Inhaled corticosteroids (ICS) — patient guide

This page covers all the single-agent preventer inhalers in the ICS family. If your inhaler is Pulmicort, Flixotide, Arnuity Ellipta, Alvesco, Asmanex, or Qvar, this is your page. Combination inhalers (Symbicort, Seretide, Breo Ellipta, Trelegy) will have their own page when published.

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Find your inhaler

Generic name	Common brand names	Device	Strengths	How often
Budesonide	Pulmicort Turbuhaler, Pulmicort Respules	DPI / nebuliser	100 / 200 / 400 mcg (Turbuhaler); 0.5 / 1 mg (Respules)	Twice daily
Fluticasone propionate	Flixotide, generics	pMDI / Accuhaler DPI	50 / 125 / 250 mcg (pMDI); 100 / 250 / 500 mcg (Accuhaler)	Twice daily
Fluticasone furoate	Arnuity Ellipta	DPI	100 / 200 mcg	Once daily
Ciclesonide	Alvesco	pMDI	80 / 160 mcg	Once daily
Mometasone furoate	Asmanex Twisthaler	DPI	200 / 400 mcg	Once daily (evening)
Beclomethasone	Qvar Autohaler, Qvar pMDI	pMDI / breath-actuated	50 / 100 mcg	Twice daily

The two fluticasones are not the same drug. Fluticasone propionate (Flixotide) and fluticasone furoate (Arnuity Ellipta, Breo Ellipta) are different molecules with different potencies. They are not interchangeable on a microgram-for-microgram basis. If your pharmacist substitutes, check the full name, not just “fluticasone”.

Supply note. The single-agent versions of Arnuity Ellipta (fluticasone furoate), Asmanex (mometasone), and Qvar (beclomethasone) have had intermittent PBS supply — confirm with your pharmacist at dispensing.

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The single most important thing on this page

A preventer is not a reliever.

Your ICS preventer (Pulmicort, Flixotide, Arnuity, Alvesco, Asmanex, Qvar) is taken every day, even when you feel well. It treats the underlying inflammation over days to weeks. It will not help in a sudden flare.

The reliever (Ventolin, Asmol, Bricanyl — salbutamol / terbutaline) opens the airway in minutes. It is for rescue — sudden breathlessness, before exercise if your action plan says so.

If you’re using your reliever more than twice a week (other than before exercise), the preventer is not doing enough. Message your GP — that’s a review trigger, not a “use more Ventolin” signal.

This sounds like an obvious distinction. It is the most consistently confused message in respiratory medicine, and reliever-only treatment is a documented contributor to asthma deaths — which is why the global asthma strategy changed in 2019 to recommend that no one over the age of 12 should use a reliever-only approach.

You are not being talked down to here. This is genuinely the message that matters most.

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After every dose — rinse, spit, brush, scrape

This is the single most useful self-care habit on any ICS. It takes 30 seconds and dramatically reduces the two commonest side effects (oral thrush and hoarse voice).

1. Rinse your mouth with water.
2. Spit — do not swallow. Swallowing puts steroid into your gut.
3. Brush your teeth.
4. Tongue-scrape — yeast loves the back of the tongue.

If you forget to do this until later in the day, rinse and spit then. If you use a pMDI (Flixotide, Alvesco, Qvar), a spacer reduces oropharyngeal deposition further — most patients on a pMDI should be using a spacer.

If oral thrush keeps coming back despite good technique, the conversation worth having is about switching to ciclesonide (Alvesco), which is activated in the lung rather than the mouth and leaves less steroid behind.

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Inhaler technique — device by device

If the technique is wrong, the medicine doesn’t reach the airway, and the dose effectively doubles or halves depending on the error. Five minutes with your pharmacist or asthma nurse on this is more valuable than swapping the medicine.

