The preferred formulary choice of inhalers containing steroids for managing asthma and COPD with suitable conversion options from a less desirable to a preferred inhaler can be found here. Further information is below.
For asthma prophylaxis, must be used regularly. Clenil Modulite® or Qvar® are most economical when lower doses are required and should be used first line. See 'CFC-Free Beclometasone Inhalers' below.
Risks associated with high dose inhaled corticosteroid (ICS)
The risk of systemic adverse effects from ICS is dose related. For adults, low to moderate doses represent little or no risk but, high-dose therapy has been directly linked to adverse effects such as skin thinning, bruising, osteoporosis, diabetes and adrenal suppression. Patients on high dose ICS should be reviewed regularly and provided with a steroid card.
Approximately 85% of patients with asthma can be controlled on doses ≤800 micrograms/day of ICS.
Patients with COPD and with an FEV 1 of less than or equal to 50% of predicted, and having two or more exacerbations per year (requiring antibiotic or oral corticosteroid) should be offered prophylactic treatment with inhaled corticosteroid as a combination with long acting therapy, and review at 8 weeks.
CFC-Free Beclometasone Inhalers
These two CFC-free products (QVAR® and Clenil Modulite®), both containing the active substance beclometasone dipropionate are NOT equipotent and this could have safety implications. When the prescriber wishes a patient to have a CFC-free formulation of beclometasone dipropionate that intention should be made clear by prescribing the product by brand name. Pharmacists receiving a generic prescription for a beclometasone dipropionate pMDI must establish which of the two available branded products should be dispensed.
1. Clenil Modulite® (Trinity-Chiesi Pharmaceuticals Limited) should be prescribed at the same dose as the CFC-containing beclometasone dipropionate pMDIs.
2. Qvar® (Ivax Pharmaceuticals Limited) has a 2 to 2.5 fold greater potency than the CFC-containing beclometasone dipropionate pMDIs and therefore should be prescribed at a lower dose than the CFC-containing beclometasone dipropionate pMDIs. Further information is available in the Summary of Product Characteristics.
3. Clenil Modulite® is authorised for use in children; Qvar® is not authorised for use in children (12 years of age and younger).
4. For all inhaled corticosteroids and in line with accepted clinical practice, when control of asthma is achieved the dose of the inhaled corticosteroid should be titrated to the lowest dose at which effective control of asthma is maintained.
All NEW patients requiring a beclometasone inhaler, should be initiated on a CFC-free brand, either QVAR® or Clenil Modulite®. The choice of brand used should be based on the dose required, the licensed indications, cost and cost effectiveness and the inhaler types available.
| GREEN Clenil Modulite® (beclometasone CFC-Free) metered dose inhaler (MDI) |
| (able to use with a Volumatic® device) |
| 50 microgram/inhalation, |
| 100 microgram/inhalation |
| 200 microgram/inhalation |
| 250 microgram/inhalation |
| GREEN Qvar® (beclometasone CFC-Free) metered dose inhaler (MDI) |
| (able to use with an Aerochamber® device). Metered dose inhaler (MDI) & Autohalers available |
| 50 microgram/inhalation |
| 100 microgram/inhalation |
| GREEN Qvar® Easi-Breathe (beclomethasone CFC free) breath actuated aerosol inhalation |
| 50mcg/metered inhalation |
| 100mcg/metered inhalation |
Other Steroid Inhalers
When considering doses, beclometasone dipropionate (Clenil® brand) and budesonide are equipotent and fluticasone is twice as potent.
GREEN Budesonide (Pulmicort®) dry powder inhaler
| 100 microgram/inhalation (Pulmicort Turbohaler 100®) |
200 microgram/inhalation (Pulmicort Turbohaler 200®)
| 400 microgram/inhalation (Pulmicort Turbohaler 400®) |
GREEN Fluticasone (only recommended when high dose therapy is required).
| Metered dose inhaler |
| Dry powder inhaler |
| 50microgram/inhalation (Flixotide 50 Accuhaler®) |
| 100microgram/inhalation (Flixotide 100 Accuhaler®) |
| 250microgram/inhalation (Flixotide 250 Accuhaler®) |
Compound preparations containing corticosteroids
If patients remain symptomatic on monotherapy, their treatment should be intensified by combining therapies from different drug classes. Combination of long-acting beta2-agonist plus inhaled steroid is a treatment option. The clinical effectiveness of combined treatments can be assessed by improvements in symptoms, activities of daily living, exercise capacity and lung function. Combination treatment should be discontinued if there is no benefit after 4 weeks.
Both DuoResp Spiromax and Symbicort Tubohaler containin budesonide/formoterol.
There are 2 strenghts of DuoResp® Spiromax 160/4.5, and DuoResp® Spiromax 320/9 ,These are equivalent to Symbicort 200/6 and Symbicort 400/12 respectively.
Although equivalent the inhaler devices are significantly different. Resultantly it is important to specify theinhaler by brand when prescribing in order to ensure patients receive a device they are familiar with.
| GREEN DuoResp® Spiromax 160/4.5 |
| equivalent to Formoterol 6micrograms/inhalation + budesonide 200micrograms/inhalation |
| (dose= 1-2 puffs twice daily, max 4 puffs twice daily) |
| GREEN DuoResp® Spiromax 320/9 |
| equivalent to Formoterol 12micrograms/inhalation + budesonide 400micrograms/inhalation |
| (dose= 1 puff twice daily, max 2 puffs twice daily) |
| GREEN Symbicort Turbohaler® 100/6,200/6 Formoterol 6micrograms/inhalation + budesonide |
| (dose= 1-2 puffs twice daily, max 4 puffs twice daily) |
| GREEN Symbicort Turbohaler® 400/12 (Formoterol 12micrograms/inhalation + budesonide 400) |
(dose= 1puff twice daily, max 2 puffs twice daily)
Note: Of the Symbicort® range, both the 200/6 and 400/12 strengths are licensed for use in COPD as are the DuoResp Spiromax.
