Fluticasone (Systemic, Oral Inhalation)

Drug class: Antineoplastic Agents

Usage of Fluticasone (Systemic, Oral Inhalation)

Asthma

Fluticasone used for long-term prevention of bronchospasm in patients with asthma.

In corticosteroid-dependent patients, fluticasone may permit a substantial reduction in the daily maintenance dosage of the systemic corticosteroid and gradual discontinuance of corticosteroid maintenance dosages.

Fluticasone/salmeterol fixed combination is used only in patients with asthma not responding adequately to long-term asthma controller therapy (e.g., inhaled corticosteroids) or whose disease severity clearly warrants initiation of treatment with both an inhaled corticosteroid and a long-acting β2-adrenergic agonist.

Once asthma control achieved and maintained, assess patient at regular intervals and step down therapy (e.g., discontinue fluticasone/salmeterol), if possible without loss of asthma control, and maintain patient on long-term asthma controller therapy (e.g., inhaled corticosteroids).

Do not use fluticasone/salmeterol in patients with asthma adequately controlled on low or medium dosage of inhaled corticosteroids.

COPD

Fixed combination with salmeterol as the oral inhalation powder (Advair Diskus) is used for maintenance treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema; also used to reduce exacerbations of COPD in patients with a history of exacerbations.

Fluticasone/salmeterol is not indicated for relief of acute bronchospasm.

Relate drugs

How to use Fluticasone (Systemic, Oral Inhalation)

General

  • Adjust dosage carefully according to individual requirements and response.
  • After a satisfactory response is obtained, decrease dosage gradually to the lowest dosage that maintains an adequate clinical response. Achieve the lowest effective dosage, particularly in children, since inhaled corticosteroids have the potential to affect growth.

    • Asthma

  • Recommended initial and maximum dosages of fluticasone oral inhalation are based on previous asthma therapy.
  • Recommended initial dosage of fluticasone in fixed combination with salmeterol (Advair Diskus) oral inhalation powder based on patient’s asthma severity.
  • Recommended initial dosage of fluticasone in fixed combination with salmeterol (Advair HFA) oral inhalation aerosol based on patient’s current asthma therapy.
  • After 2 weeks of fluticasone therapy alone or in fixed combination with salmeterol at the initial dosage, if asthma is inadequately controlled, replace the current strength with a higher strength.

    • Conversion to Orally Inhaled Therapy in Patients Receiving Systemic Corticosteroids

  • When switching from systemic corticosteroids to orally inhaled fluticasone, asthma should be reasonably stable before initiating treatment with the oral inhalation.
  • Initially, administer fluticasone oral inhalation concurrently with the maintenance dosage of the systemic corticosteroid. After at least 1 week, gradually withdraw the systemic corticosteroid.
  • Decrements of the systemic corticosteroid usually should not exceed 2.5–5 mg of prednisone (or its equivalent) each week in patients receiving fluticasone oral inhalation. Once oral corticosteroids are discontinued and symptoms of asthma have been controlled, titrate fluticasone dosage to the lowest effective level.
  • Slowly withdraw patients requiring oral corticosteroids from systemic corticosteroid use after transferring to fluticasone/salmeterol (Advair Diskus) oral inhalation powder. Prednisone dosage reduction may be accomplished by reducing daily dosage of prednisone by 2.5 mg weekly during therapy with fluticasone/salmeterol oral inhalation powder.
  • Do not use fluticasone/salmeterol (Advair HFA) oral inhalation aerosol for transferring patients from systemic corticosteroid therapy.
  • Death has occurred in some individuals in whom systemic corticosteroids were withdrawn too rapidly. (See Withdrawal of Systemic Corticosteroid Therapy under Cautions.)

    • Administration

    Administer by oral inhalation.

    Oral Inhalation

    Administer fluticasone alone or in fixed combination with salmeterol (Advair HFA) as a microcrystalline suspension by oral inhalation using an oral aerosol inhaler with hydrofluoroalkane (HFA; non-chlorofluorocarbon) propellant.

    Administer inhalation powder in fixed combination with salmeterol using a special oral inhaler (Advair Diskus) that delivers the drug from foil-wrapped blisters.

    Following each treatment, rinse the mouth thoroughly with water without swallowing.

