3.1.1 Adrenoceptor agonists

Advice on how to obtain placebo inhalers can be obtained from the NHS Devon CCG Medicines Optimisation Team, please contact: d-ccg.medicinesoptimisation@nhs.net

Generic prescribing of inhalers should be avoided as this might lead to patients being given an unfamiliar inhaler device which they are not able to use properly; in addition, not all inhalers with the same primary ingredient are interchangeable due to differences in particle size.

Different products and doses are licensed for different age groups and some may be applicable only to older children or adults (aged 18 years and over). Prior to prescribing, the relevant Summary of Product Characteristics (SPC) should be checked.

Patient preference should be considered when prescribing treatments. It is essential that patients can demonstrate the proper inhaler technique when prescribing an inhaler device; recheck patient technique at each visit to ensure continued correct use of the inhaler. Adherence to treatment regimens should also be checked. When discussing inhaled treatment options, consideration should also be given to the environmental impact of inhalers.

NICE has produced a patient decision aid to help people with asthma and their healthcare professionals discuss their options for inhaler devices (available here); it is suitable for use by people aged 17 years and over, and many of the considerations are also applicable to patients with COPD.

pMDI = Pressurised metered dose inhaler; BAI = Breath actuated inhaler; DPI = Dry powder inhaler

When prescribing a pressurised MDI, remind patients to check and remove the mouthpiece cover fully, shake the inhaler to remove loose objects that may not be visible, and check the inside and outside of the mouthpiece are clear before inhaling a dose. To prevent objects entering the mouthpiece during storage, the mouthpiece cover should be replaced securely after use. See MHRA Drug Safety Alert July 2018 for further details.

Short-acting beta2 agonists (SABAs)

Salbutamol
  • Aerosol inhalation 100 micrograms/ metered inhalation (pMDI) (£1.50 = 200 doses)
  • Airomir Autohaler® breath-actuated aerosol inhalation 100 micrograms/ metered inhalation (BAI) (£6.02 = 200 doses)
  • Salamol Easi-breathe® breath-actuated aerosol inhalation 100 micrograms/ metered inhalation (BAI) (£6.30 = 200 doses)
  • Nebuliser liquid 1mg/ml, 2mg/ml, 5mg/ml (click here for preferred brand)
  • Injection 500 micrograms/ml
  • Solution for IV infusion 5mg in 5ml

Indications

Dose

  • Adults, by aerosol inhalation: 100–200 micrograms (1–2 puffs); for persistent symptoms up to 4 times daily
  • Child, by aerosol inhalation: 100–200 micrograms (1–2 puffs); for persistent symptoms up to 4 times daily
  • Adults, by aerosol inhalation, prophylaxis of allergen or exercise-induced bronchospasm: 200 micrograms (2 puffs)
  • Adults, inhalation of nebulised solution: 2.5–5mg repeated up to 4 times daily or more frequently in severe cases

Notes

  1. If delivery of SABA via a spacer and face mask fails in children, usually calm persistence prevails
  2. See notes on nebulised therapy, which should be initiated by a Consultant
  3. Injections of beta2 agonists are only recommended for those patients unable to tolerate aminophylline infusion (use I/V salbutamol) or for a small number of brittle asthmatics (use S/C terbutaline)
  4. pMDIs and BAIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)
  5. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)
Terbutaline
  • Bricanyl® Turbohaler® Dry powder inhaler 500 micrograms/ metered inhalation (DPI) (£8.30 = 120 doses)
  • Nebuliser solution 2.5mg/ml (£4.27 = 20 units)
  • Injection 500 micrograms/ml

Indications

Dose

  • Adult and child over 5 years by inhalation of powder: 500 micrograms (1 inhalation) up to 4 times daily for persistent symptoms
  • Adults, inhalation of nebulised solution: 5–10mg 2–4 times daily; additional doses may be necessary in severe acute asthma

Notes:

  1. Injections of beta2 agonists are only recommended for those patients unable to tolerate aminophylline infusion (use I/V salbutamol) or for a small number of brittle asthmatics (use S/C terbutaline)
  2. See notes on nebulised therapy
  3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)

Long-acting beta2 agonists (LABAs)

In asthma LABAs should only be prescribed as combination products with inhaled corticosteroids.

Oxis® Turbohaler®

(Formoterol)

  • Dry powder inhaler 6 micrograms/dose, 12 micrograms/dose (DPI) (£24.80 = 60 dose unit)

Indications and dose

Notes

  1. In asthma, LABAs should only be prescribed as combination products with inhaled corticosteroids. Combination products are listed here
  2. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
Atimos® Modulite®

(Formoterol)

  • Aerosol inhalation 12 micrograms/dose (pMDI) (£30.06 = 100 dose unit)

Indications and dose

Notes

  1. In asthma, LABAs should only be prescribed as combination products with inhaled corticosteroids. Combination products are listed here
  2. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)
Onbrez® Breezhaler®

(Indacaterol)

  • Inhalation powder, hard capsule 150 micrograms, 300 micrograms (DPI) (£32.19 = 30 caps)

Indications and dose

Notes

  1. The commissioning of indacaterol inhalation powder hard capsules for inhalation is accepted in Devon for the maintenance treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) who require a long acting bronchodilator (see Commissioning Policy for more details)
  2. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
Soltel®

(Salmeterol)

  • Aerosol inhalation 25 micrograms/ metered dose inhalation (pMDI) (£19.95 = 120 doses)

Indications and dose

Notes

  1. Contains soya lecithin and is contraindicated in patients who have peanut or soya allergies
  2. In asthma, LABAs should only be prescribed as combination products with inhaled corticosteroids. Combination products are listed here
  3. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)
Serevent® Accuhaler®

(Salmeterol)

  • Dry powder for inhalation 50 micrograms/ blister (DPI) (£35.11 = 60 dose unit)

Indications and dose

Notes

  1. In asthma, LABAs should only be prescribed as combination products with inhaled corticosteroids. Combination products are listed here
  2. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
Last updated: 16-12-2019

 

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