3.1.4 Combination inhalers

Generic prescribing of inhalers should be avoided as this might lead to people with asthma 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.

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

For information on inhaled corticosteroid dose comparisons in asthma see here

Metered dose inhaler = (MDI); Dry powder inhaler = (DPI); Beclometasone dipropionate = BDP

When prescribing a pressurised MDI, remind patients to check and remove the mouthpiece cover properly before inhaling a dose and to shake the inhaler to remove loose objects that may have become trapped in the inhaler during storage. The mouthpiece cover should be replaced securely after use. See MHRA Drug Safety Alert July 2018 for further details

Inhaled corticosteroid (ICS) / Long-acting beta2 agonists (LABA)

BDP and formoterol fumarate

Fostair®

(combination of BDP (extrafine) and formoterol fumarate)

  • Aerosol inhalation 100 micrograms / 6 micrograms / metered dose (MDI) (£29.32 = 120 doses)
  • Aerosol inhalation 200 micrograms / 6 micrograms / metered dose (MDI) (£29.32 = 120 doses)

Indications and dose

  • Asthma, adults (maintenance therapy, aged ≥ 18 years):
    • 100 micrograms / 6 micrograms: One or two inhalations twice daily
    • 200 micrograms / 6 micrograms: Two inhalations twice daily
  • Chronic obstructive pulmonary disease (100 micrograms / 6 micrograms):
    • Aged ≥ 18 years: Two inhalations twice daily

Notes

  1. Fostair® contains extra-fine beclometasone particles and is more potent than traditional beclometasone dipropionate CFC-free inhalers (Clenil®)
  2. The manufacturer states that 100 micrograms of BDP extrafine in Fostair® are equivalent to 250 micrograms of BDP in a non-extrafine formulation.
  3. Fostair® 100/6 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details
Fostair® NEXThaler®

(combination of BDP (extrafine) and formoterol fumarate)

  • Dry powder inhalation 100 micrograms / 6 micrograms / metered inhalation (DPI) (£29.32 = 120 inhalations)
  • Dry powder inhalation 200 micrograms / 6 micrograms / metered inhalation (DPI) (£29.32 = 120 inhalations)

Indications and dose

  • Asthma, adults (aged ≥ 18 years):
    • 100 micrograms / 6 micrograms: One or two inhalations twice daily
    • 200 micrograms / 6 micrograms: Two inhalations twice daily
  • Chronic obstructive pulmonary disease (100 micrograms / 6 micrograms):
    • Aged ≥ 18 years: Two inhalations twice daily

Notes

  1. Fostair® NEXThaler® contains extrafine beclometasone particles and is more potent than traditional beclometasone dipropionate CFC-free inhalers (Clenil®)
  2. The manufacturer states that 100 micrograms of BDP extrafine in Fostair® NEXThaler® are equivalent to 250 micrograms of BDP in a non-extrafine formulation.
  3. Fostair® NEXThaler® should be used as maintenance therapy only.

Budesonide and formoterol fumarate

Duoresp® Spiromax®

(combination of budesonide and formoterol fumarate)

  • Dry powder inhalation 160 micrograms / 4.5 micrograms / delivered dose (DPI) (£27.97 = 120 doses)
  • Dry powder inhalation 320 micrograms / 9 micrograms / delivered dose (DPI) (£27.97 = 60 doses)

Indications and dose

  • Asthma, adults (maintenance therapy, aged ≥ 18 years):
    • 160 micrograms / 4.5 micrograms: One to two inhalations twice daily
    • 320 micrograms / 9 micrograms: One inhalation twice daily
  • Chronic obstructive pulmonary disease:
    • 160 micrograms / 4.5 micrograms: Two inhalations twice daily
    • 320 micrograms / 9 micrograms: One inhalation twice daily

Notes

  1. Duoresp® Spiromax® is licensed for patients 18 years and over and currently available in two strengths 160/4.5 and 320/9. These strengths are equivalent to the Symbicort® 200/6 and 400/12 preparations respectively. Duoresp® Spiromax® strengths refer to the delivered dose whereas the Symbicort® strengths refer to the total dose contained in each actuation.
  2. Duoresp® Spiromax® 160/4.5 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details
Symbicort® Turbohaler®