    Inhalation Powder

    Administer fluticasone in fixed combination with salmeterol using a special oral inhaler (Advair Diskus). Administer twice daily (morning and evening), about 12 hours apart.

    Hold the Diskus device in one hand, put the thumb of the other hand on the thumbgrip, and push the thumbgrip until the mouthpiece appears and snaps into position.

    Depress the lever away from the body until a click is heard; the lever pierces the foil blister and releases the powdered drug into an exit port. Do not tilt or close the Diskus device, play with the lever, or advance the lever more than once at this point. A dose counter will advance each time the lever is depressed.

    Exhale slowly and completely and place the mouthpiece of the inhaler well into the mouth with lips closed around it. After inhaling dose through the mouth, hold the breath for 10 seconds, and exhale slowly.

    Do not exhale into the Diskus device. Do not use an extra dose from the Diskus device if patient does not feel or taste the drug.

    Rinse the mouth after inhalation of fluticasone/salmeterol. Slide the thumbgrip toward the body to close the Diskus device and reset the device for the next dose. Do not wash the inhaler or take it apart.

    Do not use fluticasone/salmeterol with a spacer device.

    Inhalation Aerosol

    Shake well (5 seconds) immediately prior to initial use. Actuate fluticasone aerosol inhaler 4 times prior to initial use. Test spray the aerosol inhaler containing fluticasone in fixed combination with salmeterol (Advair HFA) 4 times into the air (away from face) before initial use, and shake well for 5 seconds before each spray.

    Actuate fluticasone inhaler once prior to use if it has not been used for >1 week or if inhaler was dropped. If Advair HFA aerosol inhaler not used for >4 weeks or if inhaler was dropped, test spray inhaler twice into the air (away from face) and shake well for 5 seconds before each spray.

    Exhale slowly and completely and place the mouthpiece of the inhaler well into the mouth with lips closed around it. Inhale slowly and deeply through the mouth while actuating the inhaler. Hold the breath for 10 seconds, withdraw the mouthpiece, and exhale slowly.

    Allow 30 seconds to elapse between subsequent inhalations from aerosol inhaler.

    Following each treatment, rinse the mouth thoroughly.

    Clean fluticasone inhaler at least once a week after the evening dose by removing the mouthpiece cap from the inhaler and washing the mouthpiece with moistened cotton; allow the actuator to air-dry overnight.

    Clean Advair HFA aerosol inhaler by wiping the opening where medicine sprays out of metal canister and mouthpiece with a dry cotton swab and dampened tissue, respectively, at least once a week after evening dose; allow actuator to air-dry overnight.

    When dose counter on the aerosol inhaler for fluticasone alone or in fixed combination with salmeterol (Advair HFA) reads “020”, recommend that the patient contact the pharmacy for a refill or consult clinician to determine need for a refill. Discard aerosol inhaler when the dose counter reads “000”. Never alter or remove dose counter from canister.

    Dosage

    Unless otherwise stated, the dose of fluticasone propionate administered as an aerosol via metered-dose inhaler is expressed as the amount delivered from the actuator of the inhaler per metered spray.

    Fluticasone propionate oral inhalation aerosol delivers 50, 125, or 250 mcg from the valve, and 44, 110, or 220 mcg, respectively, from the actuator per metered spray. The 10.6- or 12-g canister delivers 120 metered sprays.

    Doses of fluticasone propionate and salmeterol in the fixed combination oral inhalation powder (Advair Diskus) are expressed as the nominal (labeled) doses contained in each foil-wrapped blister. The amount of drug powder delivered to the lungs depends on factors such as the patient’s inspiratory flow.

    Each actuation of the Advair HFA oral aerosol inhaler delivers 50, 125, or 250 mcg of fluticasone propionate and 25 mcg of salmeterol from the valve. Dosages of Advair HFA are expressed in terms of drug delivered from the mouthpiece; each actuation of the inhaler delivers 45, 115, or 230 mcg of fluticasone propionate and 21 mcg of salmeterol from the mouthpiece.

    Commercially available Advair HFA inhalation aerosol delivers 60 or 120 metered sprays per 8- or 12-g canister, respectively.

