NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Prescribing
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3 Respiratory system

3.2 Corticosteroids

The prescribing resources page contains useful resources for prescribing inhaler devices including device guides and patient information leaflets.

3.2.1 Single agent inhaled devices

Patients receiving inhaled corticosteroids for asthma should have their treatment reviewed regularly with those patients on a high-dose inhaled steroid being considered for step-down if appropriate. Patients receiving >1000 micrograms of beclometasone daily (or equivalent, e.g. fluticasone 500 microgram or 800 microgram budesonide) should be issued with a steroid card.

Preferred list
BECLOMETASONE

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

Brands include:

  • Clenil Modulite® (aerosol inhaler)
  • Asmabec Clickhaler® (dry powder inhaler)
  • Pulvinal® (dry powder inhaler)
  • Easyhaler Beclometasone® (dry powder inhaler)
  • Qvar® (aerosol inhaler)

Clenil Modulite® is the preferred inhaled steroid. Where patients are unable to tolerate or use this preparation, other medicines and devices may be considered. Different brands of beclometasone CFC-free inhalers are not equipotent and should be prescribed by brand name for safety reasons.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2986.htm

Total Formulary
BUDESONIDE

Restrictions: Budesonide RespulesĀ® are restricted to hospital inpatient treatment of croup only.

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

Brands include:

  • Pulmicort Turbohaler® (dry powder inhaler)
  • Budeline Novolizer® (dry powder inhaler)
  • Easyhaler Budesonide® (dry powder inhaler)

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2999.htm

FLUTICASONE (Flixotide)

Restrictions: Fluticasone nebuliser solution remains non-Formulary.

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

Brands and devices include:

  • Flixotide Evohaler® (aerosol inhaler)
  • Flixotide Accuhaler® (dry powder inhaler)

Fluticasone provides equal clinical activity to regular beclometasone and budesonide at half the dosage.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3004.htm

3.2.2 Combination inhaled devices

In asthma, patients receiving inhaled corticosteroids should have their treatment reviewed regularly with those patients on a high-dose inhaled steroid being considered for step-down if appropriate. Patients receiving >1000 micrograms of beclometasone daily (or equivalent, e.g. fluticasone 500 microgram or 800 microgram budesonide) should be issued with a steroid card.

Preferred list
BECLOMETASONE AND FORMOTEROL

Restrictions: For use in asthma, Fostair 100/6 is restricted for use in patients on step 3 or above of the BTS/SIGN asthma guidelines and the 200/6 strength at step 4 or above. Use of the 100/6 strength for the treatment of severe COPD (FEV1 <50% predicted normal) is restricted to use in accordance with the current NHSGGC COPD guidelines.

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

Brands and devices include:

  • Fostair® (aerosol inhaler)
  • Fostair NEXTHaler® (dry powder inhaler)

In selected adult patients with asthma at step 3 who are poorly controlled or in selected adult patients at step 2 (above beclometasone 400micrograms/day or equivalent and poorly controlled), the use of beclometasone and formoterol 100/6 in a single inhaler as rescue medication instead of a short-acting beta2 agonist, in addition to its regular use as controller therapy, has been shown to be an effective treatment regime.

Fostair 200/6 strength aerosol inhaler and  NEXThaler are not currently licensed for use in COPD or for the maintenance and relief use in asthma (as described in the paragraph above).

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/200011.htm#_200011

BUDESONIDE AND FORMOTEROL

Restrictions: Restricted for use in patients on step 3 or above of the BTS/SIGN asthma guidelines or for patients with COPD in accordance to current NHSGGC COPD Guidelines.

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

Brands include:

  • DuoResp Spiromax® (dry powder inhaler)
  • Symbicort Turbohaler® (dry powder inhaler)

In terms of comparative doses, one dose of Duoresp® 160/4.5 delivers an equivalent amount of the constituents as one dose of Symbicort® 200/6.  Similary, DuoResp ® 320/9 is the equivalent of Symbicort® 400/12.

In selected adult patients with asthma at step 3 who are poorly controlled or in selected adult patients at step 2 (above beclometasone 400micrograms/day or equivalent and poorly controlled), the use of budesonide and formoterol in a single inhaler as rescue medication instead of a short-acting beta2 agonist, in addition to its regular use as controller therapy, has been shown to be an effective treatment regime.

