Advice on how to obtain placebo inhalers can be obtained from the NHS Devon ICB Medicines Optimisation Team, please contact: d-icb.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

• Salamol CFC-free aerosol inhalation 100 micrograms/ metered inhalation (pMDI) (£1.46 = 200 doses)
• Salamol Easi-Breathe breath-actuated aerosol inhalation 100 micrograms/ metered inhalation (BAI) (£6.30 = 200 doses)
• Airomir Autohaler breath-actuated aerosol inhalation 100 micrograms/ metered inhalation (BAI) (£6.02 = 200 doses)
• Nebuliser liquid 1mg/ml, 2mg/ml (£15.74 = 20 x 2mg/ml) (see note 1)
• Nebuliser liquid 5mg/ml (click here for preferred brand)
• Injection 500 micrograms/ml
• Solution for IV infusion 5mg in 5ml

Indications

• Asthma, adults
• Asthma, children
• Chronic obstructive pulmonary disease

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. National Patient Safety Alert (26th February 2024): Shortage of salbutamol 2.5mg/2.5ml and 5mg/2.5ml nebuliser liquid unit dose vials.
   
   1. Information on supply has been superseded by a Medicine Supply Notification (see note 2).
      
   2. Primary care prescribers should review need for home nebuliser use, and if deemed necessary, determine if the patient has sufficient supplies of nebuliser liquid at home before issuing repeat prescriptions (see nebulisation guidance and note 8 below).
      
   3. Refer to the NatPSA for further information for secondary care providers.
      
2. Medicine Supply Notification 06 March 2024 (MSN/2024/028): Salbutamol 2.5mg/2.5ml nebuliser liquid dose vials.
   
   1. Salbutamol 2.5mg/2.5ml nebules will be in limited supply from mid-April until late June 2024. Unlicensed supplies can be sourced (see Supporting Information in MSN), lead times vary.
      
   2. Salbutamol 5mg/2.5ml nebules will remain available, however, cannot support an increase in demand.
   3. Alternative beta₂-agonists for nebulisation and intravenous administration remain available, however, cannot support an increase in demand.
   4. Access to licensed salbutamol 2.5mg/2.5ml nebules will be actively monitored and prioritised for primary care and ambulance services who are less able to use unlicensed supplies.
   5. Refer to the MSN for actions for procurement teams.
      
3. If delivery of SABA via a spacer and face mask fails in children, usually calm persistence prevails; a home nebuliser may be considered in certain circumstances (see nebulisation guidance and note 8 below).
   
4. 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).
5. pMDIs and BAIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers).
6. Salamol CFC-free is estimated to have less than half of the carbon footprint of Ventolin Evohaler.
7. 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).
8. MHRA Drug Safety Update (August 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists.

Terbutaline

• Bricanyl Turbohaler dry powder inhaler 500 micrograms/ metered inhalation (DPI) (£8.30 = 120 doses)
• Nebuliser solution 2.5mg in 1ml (£8.86 = 20 units)
• Injection 500 micrograms in 1ml

Indications

• Asthma, adults (second line)
• Asthma, children (second line)
• Chronic obstructive pulmonary disease

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 and note 4 below.
3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
4. MHRA Drug Safety Update (August 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists.

Long-acting beta₂ agonists (LABAs)

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

Formoterol Easyhaler

(Formoterol)

• Dry powder inhaler 12 micrograms/metered dose (DPI) (£23.75 = 120 dose unit)

Indications and dose

• Chronic obstructive pulmonary disease
  • 12 micrograms twice daily
    

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).

Oxis Turbohaler

(Formoterol)

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

Indications and dose

• Chronic obstructive pulmonary disease
  • 12 micrograms twice daily

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

• Chronic obstructive pulmonary disease
  • 12 micrograms (1 puff) twice daily

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). For this reason, pMDIs (with the exception of salbutamol and ipratropium) are not generally considered first line options).

Onbrez Breezhaler

(Indacaterol)

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

Indications and dose

• Chronic obstructive pulmonary disease
  • 150 micrograms once daily, increased to maximum 300 micrograms once daily

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

• Chronic obstructive pulmonary disease
  • 50 micrograms (2 puffs) twice daily

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). For this reason, pMDIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.

Serevent Accuhaler

(Salmeterol)

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

Indications and dose

• Chronic obstructive pulmonary disease
  • 50 micrograms twice daily

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).