The preferred formulary choice of inhalers containing steroids for managing asthma and COPD with suitable
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conversion options from a less desirable to a preferred inhaler can be found here. Further information is below.
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Asthma
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For asthma prophylaxis, must be used regularly. Clenil Modulite® or Qvar® are most economical when lower doses
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are required and should be used first line. See 'CFC-Free Beclometasone Inhalers' below.
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Risks associated with high dose inhaled corticosteroid (ICS)
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The risk of systemic adverse effects from ICS is dose related. For adults, low to moderate doses represent little or no risk
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but, high-dose therapy has been directly linked to adverse effects such as skin thinning, bruising, osteoporosis, diabetes and
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adrenal suppression.
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Patients on high dose ICS should be reviewed regularly and provided with a steroid card.
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Approximately 85% of patients with asthma can be controlled on doses ≤800 micrograms/day of ICS
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COPD
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Patients with COPD and with an FEV1 of less than or equal to 50% of predicted, and having two or more exacerbations per
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year (requiring antibiotic or oral corticosteroid) should be offered prophylactic treatment with inhaled corticosteroid as a
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combination with long acting therapy, and review at 8 weeks.
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CFC-Free Beclometasone Inhalers
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These two CFC-free products (QVAR® and Clenil Modulite®), both containing the active substance beclometasone
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dipropionate are NOT equipotent and this could have safety implications. When the prescriber wishes a patient to have a
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CFC-free inhaler Pharmacists receiving a generic prescription for a beclometasone dipropionate pMDI must establish which
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of the two available branded products should be dispensed.
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1. Clenil Modulite® (Trinity-Chiesi Pharmaceuticals Limited) should be prescribed at the same dose as the CFC-
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| containing beclometasone dipropionate pMDIs. |
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2. Qvar® (Ivax Pharmaceuticals Limited) has a 2 to 2.5 fold greater potency than the CFC-containing beclometasone
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| diproprionate pMDIs and therefore should be prescribed at a lower dose than the CFC-containing beclomethasone |
| dipropionate PDMIs. |
| Further information is available in the Summary of Product Characteristics. |
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3. Clenil Modulite® is authorised for use in children; Qvar® is not authorised for use in children (12 years of age
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| and younger). |
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4. For all inhaled corticosteroids and in line with accepted clinical practice, when control of asthma is achieved the dose of
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| the inhaled corticosteroid should be titrated to the lowest dose at which effective control of asthma is maintained. |
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All NEW patients requiring a beclometasone inhaler, should be initiated on a CFC-free brand, either QVAR® or Clenil Modulite®.
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The choice of brand used should be based on the dose required, the licensed indications, cost and cost effectiveness and the
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inhaler types available.
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GREEN Clenil Modulite® (beclometasone CFC-Free) metered dose inhaler (MDI) (able to used with a Volumatic® device)
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| 50 microgram/inhalation, |
| 100 microgram/inhalation |
| 200 microgram/inhalation |
| 250 microgram/inhalation |
GREEN Qvar® (beclometasone CFC-Free) metered dose inhaler (MDI) (able to used with an Aerochamber® device).
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| Metered dose inhaler (MDI) & Autohalers available |
| 50 microgram/inhalation |
| 100 microgram/inhalation |
GREEN Qvar® Easi-Breathe (beclomethasone CFC free)
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| breath actuated aerosol inhalation |
| 50mcg/metered inhalation |
| 100mcg/metered inhalation |
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Other Steroid Inhalers
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When considering doses, beclometasone dipropionate (Clenil® brand) and budesonide are equipotent and fluticasone is twice as
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potent.
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GREEN Budesonide (Pulmicort®) dry powder inhaler
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| 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)
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| Metered dose inhaler |
| 125microgram/inhalation, 250microgram/inhalation |
| Dry powder inhaler |
| 50microgram/inhalation (Flixotide 50 Accuhaler®) |
| 100microgram/inhalation (Flixotide 100 Accuhaler®) |
| 250microgram/inhalation (Flixotide 250 Accuhaler®) |
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| AMBER Ciclesonide inhaler 80microgram /inhalation,160mcg/inhalation (Alvesco® inhaler) |
| [Treatment option in asthma where exacerbations continue despite other step 4 therapies, secondary care initiation] |
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| Treatment of Bronchopulmonary Dysplasia (BPD): Croup and acute asthma in paediatric patients |
| AMBER Budesonide nebules 1mg/2mL, 0.5mg/2mL (paediatric specialist use only) |
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Compound preparations containing corticosteroids
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If patients remain symptomatic on monotherapy, their treatment should be intensified by combining therapies from different drug
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classes. Combination of long-acting beta2-agonist plus inhaled steroid is a treatment option. The clinical effectiveness of combined
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treatments can be assessed by improvements in symptoms, activities of daily living, exercise capacity and lung function.