    Pediatric Patients

    Asthma Fluticasone Oral Inhalation Aerosol

    Children 4–11 years of age: Initial and maximal dosage is 88 mcg twice daily.

    Children ≥12 years of age previously receiving bronchodilators alone: Initially, 88 mcg twice daily. If control of asthma is inadequate after 2 weeks of therapy at the initial dosage, a higher strength may provide additional asthma control. If required, dosage may be increased to a maximum of 440 mcg twice daily. Consider initial dosages >88 mcg twice daily in children with inadequate asthma control.

    Children ≥12 years of age previously receiving inhaled corticosteroids: Initially, 88–220 mcg twice daily. If required, dosage may be increased to a maximum of 440 mcg twice daily. Consider initial dosages >88 mcg twice daily in those receiving inhaled corticosteroids at higher end of dosage range.

    Children ≥12 years of age previously receiving oral corticosteroids: Initially, 440 mcg twice daily; maximum dosage is 880 mcg twice daily.

    Fluticasone/Salmeterol Fixed Combination Oral Inhalation Aerosol

    Children ≥12 years of age: 90, 230, or 460 mcg of fluticasone propionate and 42 mcg of salmeterol (2 inhalations) twice daily, given approximately 12 hours apart (morning and evening); recommended initial dosage is based on patient’s current asthma therapy.

    If control of asthma is inadequate after 2 weeks of therapy at the initial dosage, replacing the current strength of the fixed combination with a higher strength (higher strengths contain higher dosages of fluticasone only) may provide additional asthma control.

    Oral Inhalation Powder

    Children 4–11 years of age: 100 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily, given approximately 12 hours apart (morning and evening).

    Children ≥12 years of age: 100, 250, or 500 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily, given approximately 12 hours apart (morning and evening); recommended initial dosage is based on patient’s asthma severity.

    If control of asthma is inadequate after 2 weeks of therapy at the initial dosage, replacing the current strength with a higher strength (higher strengths contain higher dosages of fluticasone only) may provide additional asthma control.

    Adults

    Asthma Fluticasone Oral Inhalation Aerosol

    Previously receiving bronchodilators alone: Initially, 88 mcg twice daily. If required, dosage may be increased to a maximum of 440 mcg twice daily. Consider initial dosages >88 mcg twice daily in adults with inadequate asthma control.

    Previously receiving inhaled corticosteroids: Initially, 88–220 mcg twice daily. If required, dosage may be increased to a maximum of 440 mcg twice daily. Consider initial dosages >88 mcg twice daily in those receiving inhaled corticosteroids at higher end of dosage range.

    Previously receiving oral corticosteroids: Initial and maximum dosage is 880 mcg twice daily.

    If control of asthma is inadequate after 2 weeks of therapy at the initial dosage, a higher strength may provide additional asthma control.

    Fluticasone/Salmeterol Fixed Combination Oral Inhalation Aerosol

    90, 230, or 460 mcg of fluticasone propionate and 42 mcg of salmeterol (2 inhalations) twice daily, given approximately 12 hours apart (morning and evening); recommended initial dosage is based on patient’s current asthma therapy.

    If control of asthma is inadequate after 2 weeks of therapy at the initial dosage, replacing the current strength with a higher strength (higher strengths contain higher dosages of fluticasone only) may provide additional asthma control.

    Oral Inhalation Powder

    100, 250, or 500 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily, given approximately 12 hours apart (morning and evening); recommended initial dosage is based on patient’s asthma severity.

    If control of asthma is inadequate after 2 weeks of therapy at the initial dosage, replacing the current strength with a higher strength (higher strengths contain higher dosages of fluticasone only) may provide additional asthma control.

    COPD Fluticasone/Salmeterol Fixed Combination Oral Inhalation Powder

    250 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily, given approximately every 12 hours (morning and evening).

    Prescribing Limits

    Pediatric Patients

    Asthma Fluticasone Oral Inhalation Aerosol

    Children 4–11 years of age: Maximum 88 mcg twice daily.

    Children ≥12 years of age previously receiving bronchodilators alone or inhaled corticosteroids: Maximum 440 mcg twice daily.

    Children ≥12 years of age previously receiving oral corticosteroids: Maximum 880 mcg twice daily.

