803FM.

1 ASTHMA - INHALED TREATMENT ALGORITHM - ADULTS

Please see the algorithm on the following pages.

Title of Guideline Asthma Inhaled Treatment Algorithm - Adults

Guideline Number 803FM
Version 1
Effective Date April 2014
Review Date April 2017
Approvals:
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Formulary Management Group 26 February 2014
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Clinical Guidelines Subgroup 13 March 2014
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Buckinghamshire Area Prescribing 19 March 2014
Committee
Author/s Dr Chris Wathen, Consultant, Respiratory Medicine
Maire Stapleton, Formulary Manager
Elaine Sharpe, Prescribing Support Pharmacist, Aylesbury
Vale and Chiltern Clinical Commissioning Groups
SDU(s)/Department(s) responsible Respiratory Medicine
for updating the guideline Pharmacy
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Uploaded to Intranet 10 April 2014
Buckinghamshire Healthcare NHS Trust/Aylesbury Vale and Chiltern Clinical Commissioning
Groups

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 Asthma – Inhaled Treatment Algorithm - Adults
BTS Guideline Compliance is always an issue. Check that patient can use device effectively at every visit.
Steps All patients who are using an MDI should be supplied with a spacer device.

Step 1 Salbutamol 100 micrograms 2 puffs qds/prn MDI

Step 2 Beclometasone dipropionate (CLENIL®) 100 micrograms 2 puffs bd MDI £4.45*

This is equivalent to beclometasone dipropionate (extra fine BDP) QVAR® 50 micrograms 2 puffs bd non-formulary £4.72*
Add inhaled steroid (ICS)
(Prescribe by brand) 400 micrograms standard beclometasone dipropionate (BDP) equivalent

Prescribe ONE inhaler, review at ONE month. ** STOP if no benefit.

Step 3
Stage 1:
Trial of LABA. Keep ICS
dose the same.
See MDI and DPI
options.
Stage 2:
If necessary increase ICS
dose. If no response to
LABA consider oral
montelukast.
Step 4
Consider trial of
increased ICS dose.
See MDI and DPI
options.
Consider oral
montelukast and/or
theophylline m/r.
Option: ICS/LABA MDI administered via a spacer Option: ICS/LABA Dry Powder Inhaler (DPI)
st st
1 CHOICE: Flutiform® 50/5 MDI 2 puffs bd 1 CHOICE: Seretide 100 Accuhaler® 1 puff bd
(fluticasone/formoterol 50/5) £18.00* (fluticasone/salmeterol 100/50) £18.00*
nd nd
2 CHOICE: Seretide 50 Evohaler® MDI 2 puffs bd 2 CHOICE: Symbicort 100 Turbohaler® 2 puffs bd
(fluticasone/salmeterol 50/25) £18.00* (budesonide/formoterol 100/6) £33.00*
400 micrograms standard BDP equivalent 400 micrograms standard BDP equivalent
st st
1 CHOICE: Flutiform® 125/5 MDI 2 puffs bd 1 CHOICE: Seretide 250 Accuhaler® 1 puff bd
(fluticasone/formoterol 125/5) £29.26* (fluticasone/salmeterol 250/50) £35.00*
nd
2 CHOICE: Seretide 125 Evohaler® MDI 2 puffs bd 1000 micrograms standard BDP equivalent
(fluticasone/salmeterol 125/25) £35.00* 2
nd
CHOICE: Symbicort 200 Turbohaler® 2 puffs bd
Please note Fostair® 100/6 MDI 2 puffs bd is non-formulary (budesonide/formoterol 200/6) £38.00*
(beclometasone/formoterol 100/6 ***) £29.32* 800 micrograms standard BDP equivalent
*** extra fine particles
1000 micrograms standard BDP equivalent
st
1 CHOICE: Flutiform® 250/10 MDI 2 puffs bd
Seretide 500 Accuhaler® 1 puff bd
(fluticasone/formoterol 250/10) £45.56*
nd (fluticasone/salmeterol 500/50) £40.92*
2 CHOICE: Seretide 250 Evohaler® MDI 2 puffs bd
2000 micrograms standard BDP equivalent
(fluticasone/salmeterol 250/25) £59.48*
2000 micrograms standard BDP equivalent