• pMDI (Flixotide pMDI, Alvesco, Qvar pMDI) — use a spacer. Shake, breathe out, mouthpiece in, slow steady inhale while pressing the canister once, hold for 5–10 seconds. A spacer (Volumatic, Breath-A-Tech, AeroChamber) gives you a longer window to inhale and catches the propellant-driven blast that would otherwise hit the back of the throat.
• Turbuhaler (Pulmicort Turbuhaler) — fast, deep inhale. Twist the grip until it clicks. Breathe out away from the device (moisture jams the powder). Seal lips around the mouthpiece. Inhale fast and deep. You don’t need to taste anything — the dose is too small to taste reliably. Hold for 5–10 seconds.
• Accuhaler (Flixotide Accuhaler) — fast, deep inhale. Slide the lever to load a dose, then inhale fast and deep through the mouthpiece. Hold for 5–10 seconds.
• Ellipta (Arnuity Ellipta) — fast, deep inhale, once daily. Slide the cover down to load the dose. Inhale fast and deep through the mouthpiece. Hold for 3–4 seconds. Close the cover (which counts as marking the dose used).
• Twisthaler (Asmanex) — fast, deep inhale. Twist the cap off to load the dose. Inhale fast and deep. Hold for 5–10 seconds.
• Qvar Autohaler — breath-actuated pMDI. Push the lever up, breathe out, mouthpiece in, breathe in steadily — the device fires automatically when your inhalation is strong enough. Useful if pMDI co-ordination is poor.

A useful exercise — film yourself on your phone using your inhaler, then watch it back with the technique notes from the National Asthma Council inhaler videos. Almost everyone finds at least one step they’re doing wrong.

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What to expect in the first 6 weeks

Week 1

• Probably won’t feel a dramatic difference. ICS works on a “build up” principle, not a “top up” one.
• Daily use is non-negotiable, including days you feel completely fine.

Weeks 2–4

• Less night waking, less morning chest tightness, less reliever use for most people.
• If you have a peak flow meter or a home spirometry device, the morning numbers usually start lifting.

Weeks 4–12

• Full effect. The airway lining genuinely reorganises over this window.
• This is the right time for a review — your GP looks at symptom diary, reliever use, peak flow if relevant, and adjusts.

If nothing has shifted by 6 to 8 weeks of consistent daily use with good technique, the conversation to have is about dose, device, or whether something else is going on — allergic rhinitis driving post-nasal drip cough, reflux, anxiety-driven breathlessness, vocal cord dysfunction, or an eosinophilic phenotype that may need specialist referral.

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Tap any section below to expand the detail.

How does it work?

Inhaled corticosteroids deliver a small dose of steroid directly to the airway lining. The steroid binds to glucocorticoid receptors in airway cells and shifts the genetic program of those cells away from inflammation — over days to weeks. Eosinophils (a type of white blood cell that drives the asthma inflammation pattern) drop. Mucus production decreases. The airway becomes less twitchy in response to triggers (cold air, exercise, pollen, dust).

This is structural — it changes how the airway behaves over time. That is why it works differently from a reliever (which physically opens an already-tightened airway in minutes via a separate mechanism).

The dose that reaches the bloodstream is a tiny fraction of the inhaled dose — most acts locally and is broken down in the lung or first-pass-metabolised in the liver if swallowed. This is why ICS has a much smaller systemic-steroid signature than oral prednisolone at equivalent anti-inflammatory effect.

Side effects in detail

Common (usually mild and technique-related)

• Oral thrush (candidiasis) — white patches on the tongue, palate, or inner cheeks; sore mouth; altered taste. Dose-related. The rinse-spit-brush-scrape habit prevents most cases. Treatment is topical antifungal (nystatin drops or miconazole oral gel) — does not usually mean stopping the ICS.
• Hoarse voice (dysphonia) — local effect of steroid on the vocal cords. Often improves with spacer use, lower dose, or a switch to ciclesonide. Persistent hoarseness lasting more than 3 weeks warrants ENT review to rule out other causes.
• Sore throat / mild cough on inhalation — usually settles. A spacer helps with pMDIs.

Uncommon

• Bruising of the skin — at very high doses, long-term.
• Mild adrenal effects — see below.

Rare but worth knowing

• Paradoxical bronchospasm. Sudden chest tightness or wheeze immediately after using the inhaler. Rare, but documented. Stop the inhaler, use your reliever, and contact your GP urgently — usually means switching to a different formulation.
• Adrenal suppression. Uncommon at usual doses. The risk rises with sustained high-dose use (over 1000 mcg/day beclomethasone-equivalent in adults, proportionate paediatric doses), concurrent intranasal or topical steroids, oral steroid courses, and CYP3A4 inhibitors (ritonavir, itraconazole, clarithromycin). Symptoms — fatigue, unexplained weight loss, dizziness, nausea, episodes of low blood sugar — need urgent assessment. Never stop a long-term high-dose ICS abruptly without medical input; the adrenal axis may need stepping down.
• Reduced bone mineral density — a small effect at sustained high doses; clinically meaningful mostly in postmenopausal women and older adults already at osteoporosis risk.
• Cataract and glaucoma — small increased risk with long-term high-dose use, particularly in older adults. Routine eye review every 1 to 2 years is reasonable in long-term high-dose users.