(combination of budesonide and formoterol fumarate)

  • Dry powder inhalation 100 micrograms / 6 micrograms / metered dose (DPI) (£28.00 = 120 doses)
  • Dry powder inhalation 200 micrograms / 6 micrograms / metered dose (DPI) (£28.00 = 120 doses)
  • Dry powder inhalation 400 micrograms / 12 micrograms / metered dose (DPI) (£28.00 = 60 doses)

Indications and dose

  • Asthma, adults (maintenance therapy, aged ≥ 12 years):
    • 100 micrograms / 6 micrograms : One or two inhalations twice daily
    • 200 micrograms / 6 micrograms: One or two inhalations twice daily
    • 400 micrograms / 12 micrograms: One inhalation twice daily
  • Asthma, children (maintenance therapy, aged ≥ 6 years):
    • 100 micrograms / 6 micrograms: Two inhalations twice daily
  • Chronic obstructive pulmonary disease (adults):
    • 200 micrograms / 6 micrograms: Two inhalations twice daily
    • 400 micrograms / 12 micrograms: One inhalation twice daily

Notes

  1. Symbicort® Turbohaler® 100/6 is licensed for use in asthma in patients aged 6 years and older
  2. Symbicort® Turbohaler® 200/6 and 400/12 are licensed for use in asthma patients 12 years and older
  3. Symbicort® Turbohaler® 200/6 and 400/12 strengths are licensed for use in COPD patients aged 18 years and older.
  4. Symbicort® Turbohaler® 200/6 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details

Fluticasone furoate and vilanterol

Relvar® Ellipta®

(combination of fluticasone furoate and vilanterol)

  • Dry powder inhalation 92 micrograms / 22 micrograms / delivered dose (DPI) (£22.00 = 30 doses)
  • Dry powder inhalation 184 micrograms / 22 micrograms / delivered dose (DPI) (£29.50 = 30 doses)

Indications and dose

Notes

  1. Relvar® Ellipta® inhaler has an in-use shelf life of 6 weeks
  2. Prescribe by brand
  3. Fluticasone furoate in Relvar® Ellipta® has a higher potency compared to fluticasone propionate; doses are not interchangeable. In patients with asthma, Relvar® Ellipta® 92/22 once daily is approximately equivalent to BDP 1000 micrograms daily, while Relvar® Ellipta® 184/22 once daily is approximately equivalent to BDP 2000 micrograms daily
  4. The routine commissioning of Relvar® Ellipta® is accepted in Devon for the treatment of asthma in adults and adolescents aged 12 years and older (see Commissioning Policy for more details)
  5. The routine commissioning of Relvar® Ellipta® is accepted in Devon for the symptomatic treatment of adults with COPD and an exacerbation history despite regular bronchodilator therapy (see Commissioning Policy for more details)
  6. The Relvar® Ellipta® 184 micrograms / 22 micrograms is not licensed for patients with chronic obstructive pulmonary disease

Fluticasone propionate and salmeterol

AirFluSal® MDI

(combination of fluticasone propionate and salmeterol)

  • Aerosol inhalation 125 micrograms / 25 micrograms / metered dose (MDI) (£18.50 = 120 doses)
  • Aerosol inhalation 250 micrograms / 25 micrograms / metered dose (MDI) (£29.95 = 120 doses)

Indications and dose

Notes

  1. AirFluSal® metered dose inhaler is not licensed for the management of COPD
  2. AirFluSal® is licensed for use in adults aged 18 years and above
Seretide® Evohaler®

(combination of fluticasone propionate and salmeterol)

  • Aerosol inhalation 50 micrograms / 25 micrograms / metered dose (MDI) (£18.00 = 120 doses)

Indications and dose

Notes

  1. Seretide® Evohaler® 50 micrograms/ 25 micrograms remains in the formulary for use in children aged 4 years and above
Seretide® Accuhaler®

