Alvesco (Ciclesonide)
Inhaled corticosteroid for chronic asthma maintenance
Quick facts about Alvesco
Key takeaways about Alvesco
- Prodrug activated in the lungs: Ciclesonide is converted to its active form (des-ciclesonide) directly in the airways, resulting in fewer local side effects like oral thrush compared to other inhaled steroids
- Once-daily dosing for most patients: The recommended dose of 160 mcg once daily provides effective asthma control, making it simple to incorporate into daily routine
- Not a rescue inhaler: Alvesco is a preventer medicine for daily use and must not be used to relieve sudden asthma attacks – always keep a short-acting bronchodilator available
- Takes time to build full effect: Improvement may begin within 24 hours, but full benefit requires consistent daily use over 1–2 weeks
- Important drug interactions: Strong CYP3A4 inhibitors such as ketoconazole, itraconazole, and ritonavir can significantly increase ciclesonide exposure and should be discussed with your doctor
What Is Alvesco and What Is It Used For?
Alvesco (ciclesonide) is a preventer inhaler containing an inhaled corticosteroid that reduces inflammation in the airways. It is used for the long-term management of chronic persistent asthma in adults and adolescents aged 12 years and older. It must be taken daily, even when you feel well, and is not intended for relieving acute asthma attacks.
Alvesco is supplied as a clear, colourless pressurised metered-dose inhaler (MDI) that delivers a fine aerosol mist of ciclesonide directly into the lungs when you breathe in through the mouthpiece. It belongs to the class of medicines known as inhaled corticosteroids (ICS), which are the cornerstone of asthma maintenance therapy according to current international guidelines, including the Global Initiative for Asthma (GINA) 2024 report.
What makes ciclesonide unique among inhaled corticosteroids is its status as a prodrug. The molecule you inhale is pharmacologically inactive. It is only when ciclesonide reaches the small airways of the lungs that local esterase enzymes cleave the molecule to release des-ciclesonide (des-CIC), the pharmacologically active metabolite. Des-CIC has approximately 100 times greater affinity for the glucocorticoid receptor than the parent compound, meaning the medicine targets its anti-inflammatory action precisely where it is needed most.
This targeted activation mechanism provides a clinically meaningful advantage. Because the drug is not activated in the mouth and throat, patients using Alvesco tend to experience a lower incidence of oropharyngeal side effects – particularly oral candidiasis (thrush) and dysphonia (hoarseness) – compared with conventional inhaled corticosteroids such as budesonide and fluticasone propionate. Several randomised controlled trials and head-to-head comparisons have confirmed this favourable local tolerability profile.
Alvesco works by suppressing the chronic airway inflammation that underlies persistent asthma. The active metabolite des-CIC enters airway epithelial cells, binds to intracellular glucocorticoid receptors, and modulates the transcription of numerous pro-inflammatory genes. This reduces the production of inflammatory cytokines, chemokines, adhesion molecules, and inflammatory enzymes, ultimately decreasing airway hyperresponsiveness, mucosal oedema, and mucus hypersecretion. Regular use reduces both the frequency and severity of asthma symptoms including wheezing, breathlessness, chest tightness, and coughing.
Alvesco is a maintenance preventer medicine and must not be used to treat a sudden asthma attack or episode of acute breathlessness. In such situations, use your quick-relief (rescue) bronchodilator inhaler (e.g. salbutamol/albuterol) as directed. If your rescue inhaler does not provide adequate relief, seek medical attention immediately.
What Should You Know Before Taking Alvesco?
Before starting Alvesco, tell your doctor about all medical conditions you have – especially a history of tuberculosis, fungal, viral, or bacterial infections – and all medications you are taking. Certain antifungal and antiviral drugs can interact with ciclesonide. Special care is needed when switching from oral corticosteroid tablets to Alvesco.
Contraindications
Do not use Alvesco if you are allergic (hypersensitive) to ciclesonide or any of the other ingredients in this medicine, including anhydrous ethanol and the propellant norflurane (HFA-134a). Allergic reactions, though rare, can include rash, itching, hives, and in very rare cases, swelling of the lips, tongue, or throat. If you experience any signs of a severe allergic reaction after using Alvesco, stop taking the medicine and seek medical attention immediately.