In children — growth velocity

This deserves an honest answer. The Cochrane review by Pruteanu (2014) showed roughly 0.5 to 1 cm reduction in growth velocity in the first year of ICS therapy in children. Long-term follow-up of the CAMP study (NEJM 2012) showed about 1 cm shorter final adult height in children who had used inhaled budesonide. Hold both of these things at once — that 1 cm is real, AND uncontrolled asthma is itself growth-limiting and life-threatening. The practical approach is the lowest dose that keeps the airway controlled, growth review at each visit, and never deter from ICS in a child who genuinely needs it.

In COPD — pneumonia signal

TORCH (NEJM 2007) and IMPACT (NEJM 2018) both showed a small but consistent increase in pneumonia risk with fluticasone-containing regimens in COPD. The signal for budesonide-containing regimens is weaker. The risk-benefit calculation favours ICS in COPD patients with frequent exacerbations or an eosinophilic phenotype, and is less clear in pure emphysema with infrequent exacerbations. This is a review-periodically conversation, not a never-use conversation.

Drugs, food, and what to flag

Tell your GP or pharmacist before combining with:

• Potent CYP3A4 inhibitors — ritonavir, cobicistat-boosted regimens (used in some HIV treatment), itraconazole, ketoconazole, clarithromycin, erythromycin. These raise systemic ICS exposure and can cause adrenal suppression even at usual inhaled doses. Most pronounced with fluticasone furoate and fluticasone propionate. Ciclesonide and beclomethasone are usually safer alternatives where the combination is unavoidable.
• Other steroid exposure — oral prednisolone courses, intranasal steroids (Nasonex, Avamys, Rhinocort), topical steroid creams for eczema. The body sees a total steroid load. If you’re on multiple steroid-class medicines, your GP needs to know the total.
• Beta-blockers, especially non-selective (propranolol, sotalol). These can cause bronchoconstriction in asthma. Cardio-selective beta-blockers (bisoprolol, metoprolol, atenolol) are generally tolerated in mild-to-moderate asthma and in COPD — but the conversation should happen.
• Live vaccines (BCG, MMR, varicella, yellow fever, oral typhoid). Reassuring news — inhaled corticosteroids at usual doses are not a contraindication to live vaccines. Only high systemic exposure (oral prednisolone ≥20 mg/day for ≥2 weeks or equivalent) blocks live vaccination. Your ICS is fine.
• Aspirin and other NSAIDs in Samter’s triad — a subset of asthmatic patients (nasal polyps + asthma + aspirin sensitivity) reacts to aspirin and NSAIDs with severe bronchospasm. If you’ve had a reaction, avoid aspirin and NSAIDs and tell every clinician.

Food. No specific food restrictions. The lactose-carrier note above only matters in documented severe IgE-mediated milk-protein allergy.

Alcohol. No direct ICS-alcohol interaction. Heavy drinking impairs adherence to any daily medicine — which is the practical risk.

Generic substitution at the pharmacy. Same active drug, same strength, same device = bioequivalent. The two situations where generic substitution gets confusing are (a) when the device is different (a substituted pMDI from a different manufacturer may use a different actuator and need re-priming) — your pharmacist will brief you, and (b) the fluticasone-propionate-vs-furoate confusion noted above.

Monitoring — what your GP checks and when

• Symptom review at 4 to 12 weeks after starting (or after any dose change). Sleep quality, morning chest tightness, exercise tolerance, reliever use, days off school or work.
• Inhaler technique check at every visit. Genuinely — this is the single highest-yield monitoring item. Film yourself using your inhaler and bring it.
• Written asthma action plan — every patient on a preventer should have one. It tells you what to do when symptoms shift (increase preventer dose, add reliever, start a course of oral steroid, when to call 000). Ask your GP if you don’t have one. Template here.
• Growth in children — height and weight plotted at each visit.
• Eye review every 1 to 2 years in long-term high-dose users.
• Bone density review in postmenopausal women and older adults on sustained high doses, particularly if other osteoporosis risk factors are present.
• Annual flu vaccination, 5-yearly pneumococcal vaccination per RACGP Red Book — both reasonable in any patient with chronic lung inflammation.