    Fluticasone/Salmeterol Fixed Combination Oral Inhalation Aerosol

    Children ≥12 years of age: Maximum 460 mcg of fluticasone propionate and 42 mcg of salmeterol (2 inhalations) twice daily.

    Oral Inhalation Powder

    Children 4–11 years of age: Maximum 100 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily.

    Children ≥12 years of age: Maximum 500 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily.

    Adults

    Asthma Fluticasone Oral Inhalation Aerosol

    Previously receiving bronchodilators alone or inhaled corticosteroids: Maximum 440 mcg twice daily.

    Previously receiving oral corticosteroids: Maximum 880 mcg twice daily.

    Fluticasone/Salmeterol Fixed Combination Oral Inhalation Aerosol

    Maximum 460 mcg of fluticasone propionate and 42 mcg of salmeterol (2 inhalations) twice daily.

    Oral Inhalation Powder

    Maximum 500 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily.

    COPD Fluticasone/Salmeterol Fixed Combination Oral Inhalation Powder

    Maximum 250 mcg of fluticasone propionate and 50 mcg of salmeterol (1 inhalation) twice daily. Use of higher than recommended dosages does not improve lung function.

    Special Populations

    The following information addresses dosage of fluticasone propionate in special populations. When fluticasone propionate is used in fixed combination with salmeterol, dosage requirements for salmeterol should be considered.

    Geriatric Patients

    Inhalation aerosol: Select dosage with caution, reflecting the greater frequency of decreased hepatic function, presence of coexisting conditions, or other drug therapies.

    Fluticasone/salmeterol: Dosage adjustments not recommended solely because of age.

    Warnings

    Contraindications

  • Primary treatment of severe acute asthmatic attacks or status asthmaticus when intensive measures (e.g., oxygen, parenteral bronchodilators, IV corticosteroids) are required.
  • Fluticasone in fixed combination with salmeterol: primary treatment of status asthmaticus or other acute episodes of asthma or COPD when intensive measures are required.
  • Known hypersensitivity to fluticasone or any ingredient (e.g., milk protein) in the formulation.

    • Warnings/Precautions

    Warnings

    Use of Fixed Combinations

    When used in fixed combination with salmeterol, consider cautions, precautions, contraindications, and interactions associated with each drug.

    Serious Asthma-related Events

    Long-acting β2-adrenergic agonists, such as salmeterol, a component of Advair, increase the risk of asthma-related death when used as monotherapy. Data from clinical trials suggest that monotherapy with long-acting β2-adrenergic agonists also increases the risk of asthma-related hospitalization in children and adolescents.

    Use the fixed combination of fluticasone and salmeterol only in patients with asthma who have not responded adequately to long-term asthma controller therapy (e.g., inhaled corticosteroids) or whose disease severity clearly warrants initiation of treatment with both an inhaled corticosteroid and a long-acting β2-adrenergic agonist. (See Asthma under Uses.)

    Based on review of 4 clinical trials (3 in adults and adolescents and 1 in children), FDA concluded there is no clinically important increased risk of serious asthma-related events (i.e., asthma-related hospitalization, intubation, death) associated with use of concomitant therapy with long-acting β2-adrenergic agonists and inhaled corticosteroids compared with use of inhaled corticosteroids alone for the treatment of asthma. These studies also showed that fixed-combination therapy with long-acting β2-adrenergic agonists and inhaled corticosteroids was more effective in reducing the incidence of asthma exacerbations compared with use of inhaled corticosteroids alone.

    Acute Exacerbations of Asthma or COPD

    Do not initiate therapy with the fixed combination of fluticasone and salmeterol in patients with substantially worsening or acutely deteriorating asthma or acute symptoms of COPD.

    Failure to respond to a previously effective dosage of fluticasone in fixed combination with salmeterol may indicate substantially worsening asthma or COPD that requires reevaluation.

    Do not initiate fluticasone in fixed combination with salmeterol therapy in patients with acute symptoms of asthma (e.g., unresponsive to usual medications, increasing need for inhaled short-acting β-agonists, marked increase in symptoms, recent emergency room visits, sudden or progressive deterioration in pulmonary function).