Warnings and Precautions
Talk to your doctor or pharmacist before using Alvesco if you have ever been treated for, or are currently receiving treatment for, pulmonary tuberculosis (TB) or any fungal, viral, or bacterial respiratory infection. These infections may need to be brought under control before inhaled corticosteroid therapy can be started safely.
During treatment with Alvesco, contact your doctor immediately if you experience any of the following:
- Difficulty breathing or worsening symptoms (increased coughing, breathlessness, wheezing, chest tightness, or audible lung sounds) – use your quick-relief bronchodilator as usual
- Waking at night due to asthma symptoms
- Your quick-relief inhaler no longer provides adequate symptom relief
- You need to use your quick-relief inhaler more than 2–3 times per week
- Blurred vision or other visual disturbances
Patients with severe asthma are at increased risk of acute exacerbations and should undergo regular and careful monitoring, including periodic lung function tests, to ensure optimal disease control.
If you are currently taking corticosteroid tablets (e.g. prednisolone), Alvesco may be used as a replacement or to reduce your tablet requirement. Your doctor will supervise this transition carefully. You should begin tapering the oral corticosteroid dose approximately one week after starting Alvesco inhalations. The dose reduction should be gradual, and you may temporarily feel generally unwell during the transition. It is essential to continue using Alvesco and to follow the tapering schedule precisely.
If you develop severe symptoms such as nausea, vomiting, diarrhoea, or fever during the transition, contact your doctor. Previously suppressed allergic conditions (such as rhinitis or eczema) may re-emerge during the switch. The risk of adrenal insufficiency from prior oral corticosteroid use may persist for some time. Symptoms of adrenal insufficiency can include dizziness, fainting, nausea, decreased appetite, weakness, headache, and inability to cope with stress. Your doctor will monitor your adrenal function regularly.
During periods of stress (e.g. surgery or severe asthma exacerbations), you may need supplementary oral corticosteroid tablets. You should carry a steroid warning card with this information.
Pregnancy and Breastfeeding
If you are pregnant, think you may be pregnant, planning to become pregnant, or breastfeeding, consult your doctor before using Alvesco. There is insufficient data on the use of ciclesonide during human pregnancy. Your doctor will discuss the potential benefits and risks with you individually.
The GINA 2024 guidelines emphasise that poorly controlled asthma during pregnancy poses significant risks to both mother and baby, including pre-eclampsia, preterm birth, and low birth weight. The risk of untreated or poorly controlled asthma generally outweighs the potential risk of using inhaled corticosteroids. If your doctor determines that continued treatment is appropriate, the lowest effective dose of ciclesonide should be used.
Adrenal function should be closely monitored in newborns whose mothers received corticosteroids during pregnancy. It is not known whether inhaled ciclesonide passes into breast milk. The decision to prescribe Alvesco during breastfeeding should weigh the expected benefit to the mother against the potential risk to the infant.
Children Under 12 Years
Alvesco is not recommended for children under the age of 12, as there is insufficient data on its safety and efficacy in this age group. For younger children with asthma, your doctor will recommend an alternative inhaled corticosteroid that has been studied and approved for paediatric use.
Kidney and Liver Disease
No dose adjustment is necessary for patients with kidney or liver impairment. However, if you have severe liver disease, your doctor will monitor you more closely for potential systemic corticosteroid side effects, as impaired hepatic metabolism could lead to higher circulating levels of the active metabolite.
Driving and Operating Machinery
Alvesco and its ingredients have no known effect on the ability to drive or operate machinery. You can continue your normal activities while using this medicine.
How Does Alvesco Interact with Other Drugs?
The most clinically important interactions are with strong CYP3A4 inhibitors – particularly ketoconazole, itraconazole, ritonavir, and nelfinavir – which can significantly increase systemic exposure to the active metabolite des-ciclesonide, raising the risk of corticosteroid side effects.
Ciclesonide is primarily metabolised in the liver by the cytochrome P450 enzyme CYP3A4. Medicines that potently inhibit this enzyme can slow the clearance of des-ciclesonide (the active metabolite), leading to increased systemic corticosteroid exposure. While ciclesonide itself has minimal systemic absorption, the risk of systemic corticosteroid side effects – including adrenal suppression, Cushing’s syndrome features, and metabolic effects – cannot be excluded when strong CYP3A4 inhibitors are co-administered.
