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.

Budesonide
  • Pulmicort® Turbohaler® dry powder inhaler 100 micrograms/ metered inhalation, 200 micrograms/ metered inhalation, 400 micrograms/ metered inhalation (DPI) (£14.25 = 200 micrograms x 100 doses)
  • Nebuliser solution 250 micrograms/ml, 500 micrograms/ml (£39.49 = 500 micrograms/ml, 20 x 2ml)

Indications and dose

Notes

  1. Refer to BNF or manufacturer's Summary of Product Characteristics (SPC) for once daily dosing regimen
  2. 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
  3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
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)
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, 100 micrograms/ metered inhalation (BAI) (£16.95 = 100 micrograms x 200 doses)

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)

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. 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.
  3. Qvar® is not licensed for use in children under 5 years
  4. pMDIs and BAIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)
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
  5. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)
Last updated: 16-12-2019

 

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