3.2.2 Compound ICS/LABA preparations – [asthma]

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

Prescribing Notes

• Certain inhaler devices such those containing beclometasone (+/- formoterol) and dry powder inhalers are not suitable for generic prescribing.
• 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.
• 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.
• In 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 a lower strength of the beclometasone dipropionate component in the same inhaler is available for step-down treatment (Fostair 100/6).
• 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.