Tell your doctor or pharmacist about all medicines you are taking, have recently taken, or might take, before starting Alvesco. This includes over-the-counter medicines, herbal products, and supplements.
Major Interactions
| Interacting Drug | Drug Class | Effect | Clinical Recommendation |
|---|---|---|---|
| Ketoconazole | Antifungal (azole) | Increases des-ciclesonide exposure by approximately 3.5-fold via CYP3A4 inhibition | Avoid concurrent use if possible. If co-administration is unavoidable, monitor closely for corticosteroid side effects |
| Itraconazole | Antifungal (azole) | Significantly increases systemic ciclesonide exposure via CYP3A4 inhibition | Avoid concurrent use if possible. Monitor for signs of adrenal suppression |
| Ritonavir | Antiretroviral (protease inhibitor) | Potent CYP3A4 inhibition increases systemic corticosteroid levels substantially | Co-administration not recommended. Consider alternative ICS with fewer CYP3A4-dependent metabolic pathways |
| Nelfinavir | Antiretroviral (protease inhibitor) | CYP3A4 inhibition may increase des-ciclesonide exposure | Avoid if possible. If used, monitor adrenal function and watch for systemic steroid effects |
Minor Interactions and Considerations
Other moderate CYP3A4 inhibitors – such as erythromycin, clarithromycin, diltiazem, verapamil, and grapefruit juice – may also increase des-ciclesonide levels to some extent, though the clinical significance is generally considered lower than with strong inhibitors. Inform your doctor if you regularly consume large amounts of grapefruit juice.
Alvesco is not affected by food or drink. There are no known interactions with short-acting beta-agonists (SABAs), long-acting beta-agonists (LABAs), leukotriene receptor antagonists, or other common asthma medicines. Alvesco can be safely used as part of a step-up asthma treatment regimen alongside these medications.
This medicine contains 4.7 mg of alcohol (ethanol) per dose. The amount in a single dose is equivalent to less than 1 ml of beer or wine. This small amount of alcohol has no noticeable effects and does not interact with other medications at clinically relevant levels.
What Is the Correct Dosage of Alvesco?
The standard recommended dose of Alvesco is 160 micrograms once daily, which provides effective asthma control in most patients. Some patients may be adequately maintained on 80 micrograms once daily. The maximum dose during severe exacerbations is 640 micrograms per day (320 mcg twice daily) for a limited period.
Always use Alvesco exactly as your doctor has prescribed. Do not change the dose without consulting your doctor. The goal is to find the lowest effective dose that controls your asthma symptoms, in line with the GINA stepwise approach to asthma management.
Adults and Adolescents (12 Years and Older)
Standard Maintenance Dose
160 micrograms once daily (one puff of the 160 mcg inhaler, or two puffs of the 80 mcg inhaler), taken either in the morning or evening at a consistent time each day. This dose achieves asthma control in the majority of patients.
Lower Maintenance Dose
80 micrograms once daily (one puff of the 80 mcg inhaler). Some patients with well-controlled asthma may be adequately maintained on this lower dose. Your doctor will determine if this is appropriate for you.
Dose During Severe Exacerbations
Up to 640 micrograms per day (320 mcg twice daily) for a limited period. This temporary dose escalation may be considered for patients experiencing a significant worsening of asthma symptoms. Clinical data does not demonstrate additional benefit of these higher doses beyond 3 months. Your doctor may also prescribe oral corticosteroid tablets and/or antibiotics if appropriate.
| Patient Group | Dose | Frequency | Notes |
|---|---|---|---|
| Adults & adolescents (≥12 yrs) | 160 mcg | Once daily | Standard maintenance; morning or evening |
| Well-controlled asthma | 80 mcg | Once daily | Step-down option for stable patients |
| Severe exacerbation | Up to 320 mcg | Twice daily | Maximum 640 mcg/day; short-term only (≤3 months) |
| Children <12 years | Not recommended | – | Insufficient data; use alternative ICS |
| Renal/hepatic impairment | No dose adjustment | As above | Monitor closely in severe liver disease |
How to Use the Alvesco Inhaler
It is essential that your doctor, nurse, or pharmacist demonstrates the correct inhaler technique before you start treatment. Proper technique ensures the right amount of medicine reaches your lungs. You may wish to practise in front of a mirror the first few times.
