3.2.2 Compound ICS/LABA preparations – [asthma]

ChoiceDrugDosage
(See BNF for MART doses)
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

320/9, 1 inhalation twice daily increased if necessary to max. 2 inhalations twice daily

Or

Fobumix® Easyhaler

80/4.5

160/4.5

320/9

(Budesonide/formoterol)

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

Dose:

80/4.5, 160/4.5, 1–2 inhalations twice daily, increased if necessary up to 4 inhalations twice daily

320/9, 1 inhalation twice daily; increased if necessary up to 2 inhalations twice daily.

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

400/12, 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

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 twice daily

Containing Fluticasone furoate/ vilanterol

Reserve (still uncontrolled and non-adherence suspected)

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.
  • An additional Steroid Emergency Card for Northern Ireland has been developed in response to the National Patient Safety Alert that was issued in August 2020. The alert highlights the dangers associated with adrenal insufficiency for patients taking corticosteroid medication, and recommends that all eligible patients prescribed (or initiated on) steroids are assessed and where necessary issued with a Steroid Emergency Card. Community pharmacies and GP practices can order these from pharmacystationeryorders@hscni.net
  • 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.
  • Trimbow® (beclometasone /formoterol /glycopyrronium) is accepted for use as maintenance treatment of asthma, in adults not adequately controlled with a maintenance combination of a long-acting beta2-agonist and medium dose of inhaled corticosteroid, and who experienced one or more asthma exacerbations in the previous year. For further information see SMC