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3.2.3 Compound ICS/LABA preparations – COPD

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

ChoiceDrugDosage
Formulary choices (COPD)


If a MDI is required
Containing Beclometasone/Formoterol
Fostair NEXThaler® DPI
100/6
(Beclometasone/Formoterol)
Dose:
2 inhalations twice daily
Fostair® MDI
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

320/9, 1 inhalation twice daily
Or
Fobumix® Easyhaler 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

320/9, 1 inhalation twice daily
Or
Symbicort Turbohaler® DPI
200/6
400/12
(Budesonide/formoterol)
Dose:
200/6, 2 puffs twice daily
400/12, 1 puff twice daily
Reserve
for COPD patients using other Ellipta® devices
Containing
Fluticasone furoate/ vilanterol
Relvar Ellipta®▼ DPI
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.
  • Offer Dry Powder Inhalers (DPIs) as first choice when clinically appropriate. If MDIs are needed then chose brand and regime with care to minimse 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.
  • 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.
  • 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
  • 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.
  • Three 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 severe COPD who are not adequately treated by a combination of an ICS and a LABA.
    • Trixeo Aerosphere® (budesonide/formoterol /glycopyrronium) is accepted for use as maintenance treatment in patients with severe COPD who are not adequately treated by a combination of an ICS and a LABA or combination of a LABA and a LAMA
    • These inhalers may offer a more convenient and cost-effective option for patients requiring triple therapy. They should only be prescribed where patient meets criteria for use – refer to relevant Managed Entry Decision for further information