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NHSGG&C Prescribing Advice:

Inhaled Corticosteroid (ICS) and Long-acting β2 agonist (LABA) Combination


Inhalers for the Management of Adult Asthma (18 years and over) and
Chronic Obstructive Pulmonary Disease (COPD) in Primary Care
To be used by primary care prescribers involved in the care and review of patients with asthma and COPD
To be used in conjunction with NHSGG&C Primary Care COPD and Asthma Guidelines and Inhaler Device Guides
GGC Formulary Prescribing Resources: http://www.ggcprescribing.org.uk/prescribing-resources/

Combination ICS/LABA inhalers:


There have been a number of new combination ICS/LABA inhalers enter the market during 2014 and 2015. The
purpose of this guidance is to summarise the place in therapy for all the combination ICS/LABA inhalers in the
management of adult asthma and COPD.

ADULT ASTHMA (18 years and over)


• Combination ICS/LABA inhalers are recommended in asthmatic patients who are still symptomatic after a trial
of a single ICS equivalent to 400-800micrograms traditional beclometasone (BDP) per day
• Flexible dosing combination inhalers are the NHSGG&C inhalers of choice in adult asthmatics at Step 3A and 3B
(see Adult Asthma Inhaler Device Guide) of the asthma guidelines. The flexibility of these inhalers allows
patients to move between Step 3A, one puff twice daily and Step 3B, two puffs twice daily as appropriate
• To prevent confusion, all inhalers should be prescribed by brand name, with the exception of salbutamol
metered dose inhalers (MDI)

Step 3A Step 3B Step 4


ICS dose equivalent to ICS dose equivalent to ICS dose equivalent to
400-500 micrograms BDP/day 800-1000 micrograms BDP/day 1600-2000 micrograms BDP/day

1st 1st
choice choice

Fostair® 100/6 MDI Fostair® 100/6 MDI Fostair® 200/6 MDI


ONE puff twice daily TWO puffs twice daily TWO puffs twice daily

2nd 2nd
choice choice

Fostair® 100/6 NEXThaler Fostair® 100/6 NEXThaler Fostair® 200/6 NEXThaler


ONE puff twice daily TWO puffs twice daily TWO puffs twice daily

or 3rd
choice

DuoResp® 160/4.5 Spiromax DuoResp® 160/4.5 Spiromax Flutiform 250/10 MDI


ONE puff twice daily TWO puffs twice daily TWO puffs twice daily

or or

Symbicort® 200/6 Turbohaler Symbicort® 200/6 Turbohaler Seretide® 500 Accuhaler


ONE puff twice daily TWO puffs twice daily ONE puff twice daily Page 1 of 3
Other ICS/LABA inhalers available at Step 3A/3B/4 of asthma guidelines
but are not included in the NHSGG&C preferred formulary list:
Step 3A Step 3B Step 4
ICS dose equivalent to ICS dose equivalent to 800-1000 ICS dose equivalent to 1600-2000
400-500 micrograms BDP/day micrograms BDP/day micrograms BDP/day

Flutiform® 50/5 MDI, Flutiform® 125/5 MDI, DuoResp® 320/9 Spiromax,


two puffs twice daily two puffs twice daily two puffs twice daily

Seretide® 50 Evohaler, Relvar® Ellipta 92/22* , Relvar® Ellipta 184/22* ,


two puffs twice daily one puff once daily one puff once daily

Seretide® 100 Accuhaler, Seretide® 125 Evohaler, Seretide® 250 Evohaler,


one puff twice daily two puffs twice daily two puffs twice daily

Seretide® 250 Accuhaler, Symbicort® 400/12 Turbohaler,


one puff twice daily two puffs twice daily

• DuoResp® Spiromax 160/4.5 & 320/9 = budesonide and formoterol; dry powder inhaler (DPI); equivalent to
Symbicort 200/6 & 400/12 respectively but more cost effective. Licensed in asthma & COPD (18 years and over);
200/6 strength licensed for asthma maintenance and reliever treatment (MART)

