCs) for Clenil Modulite® [EMC, 2023a] and Asmanex® [EMC, 2025]. 

  • The GINA guideline notes that higher doses or more potent inhaled corticosteroids increase the risk of adverse effects, and incorrect inhaler technique increases the risk of local adverse effects [GINA, 2024].
  • The information on growth velocity is based on the GINA guideline [GINA, 2024].
  • The information on central serous chorioretinopathy (CSCR) is also based on the Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration [MHRA, 2017]. Blurred vision is a key symptom of CSCR, but it may also indicate other corticosteroid-related ocular complications, such as cataracts or glaucoma.

How can I reduce the risk of adverse effects in people using inhaled corticosteroids?

  • To reduce the risk of adverse effects of inhaled corticosteroids (ICS):
    • Ensure that the person and/or their parents/carers know how to use the inhaler. 
    • Prescribe the lowest effective ICS dose.
    • Review the person regularly (at least annually). During each review:
      • Check inhaler technique.
      • Review the ICS dose, and step down treatment if appropriate. 
    • In children and adolescents receiving prolonged high-dose ICS treatment or those with additional risk factors for systemic exposure:
      • Monitor height accurately and regularly (at least annually) using a growth chart, as growth velocity may decrease during the first 1–2 years of treatment.
      • If growth suppression is suspected, consider reducing the ICS dose if clinically appropriate; refer to a paediatrician if needed.
    • Taper ICS treatment gradually when withdrawing to maintain disease control and reduce the risk of adrenal suppression.
    • Provide clear information and advice to support safe use and reduce the risk of adverse effects.

Basis for recommendation

These recommendations are largely based on the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], the British National Formulary (BNF) [BNF, 2025], and the manufacturers' Summaries of Product Characteristics (SPCs) for Clenil Modulite® [EMC, 2023a] and Asmanex® [EMC, 2025]. 

Monitoring height in children and adolescents
  • The BNF recommends that the height and weight of children receiving prolonged treatment with inhaled corticosteroids (ICS) should be monitored annually; if growth is slowed, referral to a paediatrician should be considered [BNF, 2025].
  • CKS also recommends monitoring the height of children and adolescents receiving prolonged ICS treatment, as well as those with additional risk factors for systemic exposure, such as concurrent use of other corticosteroid preparations. 
  • The GINA guideline recommends that the height of children with asthma should be measured and recorded at least annually, as growth velocity may be lower in the first 1-2 years of ICS treatment [GINA, 2024]:
    • The minimum effective dose of ICS to maintain good asthma control should be used.
    • If decreased growth velocity is observed, other factors, such as poorly controlled asthma, frequent use of oral corticosteroids, and poor nutrition, should be considered, and referral should be arranged if needed.

What are the key drug interactions with inhaled corticosteroids?

Drug interactions are rare with inhaled corticosteroids (ICS), as systemic corticosteroid concentrations are usually low. However, in people on prolonged high-dose ICS treatment, systemic corticosteroid concentrations may be sufficiently high for interactions to become significant.

  • Cytochrome P450 3A4 (CYP3A4) inhibitors may reduce the metabolism of ICS, leading to an increased risk of adverse effects.
    • Avoid concurrent use with potent CYP3A4 inhibitors (such as ketoconazole, itraconazole, ritonavir, and cobicistat).
    • If concurrent treatment is necessary, advise the person to leave as much time as possible between taking the CYP3A4 inhibitor and using their ICS, and to monitor for any adverse effects.
    • Note that beclometasone is less dependent on CYP3A metabolism than some other corticosteroids and may be a suitable alternative.  
  • For information on drug interactions of systemic corticosteroids, see the section on Drug interactions in the CKS topic on Corticosteroids - oral.

Basis for recommendation

  • The manufacturer of Alvesco® inhaler states that concurrent treatment with corticosteroids and potent cytochrome P450 3A (CYP3A) inhibitors (such as ketoconazole, itraconazole, ritonavir, or nelfinavir) should be avoided unless the benefit of treatment outweighs the increased risk of systemic adverse effects [EMC, 2023b].
  • The manufacturer of Symbicort Turbohaler® states that concurrent treatment with itraconazole, ritonavir, or other potent CYP3A4 inhibitors should be avoided. If this is not possible, the interval between administration of the interacting medicines should be as long as possible [EMC, 2023c].
  • The manufacturer of Clenil Modulite® inhaler states that beclometasone is less dependent on CYP3A metabolism than some other corticosteroids, and interactions are unlikely in general; however, the possibility of systemic effects with concurrent use of strong CYP3A inhibitors (such as ritonavir and cobicistat) cannot be excluded. Therefore, caution and appropriate monitoring are advised [EMC, 2023a].
  • The Medicines and Healthcare products Regulatory Agency (MHRA) advises that coadministration of an HIV treatment-boosting agent with a CYP3A-metabolized corticosteroid is not recommended unless the potential benefit of treatment outweighs the risk, in which case the person should be monitored for systemic corticosteroid-related reactions [MHRA, 2016].

What information and advice should I give to a person receiving inhaled corticosteroids?