(combination of fluticasone propionate and salmeterol)

  • Dry powder inhalation 100 micrograms / 50 micrograms / blister dose (DPI) (£18.00 = 60 doses)
  • Dry powder inhalation 250 micrograms / 50 micrograms / blister dose (DPI) (£35.00 = 60 doses)
  • Dry powder inhalation 500 micrograms / 50 micrograms / blister dose (DPI) (£32.74 = 60 doses)

Indications and dose

Notes

  1. In children, high dose inhaled corticosteroid (ICS) (see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
  2. The maximum licensed dose of fluticasone propionate delivered by Seretide® Accuhaler® in children aged 4 years and above is 100 microgram twice daily

Fluticasone propionate and formoterol fumarate

Flutiform® (fluticasone /formoterol)

The routine commissioning of Flutiform® is not accepted in Devon for the treatment of asthma in adults and children over 12 years (see Commissioning Policy for more details).

Combination inhalers (Long-acting beta2 agonists (LABA) + Long-acting muscarinic antagonists (LAMA))

Tiotropium bromide and olodaterol

Spiolto® Respimat®

(combination of tiotropium bromide and olodaterol hydrochloride)

  • Solution for inhalation 2.5 micrograms / 2.5 micrograms / solution dose (MDI) (£32.50 = cartridge and device with 60 doses)

Indications and dose

Notes

  1. MHRA Drug Safety Update (February 2015): When using tiotropium delivered via Respimat® or HandiHaler® to treat chronic obstructive pulmonary disease (COPD):
    1. take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:
      • myocardial infarction in the last 6 months
      • unstable or life threatening cardiac arrhythmia
      • cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
      • hospitalisation for heart failure (NYHA Class III or IV) within the past year
    2. Tell these patients to report any worsening of cardiac symptoms after starting tiotropium
    3. Review the treatment of all patients already taking tiotropium as part of the comprehensive management plan to ensure that it remains appropriate for them; regularly review treatment of patients at high risk of cardiovascular events
    4. Remind patients not to exceed the recommended once daily dose
  2. The routine commissioning of Spiolto® Respimat® combination inhaler is accepted in Devon for the treatment of COPD in adults (see Commissioning Policy for more details)

Indacaterol maleate and glycopyrronium bromide

Ultibro® Breezhaler®

(combination of indacaterol maleate / glycopyrronium bromide)

  • Dry powder inhalation 85 micrograms / 43 micrograms / hard capsule (DPI) (£32.50 = 30 capsules and device)

Indications and dose

Aclidinium bromide and formoterol fumarate

Duaklir® Genuair®

(combination of aclidinium bromide and formoterol fumarate)

  • Breath-actuated dry powder inhaler 340 micrograms / 12 micrograms / metered dose (DPI) (£32.50 = 60 doses)

Indications and dose

Triple combination inhaler (Inhaled corticosteroid (ICS) + Long-acting beta2 agonists (LABA) + Long-acting muscarinic antagonists (LAMA))

Trimbow®

(combination of BDP (extrafine), formoterol fumarate dihydrate, and glycopyrronium)

  • Pressurised inhalation, solution 87 micrograms / 5 micrograms / 9 micrograms (MDI) (delivered dose) (£44.50 = 120 dose unit)

Indications and dose

Notes

  1. Trimbow is only licensed for use in moderate to severe COPD in patients who are not adequately treated by a combination of ICS/LABA
  2. Trimbow is not currently licensed for use in patients adequately controlled on triple therapy
  3. Triple therapy is only recommended for patients in COPD category D (many symptoms and with high risk of exacerbations). See Management of COPD
  4. The aerosol particles of Trimbow® are on average much smaller than the particles delivered in non-extrafine formulations. For BDP, this results in a more potent effect than formulations with a non-extrafine particle size distribution; the manufacturer states that 100 micrograms of BDP extrafine in Trimbow® are equivalent to 250 micrograms of BDP in a non-extrafine formulation.

 

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