    If inadequate control of symptoms persists with supplemental β2-agonist bronchodilator therapy or lung function (e.g., PEF) decreases appreciably, reevaluate asthma therapy promptly. Extra/increased doses of salmeterol or other long-acting inhaled β2-agonists (e.g., formoterol) should not be used in such situations. Such reevaluation may include increasing the strength of the fixed combination (higher strengths contain higher dosages of fluticasone only), adding additional inhaled corticosteroids, or initiating systemic corticosteroids. Do not increase the frequency of administration of the fixed combination.

    Withdrawal of Systemic Corticosteroid Therapy

    Possible life-threatening exacerbation of asthma or adrenal insufficiency in patients being switched from systemic corticosteroids to orally inhaled fluticasone.

    Withdraw systemic corticosteroid therapy gradually and monitor for objective signs of adrenal insufficiency (e.g., fatigue, lassitude, weakness, nausea, vomiting, hypotension) during withdrawal of systemic therapy. Also carefully monitor lung function (FEV1 or morning PEF), adjunctive β2-adrenergic agonist use, and asthma symptoms. Patients who have been maintained on ≥20 mg of prednisone (or its equivalent) daily may be most susceptible to such adverse events, particularly during the later part of the transfer.

    Corticosteroid withdrawal symptoms (e.g., joint pain, muscular pain, fatigue, lassitude, depression) may occur.

    Monitor carefully for acute adrenal insufficiency during exposure to trauma, surgery, or infection (particularly gastroenteritis) or other conditions associated with acute electrolyte loss.

    Monitor carefully for eosinophilia, vasculitic rash, worsening of pulmonary symptoms, cardiac complications, and/or neuropathy consistent with Churg-Strauss syndrome.

    Monitor carefully for unmasking of conditions previously controlled by systemic corticosteroid therapy (e.g., rhinitis, conjunctivitis, eczema, arthritis, eosinophilic conditions).

    Do not use the fixed combination of fluticasone and salmeterol as the oral inhalation aerosol (Advair HFA) for transferring patients from systemic corticosteroid therapy.

    Immunosuppressed Patients

    Increased susceptibility to infections in patients who are taking immunosuppressant drugs compared with healthy individuals. Certain infections (e.g., chickenpox, measles) can have a more serious or even fatal outcome in such patients, particularly in children.

    Take particular care to avoid exposure in susceptible patients. If exposure to chickenpox or measles occurs in susceptible patients, consider administering varicella zoster immune globulin (VZIG) or pooled immune globulin (IG), respectively. Consider treatment with an antiviral agent if chickenpox develops.

    Respiratory Effects

    Bronchospasm and/or wheezing may occur.

    If bronchospasm occurs, treat immediately (e.g., with a short-acting β-adrenergic agonist), and discontinue treatment with fluticasone.

    Sensitivity Reactions

    Immediate hypersensitivity reactions (e.g., urticaria, angioedema, rash, bronchospasm, anaphylaxis) may occur.

    Anaphylactic reactions reported in patients with severe milk protein allergy following oral inhalation of powder products containing lactose (e.g., Advair Diskus). (See Contraindications under Cautions.)

    General Precautions

    Ocular Effects

    Glaucoma, increased intraocular pressure, and cataracts reported rarely. Consider regular eye examinations.

    Systemic Corticosteroid Effects

    Administration of higher than recommended dosages of orally inhaled fluticasone may result in manifestations of hypercorticism and suppression of HPA function. If such changes occur, reduce the dosage of fluticasone slowly, consistent with accepted procedures for reducing corticosteroid dosage and management of asthma symptoms.

    Take particular care in monitoring patients postoperatively or during periods of stress for evidence of inadequate adrenal response.

    Musculoskeletal Effects

    Long-term use may affect normal bone metabolism, resulting in a loss of bone mineral density (BMD).

    Use of fluticasone in fixed combination with salmeterol can pose additional risks in patients with major risk factors for decreased BMD, such as tobacco use, advanced age, sedentary life-style, poor nutrition, family history of osteoporosis, or chronic use of drugs that can reduce bone mass (e.g., anticonvulsants, corticosteroids).

    Since patients with COPD often have multiple risk factors for reduced BMD, assess BMD prior to initiation of therapy and periodically thereafter. Consider use of agents to treat or prevent osteoporosis if appreciable reductions in BMD are seen and use of fluticasone and salmeterol in fixed combination is considered to be important for treatment of COPD.

