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Home Formulary 3.0 Respiratory System 3.2 Corticosteroids 3.2.3 Compound ICS/LABA preparations – COPD

3.2.3 Compound ICS/LABA preparations – COPD

Prescribe an inhaler with a lower carbon impact where possible – resources can be found here.

ChoiceDrugCarbon FootprintDose Counter Present (D)
Formulary choices (COPD)


Beclometasone/Formoterol

Fostair NEXThaler® DPI 100/6

If an MDI is required:

Luforbec® MDI-cost effective choice

100/6

or

Fostair® MDI 100/6

NB: the 200/6 strength of beclometasone/ formoterol is not licensed for COPD

D

 

D

 

D

Budesonide/formoterol

Fobumix® Easyhaler DPI-cost effective choice

160/4.5, 320/9

Doses are therapeutically equivalent to Symbicort Turbohaler® 200/6 and 400/12

D

Or

DuoResp Spiromax ® DPI
160/4.5, 320/9

Doses are therapeutically equivalent to Symbicort Turbohaler® 200/6 and 400/12

D

Or

Symbicort Turbohaler® DPI
200/6, 400/12

D

Fluticasone furoate/ vilanterol

Relvar Ellipta® DPI
92/22


NB: the 184/22 strength is not licensed for COPD

D
Symbol Carbon indicator

Low Carbon Footprint (<2kg CO2e per inhaler)

High Carbon Footprint (6-20kg CO2e per inhaler)

Highest Carbon Footprint (>34kg CO2e per inhaler)

Prescribing Notes

  • Inhaled corticosteroids (ICS) should only be used in specific circumstances in COPD – refer to NICE NG115 COPD and to the GOLD report for further guidance.
  • Specify brand and inhaler device when prescribing to help reduce confusion and ensure patients receive the inhaler they have been trained to use.
  • Offer dry powder inhalers (DPIs) as first choice when clinically appropriate. If MDIs are needed then chose the brand and regime with care to minimise the carbon footprint – resources to support choice can be found here.
  • Fostair® and Luforbec® contain extra-fine particles of beclometasone dipropionate and are more potent than traditional beclometasone dipropionate CFC-free inhalers. 100 micrograms of beclometasone dipropionate extra-fine is equivalent to 250 micrograms of beclometasone dipropionate in a non-extra-fine formulation. When switching from non-extra-fine formulations the dose should be reduced and adjusted according to response.
  • Most combination inhalers are taken twice daily so ensure patients taking Relvar Ellipta® are aware it is a once daily dose to prevent incorrect dosing.
  • When patients are re-ordering combination inhalers, ensure that a prescription is due. The compliance ready reckoner indicates how long the inhaler should last.
  • Prescribers should be aware of the potential risk of developing side effects from inhaled corticosteroids (including non-fatal pneumonia and possible increased risk of fractures) in people with COPD and be prepared to discuss with patients.
  • A Steroid Emergency Card should be given to patients on high doses of inhaled steroids [more than 1000micrograms/day of standard (not extra-fine) beclometasone dipropionate or equivalent]. RightBreathe gives inhaler specific advice on whether a steroid safety card is needed and SIGN 158 categorises inhaled steroids by dose (low, medium and high). Use of other corticosteroid therapy or concurrent use of drugs which inhibit corticosteroid metabolism should also be taken in to account when assessing systemic risk. Community pharmacies and GP practices can order these from pharmacystationeryorders@hscni.net

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