Priming: If the inhaler is new or has not been used for a week or more, you must prime it before use. Remove the mouthpiece cap and press the canister three times to release three puffs into the air, away from your face. You do not need to shake the inhaler before use, as the medicine is already in the form of a finely dispersed solution.
- Remove the cap – Take off the mouthpiece cap and check that the mouthpiece is clean and dry, inside and out.
- Hold correctly – Hold the inhaler upside down (canister base pointing upward) with your index finger on top of the canister and your thumb beneath the mouthpiece.
- Breathe out – Breathe out as much as you comfortably can, without straining. Do not breathe out into the inhaler.
- Inhale the dose – Place the mouthpiece in your mouth and close your lips tightly around it. As you begin to breathe in slowly and deeply through your mouth, press down on the canister to release one puff. Continue inhaling. Ensure no medicine escapes from around your mouth.
- Hold your breath – Remove the inhaler, take your finger off the canister, and hold your breath for about 10 seconds, or as long as comfortable. Then breathe out slowly through your mouth.
- Second puff – If a second puff is prescribed, wait approximately 30 seconds and repeat steps 3–5.
- Replace the cap – Always replace the mouthpiece cap securely after use to keep the device clean.
Cleaning: Once a week, clean the mouthpiece inside and out with a dry tissue. Use a dry, folded tissue to wipe over the small opening on the front where the medicine is released. Do not use water or any liquid for cleaning.
If your breathing becomes wheezy or tight after using Alvesco, do not take additional puffs. Use your quick-relief bronchodilator inhaler to ease breathing and contact your doctor immediately. Your doctor may recommend using a spacer device (such as AeroChamber Plus) if you have difficulty coordinating the inhaler. Follow the spacer manufacturer’s instructions.
Missed Dose
If you forget to take a dose, simply take the next dose at your usual time. Do not take a double dose to compensate for the missed one. Consistent daily use is important for maintaining asthma control, so consider setting a daily alarm or linking your inhaler use to an existing daily routine.
Overdose
It is important to take only the dose prescribed by your doctor. If you accidentally take more puffs than directed, you do not need emergency treatment for a single occurrence, but you should inform your doctor. Prolonged use of high doses may suppress adrenal function, and your doctor may need to monitor your adrenal glands. If a child accidentally uses the inhaler, contact your doctor, hospital, or poison control centre for advice.
Even if you feel well, do not stop using Alvesco without first speaking to your doctor. Abrupt discontinuation of an inhaled corticosteroid can lead to a loss of asthma control and worsening symptoms. If your doctor decides to discontinue Alvesco, the dose may be reduced gradually.
What Are the Side Effects of Alvesco?
Alvesco is generally well tolerated, with a favourable side-effect profile compared to many other inhaled corticosteroids. The most common side effects are uncommon (affecting fewer than 1 in 100 users) and include hoarseness, throat irritation, and oral thrush. Serious allergic reactions are very rare.
Like all medicines, Alvesco can cause side effects, although not everybody gets them. The prodrug design of ciclesonide – with activation occurring primarily in the lungs rather than the oropharynx – contributes to the relatively low incidence of local side effects. Clinical trials have consistently demonstrated that ciclesonide has a lower rate of oral candidiasis and dysphonia than equipotent doses of budesonide and fluticasone propionate.
Severe allergic reactions such as swelling of the lips, tongue, or throat (angioedema) – this is very rare (may affect up to 1 in 1,000 users). Also seek attention for worsening breathing, wheezing, or chest tightness immediately after inhalation.