• Flutiform® MDI = fluticasone propionate and formoterol; 50/5 and 125/5 strength licensed in asthma (12 years and
over); 250/5 strength licensed in asthma (18 years and over)

• Fostair® 100/6 & 200/6 = extra-fine particle size beclometasone and formoterol: 100micrograms extra-fine particle
size beclometasone is equivalent to approximately 250micrograms BDP:
o Fostair® 100/6 metered dose inhaler (MDI) & NEXThaler® (DPI): licensed in asthma (18 years and over) and
COPD; only Fostair 100/6 MDI is licensed for asthma MART
o Fostair® 200/6 MDI and NEXThaler® (DPI): licensed in asthma (18 years and over)

• Relvar® Ellipta  = fluticasone furoate* and vilanterol; DPI; 92/22 strength licensed in asthma & COPD (12 years
and over); 184/22 strength licensed in asthma only (12 years and over)
*Prescribers should be aware that the fluticasone furoate contained in Relvar® preparations is not equivalent to
fluticasone propionate. In patients with asthma, fluticasone furoate 100 micrograms once daily is approximately
equivalent to fluticasone propionate 250 micrograms twice daily. For other prescribing/ licensing information
please see individual SPC for guidance: https://www.medicines.org.uk/emc/

• Seretide® Evohaler (MDI) & Accuhaler (DPI): fluticasone propionate and salmeterol; Evohaler® 50 & Accuhaler®
100 licensed for asthma (5 years and over); Evohaler® 125 & 250 & Accuhaler® 250 licensed for asthma (12 years
and over); Accuhaler® 500 licensed for asthma & COPD (12 years and over)

• Symbicort® 200/6 & 400/12 Turbohaler= budesonide and formoterol; DPI; licensed for asthma & COPD (12 years
and over); 200/6 strength licensed for Symbicort maintenance and reliever therapy (SMART)

Inhaled Corticosteroid Equivalencies:


Inhaled Corticosteroid (Brand names) Equivalence to traditional
Beclometasone Dipropionate
(BDP) / day
Beclometasone Diproprionate – (Clenil®, Easyhaler®) 100 micrograms 100 micrograms
Beclometasone Diproprionate (extrafine particle size) - (Fostair®) 100 micrograms 250 micrograms
Beclometasone Diproprionate (extrafine particle size) - (Qvar®) 100 micrograms 200 to 250 micrograms
Budesonide - (Pulmicort®/ Easyhaler®/ Symbicort®) 100 micrograms 100 micrograms
Budesonide - (Duoresp® Spiromax) 160 micrograms equivalent to 200 micrograms 200 micrograms
budesonide
Fluticasone Propionate - (Flixotide®/ Flutiform®/ Seretide®) 100 micrograms 200 micrograms
®
Fluticasone Furoate – (Relvar ) 92 micrograms 1000 micrograms
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COPD
Combination ICS/LABA inhalers are only recommended in patients with COPD at Step 3 (see NHSGG&C Primary
Care COPD Guideline) who are still breathless after a trial of single LABA or LAMA and whose FEV1 < 50%
predicted and who have had 2 or more exacerbations in 12 consecutive months:

Step 3

1st choice

Fostair® 100/6 MDI, TWO puffs twice daily

2nd choice

Fostair® 100/6 NEXThaler, TWO puffs twice daily

DuoResp® 320/9 Spiromax, ONE puff twice daily

or

Symbicort® 400/12 Turbohaler, ONE puff twice daily

Other ICS/LABA inhalers available at Step 3 for the management of COPD but are not included in the
NHSGG&C formulary preferred list:
1. Relvar® Ellipta 92/22 , one puff once daily = fluticasone furoate* and vilanterol
2. Seretide® 500 Accuhaler, one puff twice daily = fluticasone propionate and salmeterol

To prevent confusion, all inhalers should be prescribed by brand name, with the exception of salbutamol MDI’s

= black triangle medicine, subject to additional monitoring by the European Medicines Agency

South Sector Prescribing Team, 18th January 2016


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