Symbicort® SMART, DuoResp Spiromax maintenance and reliever therapy and Fostair® MARTregime for asthma
Symbicort® and DuoResp Spiromax inhalers contain the inhaled steroid budesonide and the long action beta-2 agonist formoterol whilst Fostair contains ultra fine beclomethasone and formoterol. Although long acting formoterol has a quick onset of action allowing it to be used to relieve symptoms when required..The use of Symbicort® 100/6 or 200/6 used as a rescue medication instead of a short acting beta-2 agonist such as salbutamol in addition to its regular use as a controller therapy has been shown to be an effective treatment regimen. In line with updated BTS Guidance, Symbicort® SMART regimen for use in asthma in adults is approved within the following restrictions:
Only the 100/6 and 200/6 strengths should be used as part of this regimen. The 400/12 strength of Symbicort® should not be used in this way.
- In selected adult patients at step 3 of the BTS/NICE guidelines who are poorly controlled, or in selected adult patients at step 2 (above beclometasone 400micrograms/day who are poorly controlled),
- Patients taking rescue Symbicort® once a day or more should have their treatment reviewed,
- Careful patient selection and education of patients about the specific issues around this management strategy is required.
DuoResp Spiromax maintenance and reliever therapy- Only the 160/4.5microgram strength should be used as part of this regimen.
Patients take a daily maintenance dose of DuoResp Spiromax and in addition take DuoResp Spiromax as needed in response to symptoms. Patients should be advised to always have DuoResp Spiromax available for rescue use. DuoResp Spiromax maintenance and reliever therapy should especially be considered for patients with:
• inadequate asthma control and in frequent need of a reliever inhaler.
• asthma exacerbations in the past requiring medical intervention.
Adults (18 years and older): The recommended maintenance dose is 2 inhalations per day, given either as one inhalation in the morning and evening or as 2 inhalations in either the morning or evening. For some patients a maintenance dose of 2 inhalations twice daily may be appropriate. Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion.
A total daily dose of more than 8 inhalations is not normally needed; however, a total daily dose of up to 12 inhalations could be used for a limited period. Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice. They should be reassessed and their maintenance therapy should be reconsidered.
Fostair® may also be used as maintenance and reliever therapy (MART) It is currently recommended as an option for the management of asthma in adults in line with BTS guidance. This product is not licensed for use in children or adolescents under the age of 18 years.
(Fostair 100/6 MDI 1 puff twice a day plus extra puffs as required max 8 puffs daily)
Again careful patient selection and education about the specific issues around this management strategy is required.
| GREEN Beclometasone + formoterol 100micrograms/6micrograms per inhalation |
| (metered dose inhaler (Fostair® 100/6) |
| (dose= 1-2 puffs twice daily, max 4 puffs daily unless being used as MART therapy discussed above) |
| GREEN Beclometasone + formoterol 200micrograms/6micrograms per inhalation |
| (metered dose inhaler (Fostair® 200/6) |
| (dose= 2 puffs twice daily) |
Please note Fostair requires storage in a fridge prior to dispensing, and has an expiry of 5 months after dispensing to the patient (who should then keep the inhaler at room temperature). Note it contains a small amount of alcohol in the formulation.
| Trimbow® inhaler - link to guideline |
|First line use in Patient Group D, where patient requires Triple Therapy (LAMA+LABA+ICS) |
|(single combination inhaler, dose 2 puffs bd) |
| GREEN Beclomethasone 87mcg, formoterol fumarate 5mcg, |
| glycopyrronium bromide 9mcg (Trimbow®pMDI) |
| (dose = 2 puffs twice daily) |
| These are currently not included in the ELMMB Asthma and COPD guidelines for adults over 18 years of age. |
|There are more than one product containing the combination of fluticasone/salmeterol. |
|These are AirFlusal®, Fospiro , Sirdupla® and Seretide. Whilst these products are clinically equivalent, the |
|devices differ. In order to prevent confusion to patients such combination inhalers should be prescribed by brand. |
|When Fostair® or Duoresp® are not suitable or the patient wishes to remain on Fluticasone then AirFlusal® is the preferred product of choice. |
For 12-18 year olds at Step 3 of the asthma guidelines who cannot use Symbicort Turbohaler, Fostair or Sirdupla are not licensed. The alternative choice therefore is Seretide 50 MDI 2 puffs BD at Step 3a and Seretide 125 2 puffs BD at Step 3b.
| GREEN Salmeterol 25micrograms/inhalation + fluticasone |
| (dose=2 puffs twice daily) |
| (AirFluSal® 25/125mcg MDI/ 25/250mcg MDI - preferred choice) |
(Sirdupla® inhaler or Seretide Evohaler® 125, 250 Seretide Evohaler® 50)
| GREEN Salmeterol 50micrograms/blister + fluticasone |
| (dose=1 blister twice daily) |
| Dry powder inhaler AirFluSal®Forspiro (preferred choice) |
| Seretide Accuhaler® 100, 250, 500) |
| Please note the difference in dosing between: |
> Metered dose inhalers (2 puffs twice daily) and
> Accuhalers® (One blister twice daily).
NOTE: Of the Seretide® range, only the Seretide® Accuhaler 500 is licensed for use in COPD.
Neither the Seretide® Evohaler nor the Accuhaler® strengths are licensed for use in COPD.