  • Ensure that the person and/or their parents/carers understand how to use the inhaler correctly.
  • Advise the person to:
    • Use their inhaler regularly (usually twice daily), even when asymptomatic. 
    • Seek medical advice before making any changes to their treatment plan.
    • Follow the manufacturer's instructions for cleaning and maintaining their inhaler. Additional guidance is available on the Asthma + Lung UK website (www.asthmaandlung.org.uk).
    • Keep track of the remaining doses in their inhaler to ensure continuous treatment and avoid running out unexpectedly.
      • Some inhalers have integrated dose counters that indicate when all therapeutic doses have been used.
      • For inhalers without a dose counter, the only way to determine the remaining number of effective doses is to record each actuation used or calculate when the inhaler is likely to become empty based on the prescribed dosage.
      • Shaking, weighing, or floating the inhaler device, or using it until it no longer actuates, are inaccurate and not recommended. 
      • Metered-dose inhalers contain a fixed number of doses. Once used up, they may still actuate, releasing only propellant without medication. This could lead to symptom exacerbation and unnecessary expulsion of harmful propellant gas into the environment.
    • Return used or expired inhalers to a pharmacy for safe, environmentally friendly disposal.
  • Discuss the possible adverse effects of inhaled corticosteroids (ICS).
    • Explain that the risk of adverse effects can be reduced by:
      • Good inhaler technique.
      • Using a spacer device with pressurized metered-dose inhalers (pMDIs).
      • Gargling with water and cleaning the mouth and surrounding skin after inhaling a dose of ICS.
      • Continuing their treatment as prescribed and not stopping suddenly, especially after long-term use.
    • Advise the person to:
      • Be alert for the symptoms of adrenal insufficiency (such as dizziness, nausea, lethargy, and hypotension) and seek urgent medical attention if these occur. For more information, see the section on Adrenal insufficiency in the CKS topic on Corticosteroids - oral.
      • Seek medical advice if they experience other adverse effects, such as visual disturbances, mood or behavioural changes, or easy bruising.
      • Attend all review appointments with the primary care team and, if applicable, their specialist to ensure safe monitoring and effective management of their condition.
  • Advise people using pMDIs to:
    • Use only the spacer prescribed for their inhaler, as spacers are not universally compatible. 
      • Compatibility information is available on the RightBreathe website (www.rightbreathe.com).
      • Advise the person to follow the manufacturer's instructions for cleaning and maintaining the spacer. Additional guidance is available on the Asthma + Lung UK website (www.asthmaandlung.org.uk).
    • Always check the mouthpiece before use to avoid inhaling loose objects. Advise them to:
      • Remove the mouthpiece cover completely.
      • Shake the device and check that the inside and outside of the mouthpiece are clear and undamaged before inhaling a dose.
      • Store the inhaler with the mouthpiece cover on.
  • If the person is on prolonged high-dose ICS treatment or has additional risk factors for systemic exposure (such as concurrent use of other corticosteroids), advise them to:   
    • Carry a Steroid Treatment Card (Blue) and/or a Steroid Emergency Card (Red), as appropriate.
    • Follow sick day rules advice during illness or physical stress, if applicable.
    • Seek prompt medical advice if they become unwell or are exposed to an infectious disease, such as measles.
    • Avoid close contact with anyone who has chickenpox or shingles if they have never had chickenpox, and seek medical advice if exposed.

Basis for recommendation

These recommendations are largely based on the joint British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) [BTS/NICE/SIGN, 2024], the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], and the British National Formulary (BNF) [BNF, 2025].

Measles and chickenpox
  • These recommendations are extrapolated from information in the BNF [BNF, 2025] and the Steroid Treatment Card (Blue). 
    • The BNF advises that prolonged use of corticosteroids can increase the risk and severity of infections, and that infections may present atypically. Therefore [BNF, 2025]:
      • People taking corticosteroids should take particular care to avoid exposure to measles and seek immediate medical advice if exposure occurs.
      • People receiving systemic (oral or parenteral) corticosteroids for purposes other than replacement should be considered at risk of severe chickenpox unless they have previously had the infection. Confirmed chickenpox requires urgent treatment and specialist care.
    • The Steroid Treatment Card (Blue) advises that people should promptly consult their doctor if they become ill or come into contact with anyone who has an infectious disease. People who have never had chickenpox should avoid close contact with those who have chickenpox or shingles and seek urgent medical advice if exposed.
    • While the BNF recommendations specifically apply to systemic corticosteroids, the Steroid Treatment Card does not distinguish between systemic and other forms of corticosteroid treatment.
    • Given the potential for systemic absorption of inhaled corticosteroids (ICS), CKS has extended these recommendations to people on prolonged high-dose ICS treatment, as well as those with additional risk factors for systemic exposure, such as concurrent use of other corticosteroids.
Risk of aspiration with pressurized metered dose inhalers
  • These recommendations are based on the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects [MHRA, 2018].