Pregnancy and breastfeeding

The position from the Australian Asthma Handbook is clear — continue your preventer through pregnancy and breastfeeding. Uncontrolled asthma in pregnancy is the bigger risk to the baby; flares reduce oxygen delivery to the fetus and are associated with low birth weight and preterm birth.

• Budesonide (Pulmicort) carries the deepest pregnancy safety data and is Australian Pregnancy Category A. If you’re choosing a preventer in pregnancy, this is the usual first choice.
• Fluticasone, ciclesonide, mometasone, beclomethasone — less pregnancy-specific data but no clear safety signal. If you were already well-controlled on one of these before pregnancy, continuing it is usually the right call. Discuss with your GP.
• Planning a pregnancy? Bring it up at the next visit — your GP can review the regimen and confirm you’re on the right preventer at the right dose before you conceive.
• Breastfeeding — ICS is compatible. The amount reaching breast milk is negligible.
• Just found out you’re pregnant? Don’t stop the inhaler. Message your GP for a review.

If your child is on an ICS

This is the section most parents read three times.

The principles are:

1. Lowest effective dose. Every visit your GP should be asking — can this dose be lower without losing control? If symptoms are well-controlled for 3 months, stepping down is usually the next move.
2. Growth at every visit. Height and weight plotted on a growth chart. A small early dip in growth velocity (per the Cochrane review) is expected; sustained falling off the centile is not, and is a flag.
3. Spacer with a pMDI, always, in children under about 6. Below 4, a mask spacer.
4. Written asthma action plan, age-appropriate. Both you and the school need a copy.
5. Inhaler technique reviewed at every visit, even in older children. Technique drifts.

The thing not to do is stop the preventer because you’re worried about growth. Uncontrolled asthma is itself growth-limiting and life-threatening. The number of children admitted to hospital for asthma flares dwarfs the number harmed by appropriate ICS. The judgement call is dose and duration — not whether to treat.

If you have COPD, not asthma

ICS is not for every COPD patient.

The patients who benefit most are those with:

• Frequent exacerbations (≥2 a year requiring oral steroid or antibiotic)
• An eosinophilic phenotype on blood count (eosinophils ≥300/microL is one threshold)
• Overlapping asthma features (variable airflow, atopy, bronchodilator reversibility)

The patients in whom the risk-benefit is less clear are those with pure emphysema, low eosinophils, and infrequent exacerbations. The TORCH and IMPACT trials both showed a small but consistent pneumonia signal with fluticasone-containing regimens in COPD — review of ICS necessity in COPD periodically is good practice.

The COPD-X concise guide from Lung Foundation Australia is the AU reference.

Stopping or pausing

Do not stop without talking to your GP first. Stopping an ICS abruptly in well-controlled asthma can let the airway inflammation come back over weeks, leading to a flare you didn’t see coming.

• If side effects are the problem — usually we change ICS (switch to ciclesonide for thrush, switch device for technique, lower the dose for systemic effects), not stop entirely.
• If you’ve been well-controlled for 3 months or more — a stepwise dose reduction with monitoring is reasonable. This is a planned step-down, not a “I feel fine, so I’ll stop” decision.
• Sick day rules — ICS is one of the medicines you usually continue (or sometimes double, per your action plan) during a chest infection or flare, not stop. The action plan tells you which.
• Before surgery — most anaesthetists prefer you to continue your preventer up to and including the morning of surgery. Confirm with the anaesthetist.
• Sustained high-dose users — never stop abruptly. The adrenal axis may need a stepped withdrawal under medical supervision.

What to do in a flare-up

This is what your written asthma action plan covers — and every preventer patient should have one.

The general pattern (but follow your specific action plan):

• Reliever (Ventolin) up to every 4 hours for mild symptom increase.
• Increase preventer — sometimes double the dose for 2 weeks, per your action plan.
• Oral prednisolone if symptoms are not settling — your action plan may give you a “rescue” prescription to start at home.
• Call 000 if reliever is needed more often than every 3 hours, can’t speak in full sentences, lips/fingertips turning blue, or symptoms not improving with reliever.