Uncommon Side Effects
- Hoarseness (dysphonia)
- Burning, inflammation, or irritation of the mouth or throat
- Oral thrush (oropharyngeal candidiasis) – a fungal infection in the mouth
- Headache
- Altered taste (dysgeusia)
- Dry mouth or throat
- Nausea or vomiting
- Allergic skin reactions: rash, redness, itching, or hives
- Cough or wheezing that worsens after inhalation (paradoxical bronchospasm)
Rare Side Effects
- Palpitations (awareness of heartbeat)
- Abdominal discomfort or pain
- Increased blood pressure
- Severe allergic reaction with swelling of lips, tongue, and throat (angioedema)
Not Known (Frequency Cannot Be Estimated)
- Sleep disturbances, depression, anxiety, restlessness, agitation, nervousness, and irritability – these psychiatric effects are more likely to occur in children
- Blurred vision
Systemic Corticosteroid Effects with Long-term High-dose Use
Alvesco, like all inhaled corticosteroids, can affect the body’s normal production of cortisol, particularly in patients taking high doses over prolonged periods. These systemic effects may include:
- Growth retardation in adolescents – regular height monitoring is recommended for young patients on long-term treatment
- Decreased bone mineral density (osteoporosis) – particularly relevant in elderly patients or those with additional risk factors
- Posterior subcapsular cataract – lens opacity causing blurred vision
- Glaucoma – increased intraocular pressure leading to potential vision loss
- Cushingoid features – moon face, central weight gain, and thinning of the limbs
- Adrenal suppression – the body’s reduced ability to produce its own cortisol
These systemic effects are dose-dependent and generally less likely at the recommended maintenance doses of Alvesco. Adolescents on long-term therapy should have their height measured regularly, and the dose should be titrated to the lowest level that maintains effective asthma control. Regular medical check-ups will ensure that any side effects are identified early.
If any side effects become troublesome, or if you notice effects not mentioned in this information, please inform your doctor or pharmacist. You can also report suspected side effects to your national pharmacovigilance authority. Reporting side effects helps to continuously monitor the benefit-risk balance of medicines.
How Should You Store Alvesco?
Store Alvesco out of the sight and reach of children. Do not expose the pressurised canister to temperatures above 50°C (122°F). Do not puncture, damage, or burn the canister, even if it appears empty. Alvesco delivers a consistent dose across a temperature range of −10°C to +40°C.
Proper storage is essential to ensure the medicine remains effective and safe throughout its shelf life. Follow these guidelines:
- Keep the inhaler out of the sight and reach of children
- Do not use the inhaler after the expiry date printed on the outer carton (after “EXP”). The expiry date refers to the last day of that month
- The canister contains a liquid under pressure – do not expose it to temperatures above 50°C
- Do not puncture, damage, or burn the canister, even if it appears to be empty
- Unlike some other MDIs, Alvesco delivers a consistent dose from −10°C to +40°C, making it reliable in a range of climates
If your doctor discontinues your treatment, or if the inhaler is empty, return it to your pharmacy for safe disposal. Small amounts of medicine may remain in the canister even when it appears empty. Do not dispose of medicines in household waste or via the sewage system, as this helps protect the environment.
What Does Alvesco Contain?
Each puff of Alvesco delivers either 80 or 160 micrograms of ciclesonide as the active ingredient. The other ingredients are anhydrous ethanol and the propellant norflurane (HFA-134a).
Alvesco is a clear, colourless liquid contained in a pressurised aluminium canister. The canister delivers a precisely measured dose of ciclesonide in a fine spray through the mouthpiece. The inactive ingredients are:
- Anhydrous ethanol – acts as a co-solvent to keep ciclesonide in solution
- Norflurane (HFA-134a) – the propellant that generates the fine mist aerosol
This medicine contains a fluorinated greenhouse gas (HFA-134a). The carbon dioxide equivalent per inhaler ranges from approximately 0.006 tonnes CO2 (30-dose canister) to 0.013 tonnes CO2 (120-dose canister), based on a global warming potential (GWP) of 1,430 for HFA-134a.
Available Pack Sizes
- 30-dose inhaler – sufficient for 2–4 weeks of treatment
- 60-dose inhaler – sufficient for 1–2 months of treatment
- 120-dose inhaler – sufficient for 2–4 months of treatment
Both the 80 mcg/dose and 160 mcg/dose strengths are available in all three pack sizes. Not all pack sizes may be marketed in every country. Alvesco is manufactured by Covis Pharma Europe B.V., Amsterdam, Netherlands.