Supporting evidence

The recommendations in this CKS topic are largely based on the joint British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) [BTS/NICE/SIGN, 2024], the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], the British National Formulary (BNF) [BNF, 2025], and information from the Asthma + Lung UK website (www.asthmaandlung.org.uk), the RightBreathe website (www.rightbreathe.com), and manufacturers' Summaries of Product Characteristics (SPCs). The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on the use of inhaled corticosteroids in primary care.

Search dates

May 2020 - March 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 14th May 2020). The strategy was adapted for The Cochrane Library databases.

S44    S40 AND S43
S43    S41 OR S42 
S42    AB ( inhaled or inhaler* or inhalation* ) OR TI ( inhaled or inhaler* or inhalation* ) 
S41    (MH "Administration, Inhalation") 
S40    S8 AND S39 
S39    S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38
S38    TI infection* or pneumonia* or tuberculosis
S37    (MH "Infections+")
S36    TI growth or development
S35    (MH "Bone Density") 
S34    (MH "Bone Development+")
S33    (MH "Child Development+")
S32    (MH "Growth and Development+")
S31    (MH "Bone and Bones+") 
S30    (MH "Body Height+")
S29    (MH "Growth+")
S28    AB ( adrenal N2 (suppression or insufficiency) ) OR TI ( adrenal N2 (suppression or insufficiency)
S27    (MH "Adrenal Insufficiency+") 
S26    TI drug monitoring 
S25    (MH "Drug Monitoring") 
S24    (MH "Contraindications, Drug") 
S23    TI contraindication* or caution*
S22    TI drug interaction* 
S21    (MH "Drug Interactions+") 
S20    TI drug withdrawal 
S19    TI teratol* 
S18    (MH "Fetus+") 
S17    (MH "Breast Feeding+") 
S16    (MH "Lactation+") 
S15    (MH "Pregnancy Complications+") 
S14    TI pregnan* 
S13    (MH "Pregnancy+") 
S12    MW ae 
S11    TI side effect* or safety or toxicity
S10    TI adverse* 
S9    (MH "Drug-Related Side Effects and Adverse Reactions+") 
S8    S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 
S7    TI corticosteroid* or glucocorticoid* or steroid* or beclometasone or beclomethasone or budesonide or ciclesonide or fluticasone or mometasone or seretide or "relvar ellipta" or symbicort or fostair 
S6    (MH "Mometasone furoate") 
S5    (MH "Fluticasone+") 
S4    (MH "Budesonide+") 
S3    (MH "Beclomethasone") 
S2    (MH "Adrenal Cortex Hormones") 
S1    (MH "Glucocorticoids") 
 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Atack, K. and Clifton, I. (2018) Asthma. In: Whittlesea, C. and Hodson, K. (Eds.) Clinical Pharmacy and Therapeutics. 6th edn. London: Elsevier, 440-456.
  • BNF (2025) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • Brown, D.C. and Brown, M.J. (2018) Adrenal corticosteroids, antagonists, corticotropin. In: Brown, M.J., Sharma, P., Mir, F.A. and Bennett, P.N. (Eds.) Clinical Pharmacology. 12th edn. London: Elsevier, 594-607.
  • BTS/NICE/SIGN (2024) Asthma: diagnosis, monitoring and chronic asthma management (BTS/NICE/SIGN). National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • EMC (2023a) SPC for Clenil Modulite 100 micrograms inhaler (with Dose Indicator). Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2023b) SPC for Alvesco 80 Inhaler. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2023c) SPC for Symbicort Turbohaler 400/12, Inhalation powder. Electronic medicines compendium. Datapharm communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024) SPC for Qvar 50 Easi-Breathe. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2025) SPC for Asmanex Twisthaler 200 micrograms Inhalation Powder. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • GINA (2024) Global strategy for asthma management and prevention. Global Initiative for Asthma. https://ginasthma.org [Free Full-text]
  • Lactmed (2024) Beclomethasone. Drugs and Lactation Database. National Library of Medicine. http://www.ncbi.nlm.nih.gov [Free Full-text]
  • MHRA (2016) Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects. Medicines and Healthcare products Regulatory Agency. www.gov.uk [Free Full-text]
  • MHRA (2017) Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration. Medicines and Healthcare products Regulatory Agency. http://www.gov.uk [Free Full-text]
  • MHRA (2018) Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects. Medicines and Healthcare products Regulatory Agency. http://www.gov.uk [Free Full-text]
  • NHS Dorset CCG (2021) Steroid Treatment Cards. NHS Dorset Clinical Commissioning Group. http://www.nhsdorset.nhs.uk [Free Full-text]
  • Hertfordshire and West Essex Integrated Care Board (2023) Frequently Asked Questions - STEROID CARDS. Hertfordshire and West Essex Integrated Care Board. http://www.hweclinicalguidance.nhs.uk [Free Full-text]
  • NICE (2023) Chronic obstructive pulmonary disease in adults: Quality standard [QS10]. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • Ritter, J.M., Flower, R., Henderson, G. and Rang, H.P. (2020) Rang and Dale's Pharmacology. 9th edn. Oxford: Elsevier.
  • UKTIS (2023) Use of inhaled corticosteroids in pregnancy. UK Teratology Information Service. http://www.uktis.org [Free Full-text]
Change privacy settings