3.2.3 Compound ICS/LABA preparations – COPD

ChoiceDrugDosage
Formulary choices (COPD)

Containing beclometasone/formoterol

Fostair® MDI 100/6
(beclometasone/Formoterol)

Dose: 2 puffs twice daily

Fostair NEXThaler® (DPI) 100/6 (beclometasone/formoterol)

Dose: 2 inhalations twice 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, 2 inhalations twice daily (equivalent to metered dose 200/6)
320/9, 1 inhalation twice daily (equivalent to metered dose 400/12)

Or

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

Dose:
200/6, 2 puffs twice daily
400/12, 1 puff twice daily

Symbicort® MDI
200/6
(Budesonide/formoterol)

Dose: 2 puffs twice daily
Reserve for COPD patients using other Ellipta® devices

Containing fluticasone furoate/ vilanterol

Relvar Ellipta®▼ 92/22 (Fluticasone furoate /vilanterol)

NB: the 184/22 strength is not licensed for COPD

Dose: In COPD: 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.
  • Prescribers should follow the NICE NG115 guideline on COPD which recommends that inhaled corticosteroids (ICS) should only be used in specific circumstances (e.g. asthmatic features/features suggesting steroid responsiveness) and in a combination inhaler with a long-acting beta-agonist. The choice of drug(s) should take into account the person’s symptomatic response and preference, the drug’s potential to reduce exacerbations, its side effects and cost.
  • Information on reviewing and stepping down ‘triple therapy’ in COPD can be found on the PrescQIPP website.
  • Prescribers should be aware of the potential risk of developing side effects (including non-fatal pneumonia and possible increased risk of fractures) in people with COPD and be prepared to discuss with patients.
  • Patients on high doses of inhaled steroids (more than 1000micrograms/day of beclometasone dipropionate or equivalent) should be given a high dose inhaled corticosteroid safety card and accompanying patient information leaflet.
  • 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.
  • Two combination ‘triple therapy’ inhalers are now available:
    • Trimbow® (beclometasone/formoterol/glycopyrronium) is accepted for use for the maintenance treatment of patients with severe COPD who are not adequately treated by a combination of an ICS and a LABA.
    • Trelegy® (fluticasone furoate/vilanterol/umeclidinium) is accepted for use as maintenance treatment in patients with moderate to severe COPD who are not adequately treated by a combination of an ICS and a LABA.
    • These inhalers may offer a more convenient and cost-effective option for patients requiring triple therapy.