Ciclesonide causes less oropharyngeal candidiasis than other inhaled corticosteroids. The pharmacological basis for this advantage is:

• A It is administered only by nebulisation, avoiding pharyngeal deposition
• B It is co-formulated with an antifungal agent
• C It is conjugated to polyethylene glycol which prevents mucosal absorption
• D It is an inactive prodrug activated mainly by esterases in airway epithelium, so deposited pharyngeal drug stays inert ✓

Explanation

Ciclesonide is a soft-drug prodrug converted by esterases in the airway epithelium to its active metabolite des-ciclesonide. Drug deposited in the oropharynx remains largely inactive until swallowed and hepatically degraded, so local steroid effects on pharyngeal mucosa are minimised. High protein binding and rapid hepatic metabolism further limit systemic exposure. This on-site activation concept distinguishes ciclesonide from fluticasone and budesonide, which are active as delivered.

Reference: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 14th ed.

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