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Home Formulary 3.0 Respiratory System 3.2 Corticosteroids 3.2.2 Compound ICS/LABA preparations – [asthma]

3.2.2 Compound ICS/LABA preparations – [asthma]

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

ChoiceDrugCarbon FootprintDose Counter Present (D)MART licence *AIR licence*
Formulary choices









Beclometasone/formoterol
Fostair NEXThaler® DPI 100/6, 200/6

D100/6 - Yes
200/6 - No		No
If MDI is required:

Luforbec® MDI - Cost effective choice 

100/6, 200/6

D100/6 - Yes
200/6 - No		No
Or
Fostair® MDI 100/6, 200/6

D100/6 - Yes 200/6 - NoNo
Budesonide/formoterol

Fobumix® Easyhaler DPI- Cost effective choice 

80/4.5, 160/4.5, 320/9 

 

Doses are therapeutically equivalent to Symbicort Turbohaler 100/6, 200/6 and 400/12

D80/4.5 - Yes
160/4.5 - Yes
320/9 - No		No
Or

DuoResp Spiromax ® DPI

160/4.5, 320/9

 

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

D160/4.5 - Yes
320/9 - No		160/4.5 - Yes
320/9 - No
Or
Symbicort Turbohaler® DPI 100/6, 200/6, 400/12

D100/6 - Yes
200/6 Yes
400/12- No
100/6 - No
200/6 Yes
400/12- No
Fluticasone propionate/salmeterol

Fixkoh Airmaster® DPI- Cost effective choice 

100/50, 250/50, 500/50 

Or

DNoNo

Seretide Accuhaler® DPI

100/50, 250/50, 500/50 

DNoNo
Or
If MDI is required use a cost effective combination
e.g. Combisal® or Avenor®NoNo
Fluticasone furoate/ vilanterol
Relvar Ellipta® DPI
92/22, 184/22

DNoNo
* licenses correct at time of publication. Refer to product literature for most up to date information. See NG245 for definitions of AIR and MART.
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

  • Refer to NICE NG245 algorithm for pharmacological management of asthma in people aged 12 years and over.
  • All new adult patients with a diagnosis of asthma and those stepping down from MART should be started on low dose ICS/formoterol combination inhaler to be taken as needed (AIR therapy); a separate SABA inhaler should not be given.
  • All new adult patients with a diagnosis of asthma who are experiencing regular symptoms should be started on an appropriate dose of MART; a separate SABA inhaler should not be given.
  • 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 brand and regime with care to minimise 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.
  • Before initiating a new drug therapy practitioners should recheck adherence, inhaler technique and eliminate trigger factors.
  • 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 NICE NG245 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
  • See MHRA guidance on safe use of LABAs.

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