This asthma algorithm has been developed using BTS/SIGN British Guideline on the Management of Asthma May 2008, revised February 2014.
*Mims Price Jan 2014 **Duration of a trial of add-on therapy will depend on the desired outcome – see further information overleaf.
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 Asthma – Inhaled Treatment Algorithm – Adults
The aim of asthma management is control of the disease. Complete control is defined as:
No daytime symptoms No night time awakening due to asthma
No need for rescue medication No exacerbations
No limitations on activity including exercise Normal lung function (in practical terms FEV1 and/or PEF >80% predicted or
Minimal side effects from medication best)
Compliance with Inhaler Devices
Studies have shown that 92% of patients cannot use inhalers correctly and 91% of professionals cannot teach inhaler technique properly.
Correct inhaler technique can be difficult to learn and easy to forget.
Teach inhaler device technique before prescribing and check at every visit.
Which device?
MDI devices are usually best and should always be used with a spacer. If a person cannot use a particular device, try another. The technique for metered
dose inhalers (MDI) is different to that of dry powder inhalers (DPI), so generally patients should be prescribed the same type of device for all inhalers.
** Stepping Up Treatment
The duration of a trial of add-on therapy will depend on the desired outcome, e.g. preventing nocturnal awakening may require a relatively short trial of
treatment (days or weeks) whereas preventing exacerbations or decreasing steroid tablet use may require a longer trial of therapy (weeks or months). If there
is no response to treatment the drug should be discontinued.
Stepping Down Treatment
Patients should be maintained at the lowest possible dose of inhaled steroid. Reductions in dose should be considered every 3 months, decreasing
the dose by approximately 25 - 50%.
Prolonged use of high doses of inhaled steroid carries a risk of systemic side-effects, including adrenal suppression, (1000 micrograms inhaled
fluticasone is approximately equivalent to 10 mg oral prednisolone), decrease in bone mineral density, cataract, glaucoma, diabetes and a range of
psychological or behavioural effects. A study has shown that treatment with high dose fluticasone over 5.5 years significantly increased the risk of
onset of diabetes and also the risk of diabetes progression from oral therapy to insulin.
Fostair® (non-formulary) or Symbicort® both have licensed doses of 1 - 2 puffs bd. Many patients have their treatment ‘stepped down’ by reducing the
dose to 1 puff bd but this means that both the steroid and LABA doses are halved. N.B. Company studies have found that formoterol 12 micrograms
is approximately equipotent with 50 micrograms salmeterol in terms of duration of effect and increase in lung function.
Combination Inhalers:
Both the MHRA and NICE recommend these are used to guarantee that the LABA is not taken without the inhaled steroid and to improve inhaler
adherence.
A recent study suggested a trend towards lower adherence to ICS in patients using separate inhalers compared with combined inhalers, and that those
patients using separate ICS and LABA inhalers were significantly more adherent to the LABA than the ICS.
References:
BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised January 2012 Inhaler Technique – Thorax, December 2010; 65 (Suppl.4):A117-A118
High Dose Steroids – NPC/ QIPP Resources/inhaled corticosteroids Formoterol – personal communication
Combinations - Thorax 2012; doi: 10.1136/thoraxjnl-2011-201096 (published early online 21 March 2012)

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 Asthma – Inhaled Treatment Algorithm – Adults
Appendix: Comparison of ICS/LABA Combination Inhalers
BTS/SIGN
Daily Cost
Asthma Brand MDI/DPI
Dose Community*
Guideline
ICS/LABA (standard BDP equivalent of 400 micrograms per day)
Fluticasone/salmeterol 100 micrograms/50 micrograms Seretide Accuhaler® DPI 1 puff BD £18.00
Step 3 MDI
Fluticasone/salmeterol 50 micrograms/25 micrograms Seretide 50 Evohaler® nd 2 puff BD £18.00
Stage 1 2 choice
Fluticasone/formoterol 50 micrograms/5 micrograms Flutiform® MDI 2 puff BD £18.00
Budesonide/formoterol 100 micrograms/6 micrograms Symbicort 100 Turbohaler® DPI 2 puff BD £33.00
ICS/LABA (standard BDP equivalent of 800 to 1000 micrograms per day)
Fluticasone/formoterol 125 micrograms/5 micrograms Flutiform® MDI 2 puff BD £29.26
Step 3 Beclometasone/formoterol 100 micrograms/6 micrograms **Fostair® 2 puff BD £29.32
Stage 2/
Step 4 Fluticasone/salmeterol 250 micrograms/50 micrograms Seretide 250 Accuhaler® 1 puff BD £35.00
Fluticasone/salmeterol 125 micrograms/25 micrograms Seretide 125 Evohaler® MDI 2 puff BD £35.00
Budesonide/formoterol 200 micrograms/6 micrograms Symbicort 200 Turbohaler® 2 puff BD £38.00
ICS/LABA (standard BDP equivalent of 1600 to 2000 micrograms per day)

Fluticasone/salmeterol 500 micrograms/50 micrograms Seretide 500 Accuhaler® 1 puff BD £40.92

Step 4 Fluticasone/formoterol 250 micrograms/10 micrograms Flutiform® MDI 2 puff BD £45.56

Fluticasone/salmeterol 250 micrograms/25 micrograms Seretide 250 Evohaler® MDI 2 puff BD £59.48
Budesonide/formoterol 400 micrograms/12 micrograms Symbicort 400 Turbohaler® 2 puff BD £76.00
* Drug tariff online - January 2014 ABBREVIATIONS:
** Non-formulary MDI Metered dose inhaler ICS Inhaled corticosteroid
DPI Dry powder inhaler SABA Short acting beta2 agonist
BDP Beclometasone dipropionate LABA Long acting beta2 agonist

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