3.2 Corticosteroids

High dose pMDI inhaled corticosteroid devices should be prescribed with a spacer to reduce risk of oral candidiasis (see 3.1.5 Peak flow meters, inhaler devices and nebulisers).

For information on inhaled corticosteroid dose comparisons in asthma see here

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. In the absence of a clinical or dexterity reason for the choice of inhaler, dry powder inhalers or soft mist inhalers are generally preferred, and the product which has the cheapest acquisition cost should be chosen.

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; BDP = Beclometasone dipropionate

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.

Easyhaler Budesonide

(Budesonide)

  • Dry powder inhaler 100 micrograms/ metered inhalation, 200 micrograms/ metered inhalation, 400 micrograms/ metered inhalation (DPI) (£17.71 = 200 micrograms x 200 doses)

Indications and dose

Notes

  1. COVID-19: Only use budesonide to treat COVID-19 as part of a clinical trial (NICE NG191 COVID-19 rapid guideline)
  2. Refer to BNF or manufacturer's Summary of Product Characteristics (SPC) for once daily dosing regimen
  3. In adults with asthma, high dose ICS (such as Budesonide Easyhaler 400 micrograms - 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care
  4. In children with asthma, medium dose ICS (such as Budesonide Easyhaler 400 micrograms - 1 puff twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care
  5. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the Environmental Impact of Inhalers)
Pulmicort Turbohaler

(Budesonide)

  • Dry powder inhaler 100 micrograms/ metered inhalation, 200 micrograms/ metered inhalation, 400 micrograms/ metered inhalation (DPI) (£14.25 = 200 micrograms x 100 doses)


    Indications and dose

    Notes

    1. COVID-19: Only use budesonide to treat COVID-19 as part of a clinical trial (NICE NG191 COVID-19 rapid guideline)
    2. Refer to BNF or manufacturer's Summary of Product Characteristics (SPC) for once daily dosing regimen
    3. In adults with asthma, high dose ICS (such as Pulmicort Turbohaler 400 micrograms - 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care
    4. In children with asthma, medium dose ICS (such as Pulmicort Turbohaler 400 micrograms - 1 puff twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care
    5. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the Environmental Impact of Inhalers)
    Budesonide
    • Nebuliser solution 250 micrograms in 1ml, 500 micrograms in 1ml (£39.45 = 500 micrograms/ml, 20 x unit doses)
      Kelhale

      (BDP extrafine)

      • Aerosol inhalation 50 micrograms/ metered inhalation, 100 micrograms/ metered inhalation, (pMDI) (£5.20 = 100 micrograms x 200 doses)

      Indications and dose

      • Asthma, adults:
        • 50–200 micrograms twice daily, increased if necessary up to 400 micrograms twice daily

      Notes

      1. Prescribe by brand. BDP inhalers should be prescribed by brand since they are not all interchangeable. Kelhale and Qvar are extra-fine particle formulations and are therapeutically equivalent. They are both approximately twice as potent as Clenil Modulite.
      2. In adults with asthma, high dose ICS (such as Kelhale 100 micrograms - 4 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care
      3. Kelhale is not licensed for use in children under 18 years
      4. 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.
      Qvar

      (BDP extrafine)

      • Aerosol inhalation 50 micrograms/ metered inhalation, 100 micrograms/ metered inhalation (pMDI) (£17.21 = 100 micrograms x 200 doses)
      • Autohaler breath-actuated aerosol inhalation 50 micrograms/ metered inhalation, 100 micrograms/ metered inhalation (BAI) (£17.21 = 100 micrograms x 200 doses)
      • Easi-breathe breath-actuated aerosol inhalation 50 micrograms/ metered inhalation, 100 micrograms/ metered inhalation (BAI) (£16.95 = 100 micrograms x 200 doses) (not licensed for use in children aged < 12 years)

      Indications and dose

      • Asthma, adults and adolescents:
        • Aged ≥ 12 years: 50–200 micrograms twice daily; increased if necessary up to 400 micrograms twice daily
      • Asthma, children:
        • Aged 5 years and older: 50-100 micrograms twice daily (maximum daily dose 100 micrograms twice daily) using Autohaler or pMDI

      Notes

      1. Prescribe by brand. BDP inhalers should be prescribed by brand since they are not all interchangeable. Qvar and Kelhale are extra-fine particle formulations and are therapeutically equivalent. They are both approximately twice as potent as Clenil Modulite
      2. For new initiations of beclomethasone extrafine pMDI inhaler in adult patients, Kelhale pMDI is the preferred option due to its lower acquisition cost
      3. In adults with asthma, high dose ICS (such as Qvar 100 micrograms - 4 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
      4. Qvar is not licensed for use in children under 5 years
      5. Qvar Easi-breathe is not licensed for use in children under 12 years of age due to the lack of data
      6. pMDIs and BAIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the Environmental Impact of Inhalers). For this reason pMDIs and BAIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.
      Clenil Modulite

      (BDP)

      • Aerosol inhalation 50 micrograms/ metered inhalation, 100 micrograms/ metered inhalation, 200 micrograms/ metered inhalation, 250 micrograms/ metered inhalation (pMDI) (£16.17 = 200 micrograms x 200 doses)

      Indications and dose

      Notes

      1. Prescribe by brand. BDP inhalers should be prescribed by brand since they are not all interchangeable. Qvar and Kelhale are extrafine particle formulations and are both approximately twice as potent as Clenil Modulite
      2. In adults with asthma, high dose ICS (such as Clenil Modulite 250 micrograms - 4 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care
      3. Clenil Modulite 50 and 100 are licensed for use in children
      4. Clenil Modulite 200 and 250 are not recommended for use in children under 12 years
      5. 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.
      Last updated: 07-03-2022

       

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