Advice on how to obtain placebo inhalers can be obtained from the NHS Devon ICB Medicines Optimisation Team, please contact: d-icb.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.

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.

The NHS Devon Medicines Optimisation Team has produced additional resources to support greener respiratory care across Devon (see here).

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; DPI = Dry powder inhaler; SMI = Soft mist inhaler

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.

Short-acting muscarinic antagonists (SAMAs)

Ipratropium Bromide

• Atrovent aerosol inhalation 20micrograms/metered inhalation (pMDI) (£5.56 = 200 doses)
• Nebuliser liquid 250micrograms/1ml, 500micrograms/2ml (£5.75 = 20 x 2ml unit dose vials)

Indications and dose

• Chronic obstructive pulmonary disease
  • By aerosol inhalation, 20–40micrograms 3–4 times daily
  • By inhalation of nebulised solution, reversible airways obstruction in chronic obstructive pulmonary disease, 250–500micrograms 3–4 times daily

Notes

1. Medicine Supply Notification 15 July 2024 (MSN/2024/076): Ipratropium bromide 250micrograms/1ml and 500micrograms/2ml nebuliser liquid unit dose vials
   
   1. Ipratropium bromide 250micrograms/1ml and 500micrograms/2ml nebuliser solution is in limited
      supply until late March 2025.
   2. Ipratropium bromide 20microgram/dose inhalers remain available and can support an increase in
      demand.
   3. Salbutamol 2.5mg/2.5ml / ipratropium bromide 500micrograms/2.5ml nebuliser solution remains
      available, however, cannot support an increase in demand.
   4. Unlicensed supplies can be sourced (see Supporting Information in MSN), lead times vary.
   5. Access to licensed ipratropium nebules will be actively monitored. Where possible, supplies will be prioritised for ambulance services who are less able to use unlicensed supplies.
   6. Refer to MSN for actions required
2. Acute angle glaucoma may occur with ipratropium particularly when used in a nebuliser with salbutamol. Care should be taken to avoid escape from the mask into the eyes.
3. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)

Long-acting muscarinic antagonists (LAMAs)

Tiogiva

(Tiotropium)

• 18microgram inhalation powder, capsules (DPI) (£19.20 = 30 days, £38.40 = 60 days)
• 18microgram inhalation powder, capsules with device (DPI) (£19.99 = 30 days)

Indications and dose

• Maintenance treatment of chronic obstructive pulmonary disease
• 18micrograms (one capsule) once daily
• The delivered dose (the dose that leaves the mouthpiece) is equivalent to 10micrograms tiotropium

Notes

1. The Tiogiva inhaler is not licensed for use in patients with asthma.
2. To get a full daily dose, the patient must first breathe out completely, emptying the lungs of any air before breathing in the dose. The patient should also inhale a second time from the same capsule.
3. The Tiogiva inhaler device should be replaced after 180 days (approximately 6 months)
4. The MHRA updates below (notes 5 and 6) also apply to tiotropium delivered by the Tiogiva device.
5. MHRA Drug Safety Update (February 2015): When using tiotropium delivered via Respimat or Handihaler to treat chronic obstructive pulmonary disease (COPD):
1. take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:
• Myocardial infarction in the last 6 months
• Unstable or life-threatening cardiac arrhythmia
• Cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
• Hospitalisation for heart failure (NYHA Class III or IV) within the past year.
2. tell these patients to report any worsening of cardiac symptoms after starting tiotropium; patients with these conditions were excluded from clinical trials of tiotropium, including TIOSPIR
3. review the treatment of all patients already taking tiotropium as part of the comprehensive management plan to ensure that it remains appropriate for them; regularly review treatment of patients at high risk of cardiovascular events
4. remind patients not to exceed the recommended once daily dose.
6. MHRA Drug Safety Update (May 2018): Braltus (tiotropium): risk of inhalation of capsule if placed in the mouthpiece of the inhaler
1. Train patients in the correct use of their Zonda inhaler; a placebo device is available for training purposes and instructions for patients are provided in the patient information leaflet and on the carton.
2. Tell patients to store capsules in the screw-cap bottle provided (never in the inhaler) and to always check the mouthpiece is clear before inhaling.
7. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).

Spiriva Respimat

(Tiotropium)

• 2.5microgram/dose solution for inhalation (SMI) (£23.00 = 30 days)

Indications and dose

• Maintenance treatment of chronic obstructive pulmonary disease
  • 5micrograms (2 puffs) once daily
• Asthma in adults and children aged 6 years and older
  • 5micrograms (2 puffs) once daily

Notes

1. MHRA Drug Safety Update (February 2015): When using tiotropium delivered via Respimat or Handihaler to treat chronic obstructive pulmonary disease (COPD):
   1. take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:
      • Myocardial infarction in the last 6 months
      • Unstable or life threatening cardiac arrhythmia
      • Cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
      • Hospitalisation for heart failure (NYHA Class III or IV) within the past year
   2. tell these patients to report any worsening of cardiac symptoms after starting tiotropium; patients with these conditions were excluded from clinical trials of tiotropium, including TIOSPIR
   3. review the treatment of all patients already taking tiotropium as part of the comprehensive management plan to ensure that it remains appropriate for them; regularly review treatment of patients at high risk of cardiovascular events
   4. remind patients not to exceed the recommended once daily dose
2. SMIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)

Seebri Breezhaler

(Glycopyrronium bromide)

• 55microgram inhalation powder, hard capsule (DPI) (£27.50 = 30 capsules plus device)

Indications and dose

• Maintenance treatment of chronic obstructive pulmonary disease
  • Adults over 18 years, 55micrograms (one capsule) once daily

Notes

1. The commissioning of glycopyrronium inhaled therapy is accepted in Devon for the maintenance treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) who require a long acting bronchodilator (see Commissioning Policy for more details)
2. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)

Eklira Genuair

(Aclidinium bromide)

• Inhalation powder 375micrograms (DPI) (£32.50 = 60 dose unit)

Indications and dose

• Maintenance treatment of chronic obstructive pulmonary disease
  • One inhalation twice daily

Notes

1. There is a lack of robust published evidence directly comparing aclidinium to other bronchodilators and a lack of good quality long term data on efficacy for aclidinium. Because of this it is recommended that aclidinium is reserved for patients who cannot tolerate the first line LAMAs
2. The commissioning of aclidinium inhalation powder is accepted in Devon for the maintenance treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) who require a long acting bronchodilator (see Commissioning Policy for more details)
3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)