3.2.2 Compound ICS/LABA preparations – [asthma]

Choice

Drug

Dosage

Formulary choices

Containing beclometasone/ formoterol

Fostair® MDI 100/6, 200/6 (Beclometasone/Formoterol)

Dose:

100/6: 1 to 2 puffs twice daily; max 4 puffs daily

200/6: 2 puffs twice daily; max 4 puffs daily

Fostair NEXThaler® (DPI) 100/6, 200/6 (Beclometasone/Formoterol)

Dose:

100/6: 1-2 inhalations twice daily; max 4 inhalations daily

200/6: 2 inhalations twice daily; max 4 inhalations daily

Containing budesonide/formoterol

DuoResp Spiromax ® (DPI) 160/4.5,  320/9 (Budesonide/formoterol)

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

Dose:

160/4.5: 1-2 inhalations twice daily increased if necessary to max 4 inhalations twice daily (equivalent to metered dose 200/6)

320/9: 1 inhalation twice daily increased if necessary to max. 2 inhalations twice daily (equivalent to metered dose 400/12)

Or

Symbicort Turbohaler® 100/6, 200/6, 400/12 (Budesonide/formoterol)

Dose:

100/6, 200/6: Initially 1-2 puffs twice daily, increased if necessary up to 4 puffs twice daily; reduced to 1 puff daily, dose reduced only if control is maintained

400/6: Initially 1 puff twice daily, increased if necessary up to 2 puffs twice daily, reduced to 1 puff daily, dose reduced only if control is maintained

Containing fluticasone propionate/formoterol

Flutiform® (MDI) 50/5, 125/5, 250/10 (Fluticasone propionate/ formoterol)

Dose:
Asthma: 2 puffs twice daily

Flutiform® K-haler (breath actuated) 50/5, 125/5 (Fluticasone propionate/ formoterol)

Dose:
Asthma: 2 puffs twice daily

Containing fluticasone propionate/
salmeterol

Use a cost-effective combination MDI
e.g. AirFluSal®, Sereflo® or Sirdupla®
Dose:
Refer to BNF for product information
Or

Seretide Accuhaler® (DPI) 100/50, 250/50, 500/50 (Fluticasone propionate/ Salmeterol)

Dose
Asthma: 1 inhalation once daily

Reserve (still uncontrolled and non-adherence suspected)

Containing fluticasone furoate/vilanterol

Relvar Ellipta®▼ 92/22, 184/22

Dose:
Asthma: 1 inhalation once daily

Prescribing Notes

  • Certain inhaler devices such those containing beclometasone (+/- formoterol) and dry powder inhalers are not suitable for generic prescribing.
  • The device with the lowest acquisition cost should be prescribed which is consistent with the patient’s other inhaler devices and ability to use the device.
  • When patients are re-ordering combination inhalers please ensure that another 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 corticosteroid safety card should be given to patients on high doses of inhaled steroids (more than 1000micrograms/day of beclometasone dipropionate or equivalent). Steroid cards and accompanying patient information leaflets can be viewed here.
  • See MHRA guidance on safe use of LABAs.
  • WIth Fostair®, the beclometasone is an extra fine particle and therefore is more potent than traditional beclometasone dipropionate CFC-free inhalers. When ‘stepping up’ patients with asthma from other beclometasone dipropionate inhalers, Fostair® 100/6 can be prescribed for patients already using beclometasone dipropionate 250 micrograms in another CFC-free inhaler.  The dose of Fostair® should be adjusted according to response. Fostair 200/6 should not be used for step-down treatment but rathet a lower strength of the beclometasone dipropionate component in the same inhaler.
  • Community pharmacists must store Fostair® MDI in a fridge prior to dispensing. Patients do not need to store Fostair® MDI in a fridge following dispensing, however it can only be stored for a maximum of 5 months once out of the fridge.
  • Fostair® MDI contains a small amount of ethanol (approximately 7 mg per actuation), however at normal doses the amount of ethanol is negligible and does not pose a risk to patients.
  • Fostair® MDI 100/6, DuoResp Spiromax® 160/4.5 and Symbicort turbohaler® 200/6 are licensed for use as maintenance and reliever (MART) therapy. MART therapy can be considered for adult patients who have a history of asthma attacks on medium dose ICS or ICS/LABA. When this management option is introduced the total regular dose of daily ICS should not be decreased. Patients taking rescue doses of their combination inhaler once a day or more on a regular basis should have their treatment reviewed.
  • Most combination inhalers are taken twice daily so please ensure patients taking Relvar Ellipta®▼are aware it is a once daily dose to prevent accidental overdose.