If you don’t have a written action plan, that’s the next conversation with your GP — it is the single most useful piece of paperwork in asthma management, and it should be reviewed at least annually. Template at National Asthma Council.

Cost

Most single-agent ICS are on the PBS. From 1 January 2026, the PBS co-payment is:

• General patient: up to $25.00 per script
• Concession card holder: up to $7.70 per script

A note on PBS supply — the single-agent versions of Arnuity Ellipta (fluticasone furoate), Asmanex (mometasone), and Qvar (beclomethasone) have had intermittent supply on the PBS over recent years. If your script can’t be filled, your pharmacist can usually flag a clinically-equivalent alternative for a quick swap conversation with your GP.

Generic versions cost the same as branded ones at PBS pricing and work the same. Your actual charge may be lower if the medicine costs less than the co-payment. Confirm with your pharmacist — they can show you the exact price.

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The integrative view

Most patients on an ICS want to know what else they can do alongside the inhaler. This section is that conversation in long form. The framing throughout is both-and — the preventer is doing one piece of work (reducing airway inflammation chemically), and there are several other pieces of work that genuinely move the needle on asthma control. Combined, they work better than either alone. The goal for many patients is the lowest effective dose of the lowest-side-effect medicine, alongside genuine lifestyle inputs that reduce the underlying inflammation load.

Strong evidence — reliably useful

These are the interventions where the evidence is solid enough to recommend to any patient on an ICS for asthma or COPD.

• A written asthma action plan. Reduces hospital admissions and emergency visits more than almost any other single intervention in asthma management. Free from your GP. Template from National Asthma Council.
• Smoking cessation and avoiding second-hand smoke. Single biggest lever in COPD; large lever in asthma. Quitline 137848.
• Annual flu vaccination, 5-yearly pneumococcal vaccination per RACGP Red Book. Vaccination reduces exacerbation rates.
• Indoor air quality. Damp + mould exposure, gas-stove combustion products, dust-mite reservoirs in bedding, second-hand smoke, and bushfire smoke are documented asthma triggers. A HEPA-grade air purifier in the bedroom, frequent washing of bedding in hot water, addressing damp, and shifting from gas to induction cooking where feasible are interventions with reasonable evidence.
• Identifying and avoiding personal triggers. Pollen-driven seasonal worsening, NSAID sensitivity in the Samter’s triad subset, cold-air-induced bronchoconstriction, exercise-induced bronchoconstriction, perfume and chemical irritants. Trigger-tracking with a simple diary for 4 weeks is genuinely useful.
• Treating allergic rhinitis. Uncontrolled hay fever drives post-nasal drip, mouth breathing, and airway inflammation that worsens asthma. Intranasal steroid spray (separate to your ICS) and/or non-sedating antihistamines, plus saline rinses, are the standard moves.

Moderate evidence — likely helpful

• Vitamin D adequacy. Low vitamin D is associated with worse asthma control and more exacerbations. The strongest evidence is for correcting deficiency rather than supplementing in those already replete. Check 25(OH)D if you’re on sustained moderate-to-high dose ICS, are housebound, older, or have darker skin in southern Australia.
• Breathing retraining — Buteyko, Papworth, or physiotherapy-led breathing exercises. Evidence is modest. Will not replace your ICS. Can reduce reliever use, symptom perception, and breathing-pattern dysfunction in a subset of patients. Useful adjunct, not a substitute.

• Aerobic exercise. 150 minutes/week of moderate-intensity aerobic activity improves symptom scores and exercise tolerance in asthma and COPD. Use your reliever before exercise if your action plan says so.
• Weight loss if overweight. Even modest weight loss (5–10% of body weight) improves asthma symptom scores in patients with overlapping obesity-related airway inflammation.
• Stress and vagal tone. Anxiety and sympathetic-dominant breathing patterns amplify symptom perception and trigger reactive airways. Slow nasal breathing (around 6 breaths/minute), meditation, and yoga have modest evidence. Not a substitute for the ICS; useful where stress is a clear trigger.

