3.2.1 Single agent inhalers [asthma only]

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


Choice	Drug	Carbon Footprint	Dose Counter Present (D)
NB – inhaled steroid monotherapy is not licensed in COPD
Formulary choices	Beclometasone DPI Easyhaler® Beclometasone 200micrograms/dose		D
	Budesonide DPI Easyhaler^® Budesonide 100, 200 or 400 micrograms/dose Prescribe DPIs by brand		D
	If a MDI is required:
	Beclometasone MDI
	Soprobec® 50, 100, 200 or 250 micrograms/dose-cost effective choice
	Or
	Clenil Modulite® 50,100, 200 or 250 micrograms/dose		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)

Offer dry powder inhalers (DPIs) as first choice when clinically appropriate.
If prescribing a beclometasone MDI, the MHRA recommends prescribing by brand name to ensure the patient receives the correct dose and preparation.
When considering doses, beclometasone dipropionate (except inhalers with extra-fine particles, e.g. Qvar^®and Kelhale^®) and budesonide are considered equipotent; fluticasone propionate is considered twice as potent.
A Steroid Emergency Card should be given to patients on high doses of inhaled steroids [more than 1000 micrograms/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
Spacer devices should be prescribed for patients receiving high dose steroids via MDI.
The dose should be titrated to the lowest dose at which effective control of asthma is maintained.