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Combination treatment should be discontinued if there is no benefit after 4 weeks.
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DuoResp® Spiromax®, Fobumix Easyhaler® and Symbicort® Tubohaler contain budesonide/formoterol.
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There are 2 strengths of DuoResp® Spiromax and Fobumix Easyhaler® 160/4.5, and 320/9. These are equivalent to Symbicort 200/6
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and Symbicort 400/12 respectively.
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Although equivalent the inhaler devices are significantly different. Resultantly it is important to specify theinhaler by brand when
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prescribing in order to ensure patients receive a device they are familiar with.
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GREEN DuoResp® Spiromax 160/4.5
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| equivalent to Formoterol 6micrograms/inhalation + budesonide 200micrograms/inhalation |
| (dose= 1-2 puffs twice daily, max 4 puffs twice daily) |
GREEN DuoResp® Spiromax 320/9
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| 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
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| (dose= 1-2 puffs twice daily, max 4 puffs twice daily) |
GREEN Symbicort Turbohaler® 400/12 (Formoterol 12micrograms/inhalation + budesonide 400)
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| (dose= 1puff twice daily, max 2 puffs twice daily) |
GREEN Fobumix Easyhaler® 160/4.5 (equivalent to Budesonide 200micrograms + Formoterol 6 mcg/inhalation)
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| (dose = 2 puffs twice daily, max 4 puffs twice daily) |
GREEN Fobumix Easyhaler® 320/9 (equivalent to Budesonide 400micrograms + Formoterol 12 mcg/inhalation)
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| (dose = 2 puffs twice daily, max 2 puffs twice daily) dose for COPD is 1 puff twice a day |
| GREEN Trelegy Ellipta® (Umeclidinium+Vilanterol+Fluticasone) |
| (dose = 1 puff daily) | AMBER Anoro Ellipta® Umeclidinium bromide 65micrograms + Vilanterol 22micrograms/dose dry powder inhaler | | (dose = 1 inhalation daily) [specialist initiation] | | | | 2nd line treatment in asthma pathway, secondary care initiation only | | AMBER Relvar Ellipta® 92 micrograms/22 micrograms/dose [Futicasone with vilanterol] dry powder inhaler | | Relvar Ellipta® 184 micrograms/22 micrograms/dose [Futicasone with vilanterol] dry powder inhaler | | [dose = 1 inhalation daily] | | | | GREEN Atectura Breezhaler 125/127.5 inhalation powder, hard capsules | | [150 mcg of indacaterol (as acetate) and 160 mcg of mometasone furoate] | | Atectura Breezhaler 125/260 inhalation powder, hard capsules | | [150 mcg of indacaterol (as acetate) and 320 mcg of mometasone furoate] | | Atectura Breezhaler 125/62.5 inhalation powder, hard capsules | | [150 mcg of indacaterol (as acetate) and 80 mcg of mometasone furoate] | | [dose = 1 inhalation daily] | | GREEN Enerzair® Breezhaler® inhalation powder, hard capsules | | [150 mcg of indacaterol (as acetate), 63 mcg of glycopyrronium bromide equivalent to 50 mcg of glycopyrronium and | | 160 mcg of mometasone furoate] | | [dose = 1 inhalation daily] | | Suitable for prescribing in primary care following recommendation or initiation by a specialist |
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| 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) | |
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Note: Of the Symbicort® range, both the 200/6 and 400/12 strengths are licensed for use in COPD as are the DuoResp Spiromax.
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Symbicort® SMART, DuoResp Spiromax maintenance and reliever therapy and Fostair® MARTregime for asthma
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Symbicort® and DuoResp Spiromax inhalers contain the inhaled steroid budesonide and the long action beta-2 agonist formoterol
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whilst Fostair contains ultra fine beclomethasone and formoterol. Although long acting formoterol has a quick onset of action
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allowing it to be used to relieve symptoms when required..The use of Symbicort® 100/6 or 200/6 used as a rescue medication
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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
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be an effective treatment regimen. In line with updated BTS Guidance, Symbicort® SMART regimen for use in asthma in adults is
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approved within the following restrictions:
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> In selected adult patients at step 3 of the BTS/NICE guidelines who are poorly controlled, or in selected adult patients at
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step 2 (above beclometasone 400micrograms/day who are poorly controlled),
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| > 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
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| required. |
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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
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used in this way.
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DuoResp Spiromax maintenance and reliever therapy- Only the 160/4.5microgram strength should be used as part of this
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regimen.
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Patients take a daily maintenance dose of DuoResp Spiromax and in addition take DuoResp Spiromax as needed in response to
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symptoms. Patients should be advised to always have DuoResp Spiromax available for rescue use. DuoResp Spiromax maintenance
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| and reliever therapy should especially be considered for patients with: |
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> inadequate asthma control and in frequent need of a reliever inhaler.
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