Non-Formulary indication:

Treatment of patients with chronic obstructive pulmonary disease (COPD) with forced expiratory volume in 1 second (FEV1) 50% to 70% predicted normal (post bronchodilator) and an exacerbation history despite regular bronchodilator therapy.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP1863-compound-preparations.htm#PHP1863-compound-preparations

FLUTICASONE AND FORMOTEROL (Flutiform 250/10) (aerosol inhaler)

Restrictions: Restricted to use of the Flutiform 250/10 in the management of asthma in adults at step 4 or above of the BTS/SIGN guidelines. See the Total Formulary for other strengths and indications.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP18748-flutiform.htm#PHP18748-flutiform

FLUTICASONE AND SALMETEROL (SERETIDE 500 ACCUHALER) (dry powder inhaler)

Restrictions: Restricted to use of the Seretide 500 Accuhaler in the management of asthma in adults at step 4 or above of the BTS/SIGN guidelines. See the Total Formulary for other preparations and indications.

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

For other fluticasone and salmeterol preparations and indications in adults, see the Total Formulary.  For paediatric use, see the GGC Paediatric Formulary.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP1872-seretide.htm#PHP1872-seretide

Total Formulary
FLUTICASONE AND FORMOTEROL (Flutiform) (aerosol inhaler)

Restrictions: The use in the treatment of asthma is restricted to use in patients on step 3 or above of the BTS/SIGN Asthma Guidelines

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP18748-flutiform.htm#PHP18748-flutiform

FLUTICASONE AND SALMETEROL (SERETIDE)

Restrictions: Restricted for use in patients on step 3 or above of the BTS/SIGN asthma guidelines or for patients with COPD in accordance to current NHSGGC COPD Guidelines. Seretide 500 AccuhalerĀ® is not recommended by SMC for patients with COPD with an FEV1 of 50 - 60%.

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

Brands and devices include:

  • Seretide Accuhaler® (dry powder inhaler)
  • Seretide Evohaler® (aerosol inhaler)

Seretide Accuhaler® is preferred over the Seretide 250 Evohaler® when that dose is required on the basis of cost.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1872-seretide.htm#PHP1872-seretide

FLUTICASONE FUROATE AND VILANTEROL (Relvar Elipta) (dry powder inhaler)

Restrictions: COPD: The symptomatic treatment of adults with chronic obstructive pulmonary disease (COPD) with an exacerbation history despite regular bronchodilator therapy is restricted to use in patients with severe COPD (FEV1 <50% predicted normal and two or more exacerbations in a year) in accordance with NHSGGC COPD Guidelines. Asthma: The regular treatment of asthma in adults and adolescents aged 12 years and older where use of a combination medicinal product (long-acting beta2-agonist and inhaled corticosteroid) is appropriate in patients not adequately controlled with inhaled corticosteroids and 'as needed' inhaled short-acting beta2-agonists

Prescribing Notes:

To prevent confusion, prescribe inhaler devices by brand name.

  • Fluticasone furoate is a high-potency inhaled steroid (with a dose of 92 micrograms once daily broadly equivalent to 250 micrograms twice daily of fluticasone propionate). When used for asthma, due consideration for the likelihood of step-down should be given prior to initiation as there are no available step-down options containing a dose lower than 92 microgram of fluticasone furoate.
  • Prescribers should be aware that the fluticasone furoate contained in this preparation is not equivalent in terms of dosing to fluticasone propionate.
  • The Summary of product characteristics for this preparation advises on dose equivalence in section 4.2.
  • It should be noted that once the inhaler has been opened from its foil packaging, it has an expiry of 6 weeks.
  • The name of this device may inadvertently lead patients to confuse it as a 'reliever'. Careful counselling to avoid overuse is advised.
  • Only the 92/22 microgram strength is licensed for COPD

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP34311-relvar-ellipta.htm#PHP34311-relvar-ellipta

3.2.3 Systemic corticosteroids for acute exacerbations of asthma and COPD

Preferred list
PREDNISOLONE

Restrictions: Excludes 25mg tablets

Prescribing Notes:

The use of enteric-coated (EC) prednisolone does not offer significant benefit over the regular tablets.  Plain prednisolone tablets should be used in preference where available.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2181.htm

Total Formulary