Limited or emerging evidence

• Magnesium intake. Adequate dietary magnesium (leafy greens, legumes, nuts, seeds, wholegrains) supports smooth-muscle function. IV magnesium has a defined role in acute severe asthma in hospital. Oral magnesium supplementation has not been shown to reduce chronic asthma symptoms in well-conducted trials — don’t rely on it as a preventer alternative.
• Omega-3 (EPA + DHA), 1–3 g/day. Modest anti-inflammatory adjunct. The bigger reason to consider it is cardiovascular risk, particularly in COPD patients with concomitant cardiovascular disease.
• Probiotics for recurrent oral thrush. Weak direct evidence. If thrush keeps recurring despite good rinse-spit technique, address technique first, then consider switching to ciclesonide, then dietary fermented foods (yoghurt, kefir, sauerkraut, kimchi).
• Hibiscus tea, aged garlic, beetroot juice — recognised for blood pressure rather than asthma. No direct asthma evidence.

What does not belong in this conversation

• Stopping the ICS in favour of “natural” alternatives. There is no herbal, dietary, or breathing intervention with anywhere near the evidence base of ICS for preventing asthma exacerbations. The evidence base for preventing asthma deaths in reliever-only patients is the GINA position — the right approach is keep the ICS, add the lifestyle work, then review the dose.
• High-dose vitamin C, zinc megadoses, or unspecified “immune boosters” marketed for respiratory disease. The evidence is weak-to-absent; the marketing is loud.
• Off-label use of an ICS for eosinophilic oesophagitis (swallowed budesonide / fluticasone, or oral viscous budesonide) — this is a real specialist-led therapy in gastroenterology, but it is not initiated in general practice and not a self-directed use. If your gastroenterologist has discussed it, follow their plan.

Earning a lower dose

Most patients on an ICS for asthma can be stepped down to a lower dose once control is good for at least 3 months. The conversation is — what does the lowest dose that still keeps the airway controlled look like, given the trigger profile and the lifestyle inputs? It’s a planned, monitored step-down — not a “I feel fine, I’ll skip a few” decision. Some patients can come off entirely if asthma was mild and the trigger profile has been addressed (smoking cessation, weight loss, damp remediation, allergen management). Others stay on a low maintenance dose long-term and that’s the right answer for them.

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Track these between now and your next visit

• Reliever use — how many puffs per week. Anything above twice a week (other than before exercise) is a review trigger.
• Night waking — how many nights per week your sleep was disrupted by cough, chest tightness, or breathlessness.
• Morning symptoms — chest tightness, cough, wheeze on waking.
• Any new symptoms — sore throat, white patches in mouth, voice change, persistent cough after starting the inhaler, palpitations.
• Inhaler technique — film yourself using it and bring the video.
• Anything new you’ve bought over the counter (cold and flu tablets, NSAIDs, herbal preparations) or any new prescription medicine.

Bring the list to your review appointment.

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This is general information, not personal medical advice. Every patient is different. Decisions about your inhaler — which device, what dose, when to step down, what to combine with — are made with the doctor who prescribed it. If anything on this page appears to contradict advice from your treating doctor, follow your doctor; they have context about your situation that this page cannot.

Reading this page does not establish a doctor-patient relationship with Dr Hoebing Lo. If you are not a current patient, please discuss your inhaler with your own GP, specialist, asthma nurse, or pharmacist.

About the integrative content. The lifestyle, dietary, and complementary recommendations on this page summarise current published research. Effect sizes are approximations from clinical studies — your individual response will vary, and real-world results are commonly smaller than trial results because day-to-day life differs from study conditions. Supplements and herbal products are not interchangeable with prescribed medication and can interact with it. Talk to your doctor and pharmacist before starting any new supplement, herbal product, or significant change in diet.

Currency. This page reflects clinical practice as of the last-reviewed date. Medicine evolves; specific details may date between reviews. PBS supply for some single-agent ICS (Arnuity Ellipta, Asmanex, Qvar) has been intermittent — confirm with your pharmacist.

No commercial relationships. Dr Hoebing Lo has no financial or commercial relationship with the manufacturer of any inhaler, brand, spacer, supplement, or device mentioned on this page.

Emergencies. If you have sudden severe breathlessness, can’t speak in full sentences, lips or fingertips turning blue, chest pain, or your reliever isn’t working — call 000 or go to your nearest emergency department. Do not wait, and do not message us first.