    Infections

    Localized candidal infections of the pharynx reported. If infection occurs, appropriate local or systemic treatment and/or discontinuance of therapy may be required.

    Use with extreme caution, if at all, in patients with clinical or asymptomatic Mycobacterium tuberculosis infections of the respiratory tract; untreated fungal, bacterial, or parasitic infections; or ocular herpes simplex or untreated, systemic viral infections.

    Remain vigilant for possible development of pneumonia in patients with COPD receiving fluticasone in fixed combination with salmeterol (Advair Diskus) oral inhalation powder, since clinical features of pneumonia and COPD exacerbations frequently overlap.

    Lower respiratory tract infections, (e.g., pneumonia) reported in patients with COPD receiving inhaled corticosteroids, including fluticasone alone or in fixed combination with salmeterol (Advair Diskus) oral inhalation powder.

    Other Effects

    Unknown long-term, systemic, and local effects of the drug in humans, particularly developmental or immunologic processes in the mouth, pharynx, trachea, and lung.

    Specific Populations

    Pregnancy

    Category C.

    Lactation

    Distributed into milk in rats; not known whether distributed into human milk.

    Data also not available on effects of fluticasone on the breast-fed child or on milk production.

    Use caution in nursing women.

    Consider benefits of breast-feeding along with the woman’s clinical need for the drug and any potential adverse effects on the breast-fed child from fluticasone or underlying maternal condition.

    Pediatric Use

    Safety and efficacy of fluticasone oral inhalation aerosol or the oral inhalation powder via the Diskus containing fluticasone in fixed combination with salmeterol not established in children <4 years of age.

    Safety and efficacy of the oral inhalation aerosol containing fluticasone in fixed combination with salmeterol (Advair HFA) not established in children <12 years of age. Adverse effect profile of Flovent HFA in pediatric patients (4–11 years of age) generally is similar to that observed in adolescents and adults.

    With long-term use, slows growth rate in children and adolescents; Monitor routinely (e.g., via stadiometry) the growth and development of children receiving prolonged corticosteroid therapy. Weigh benefits of corticosteroid therapy versus possibility of growth suppression and the risks associated with alternative therapies. Use the lowest possible dosage that effectively controls asthma.

    Geriatric Use

    No substantial differences in safety and efficacy relative to younger adults, but increased sensitivity cannot be ruled out.

    Insufficient experience with fluticasone in fixed combination with salmeterol oral inhalation powder in patients ≥65 years of age with asthma to determine whether geriatric patients respond differently than younger patients.

    Increased incidence of serious adverse effects reported in patients ≥65 years of age with COPD receiving fluticasone in fixed combination with salmeterol oral inhalation powder compared with younger adults; however, distribution of adverse effects similar in the two groups. (See Geriatric Patients under Dosage and Administration.)

    Hepatic Impairment

    Plasma concentrations may be increased. Monitor patient closely.

    Common Adverse Effects

    Fluticasone oral inhalation aerosol: Upper respiratory tract infection, upper respiratory inflammation, sinusitis, sinus infection, dysphonia, throat irritation, candidiasis, cough, bronchitis, headache.

    What other drugs will affect Fluticasone (Systemic, Oral Inhalation)

    The following information addresses potential interactions with fluticasone. When used in fixed combination with salmeterol, consider interactions associated with salmeterol. No formal drug interaction studies performed to date with the fixed combinations.

    Metabolized by CYP3A4 isoenzyme.

    Drugs Affecting Hepatic Microsomal Enzymes

    Potent inhibitors of CYP3A4: potential pharmacokinetic interaction (increased fluticasone propionate plasma concentrations).

    Specific Drugs

    Drug

    Interaction

    Comments

    Erythromycin

    No effect on fluticasone pharmacokinetics

    Ketoconazole

    Increased plasma fluticasone concentrations resulting in reduced plasma cortisol AUC

    Use concomitantly with caution

    Ritonavir

    Increased plasma fluticasone concentrations and AUC, resulting in systemic corticosteroid effects (e.g., Cushing’s syndrome, adrenal suppression)

    Concomitant use not recommended unless the potential benefit outweighs the risk of systemic corticosteroid adverse effects

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