Frequently Asked Questions About Alvesco
Alvesco (ciclesonide) is used as a daily preventer inhaler for the long-term control of chronic persistent asthma in adults and adolescents aged 12 years and older. It reduces inflammation in the airways to prevent asthma symptoms such as wheezing, breathlessness, chest tightness, and coughing. Alvesco is not intended for the relief of acute asthma attacks – a short-acting bronchodilator (rescue inhaler) should be used for that purpose.
Alvesco contains ciclesonide, which is unique among inhaled corticosteroids because it is a prodrug. The inhaled molecule is inactive until it reaches the lungs, where local enzymes convert it into the active metabolite des-ciclesonide. This targeted activation means less medicine is active in the mouth and throat, resulting in a lower incidence of oral thrush and hoarseness compared to other ICS such as budesonide or fluticasone. Additionally, Alvesco is effective as a once-daily treatment, which simplifies the dosing regimen for many patients.
There is limited clinical data on the use of ciclesonide specifically during pregnancy. However, international asthma guidelines (GINA 2024) strongly recommend that pregnant women maintain good asthma control, as uncontrolled asthma poses greater risks to both mother and baby than the use of inhaled corticosteroids. Your doctor will evaluate the benefits and risks and, if treatment is continued, will prescribe the lowest effective dose. Discuss your individual situation with your healthcare provider.
Some improvement in asthma symptoms may be noticed within 24 hours of starting Alvesco. However, the full anti-inflammatory effect builds up gradually over time with consistent daily use. It typically takes 1 to 2 weeks of regular use to achieve the maximum therapeutic benefit. It is crucial to continue taking Alvesco every day, even when you are feeling well, to maintain long-term asthma control and prevent exacerbations.
Unlike many other inhaled corticosteroids, mouth rinsing is generally not considered essential with Alvesco because the prodrug mechanism means most of the active drug is released in the lungs rather than the mouth and throat. This results in a lower risk of oral thrush (candidiasis). However, some healthcare providers may still recommend rinsing as a precautionary measure, particularly in patients with a history of oral candidiasis or who are taking higher doses.
If you forget a dose, simply take your next dose at the usual scheduled time. Do not take a double dose to make up for the one you missed. Occasional missed doses are unlikely to significantly affect your asthma control, but regular and consistent daily use is important for optimal benefit. If you frequently forget doses, try setting a daily reminder on your phone or pairing your inhaler use with another daily habit, such as brushing your teeth.
References
- Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2024 Update. Available at: ginasthma.org
- European Medicines Agency (EMA). Alvesco (ciclesonide) – Summary of Product Characteristics (SmPC). Updated 2024.
- U.S. Food and Drug Administration (FDA). Alvesco (ciclesonide) Inhalation Aerosol – Prescribing Information. Revised 2023.
- Dahl R. Ciclesonide for the treatment of asthma. Ther Clin Risk Manag. 2006;2(1):25–37. doi:10.2147/tcrm.2006.2.1.25
- Derendorf H, Nave R, Drollmann A, et al. Relevance of pharmacokinetics and pharmacodynamics of inhaled corticosteroids to asthma. Eur Respir J. 2006;28(5):1042–1050.
- Bateman ED, Linnhof AE, Engel M, et al. Ciclesonide once daily versus fluticasone propionate twice daily in persistent asthma. Pulm Pharmacol Ther. 2008;21(2):264–275.
- British National Formulary (BNF). Ciclesonide. National Institute for Health and Care Excellence (NICE). Accessed January 2026.
- Nave R, Mueller H. From inhaler to lung: clinical implications of the formulations of ciclesonide and other inhaled corticosteroids. Int J Gen Med. 2013;6:99–107.
- World Health Organization (WHO). WHO Model List of Essential Medicines, 23rd List, 2023.
- Covis Pharma Europe B.V. Alvesco Patient Information Leaflet. Updated December 2024.
Editorial Team
This article has been written and reviewed by the iMedic Medical Editorial Team, comprising licensed physicians with expertise in pulmonology, respiratory medicine, and clinical pharmacology.
All content is reviewed according to international guidelines including GINA 2024, EMA SmPC, FDA prescribing information, and British National Formulary (BNF). Evidence level: 1A.
Independent medical information with no commercial funding. No pharmaceutical company sponsorship. Content follows the GRADE evidence framework. Read our editorial standards.