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Page last updated:
2 March 2023

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3.1.4 Combination inhalers

First Line
Second Line
Specialist
Hospital Only

All combination inhalers included in the formulary are included as branded products. Generic prescribing of inhalers should be avoided as this might lead to people with asthma 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.

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.

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

For information on inhaled corticosteroid dose comparisons in asthma see here

pMDI = Pressurised metered dose inhaler; DPI = Dry powder inhaler; SMI = Soft mist 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.

Inhaled corticosteroid (ICS) / Long-acting beta2 agonists (LABA)

BDP and formoterol fumarate dihydrate

Fostair NEXThaler

(combination of BDP (extrafine) and formoterol fumarate dihydrate)

  • Dry powder inhalation 100micrograms/6micrograms/metered inhalation (DPI) (£29.32 = 120 inhalations)
  • Dry powder inhalation 200micrograms/6micrograms/metered inhalation (DPI) (£29.32 = 120 inhalations) (see note 4)

Indications and dose

  • Asthma, adults (aged ≥ 18 years):
    • 100micrograms/6micrograms: one or two inhalations twice daily
    • 200micrograms/6micrograms: two inhalations twice daily (see note 4)
  • Chronic obstructive pulmonary disease (aged ≥ 18 years):
    • 100micrograms/6micrograms: two inhalations twice daily

Notes

  1. Fostair NEXThaler contains extrafine beclometasone particles and is more potent than traditional beclometasone dipropionate CFC-free inhalers (Clenil).
  2. The manufacturer states that 100micrograms of BDP extrafine in Fostair NEXThaler are equivalent to 250micrograms of BDP in a non-extrafine formulation.
  3. Fostair NEXThaler 100/6 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details.
  4. In adults with asthma, high dose ICS (such as Fostair NEXThaler 200/6 - 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
  5. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
Luforbec

(combination of BDP (extrafine) and formoterol fumarate dihydrate)

  • Aerosol inhalation 100micrograms/6micrograms/metered dose (pMDI) (£13.98 = 120 doses)
  • Aerosol inhalation 200micrograms/6micrograms/metered dose (pMDI) (£13.98 = 120 doses) (specialist, see note 4)

Indications and dose

  • Asthma, adults (maintenance therapy, aged ≥ 18 years):
    • 100micrograms/6micrograms: one or two inhalations twice daily
    • 200micrograms/6micrograms: two inhalations twice daily (see note 4)
  • Chronic obstructive pulmonary disease (aged ≥ 18 years):
    • 100micrograms/6micrograms: two inhalations twice daily

Notes

  1. Luforbec contains extrafine beclometasone particles and is more potent than traditional beclometasone dipropionate CFC-free inhalers (Clenil).
  2. The manufacturer states that 100micrograms of BDP extrafine in Luforbec are equivalent to 250micrograms of BDP in a non-extrafine formulation.
  3. Luforbec 100/6 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details.
  4. In adults with asthma, high dose ICS (such as Luforbec 200/6 pMDI - 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
  5. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers). For this reason, pMDIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.
Fostair 100/6 pMDI and 200/6 pMDI (existing patients only)
  • Fostair (BDP extrafine / formoterol fumarate dihydrate)100/6 pMDI and 200/6 pMDI have been removed from the formulary due to their high acquisition cost in comparison to Luforbec 100/6 pMDI and 200/6 pMDI. No new patients should be prescribed Fostair 100/6 pMDI or 200/6 pMDI. For existing patients, continued prescribing is accepted until the next review when the patient should be switched to Fostair NEXThaler or Luforbec pMDI if clinically appropriate.

Budesonide and formoterol fumarate dihydrate

Fobumix Easyhaler

(combination of budesonide and formoterol fumarate dihydrate)

  • Dry powder inhalation 80micrograms/4.5micrograms/metered dose (DPI) (£21.50 = 120 doses)
  • Dry powder inhalation 160micrograms/4.5micrograms/metered dose (DPI) (£21.50 = 120 doses; £10.75 = 60 doses)
  • Dry powder inhalation 320micrograms/9micrograms/metered dose (DPI) (£21.50 = 60 doses)

Indications and dose:

  • Asthma, adults (maintenance therapy)
    • 80micrograms/4.5micrograms: one or two inhalations twice daily
    • 160micrograms/4.5micrograms: one or two inhalations twice daily
    • 320micrograms/9micrograms: one inhalation twice daily
  • Chronic obstructive pulmonary disease:
    • 160micrograms/4.5micrograms: two inhalations twice daily
    • 320micrograms/9micrograms: one inhalation twice daily

Notes:

  1. Fobumix Easyhaler is available in three strengths: 80/4.5, 160/4.5 and 320/9. These strengths are equivalent to the Symbicort Turbohaler 100/6, 200/6 and 400/12 preparations respectively. Fobumix Easyhaler strengths refer to the delivered dose whereas the Symbicort Turbohaler strengths refer to the total dose contained in each actuation.
  2. Fobumix Easyhaler 80/4.5 and the 160/4.5 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details.
  3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
Symbicort Turbohaler

(combination of budesonide and formoterol fumarate dihydrate)

  • Dry powder inhalation 100micrograms/6micrograms/metered dose (DPI) (£28.00 = 120 doses)
  • Dry powder inhalation 200micrograms/6micrograms/metered dose (DPI) (£28.00 = 120 doses)
  • Dry powder inhalation 400micrograms/12micrograms/metered dose (DPI) (£28.00 = 60 doses)

Indications and dose

  • Asthma, adults (maintenance therapy, aged ≥ 12 years):
    • 100micrograms/6micrograms: one or two inhalations twice daily
    • 200micrograms/6micrograms: one or two inhalations twice daily
    • 400micrograms/12micrograms: one inhalation twice daily
  • Asthma, children (maintenance therapy, aged ≥ 6 years):
    • 100micrograms/6micrograms: two inhalations twice daily
  • Chronic obstructive pulmonary disease (adults):
    • 200micrograms/6micrograms: two inhalations twice daily
    • 400micrograms/12micrograms: one inhalation twice daily

Notes

  1. Symbicort Turbohaler 100/6 is licensed for use in asthma in patients aged 6 years and older.
  2. Symbicort Turbohaler 200/6 and 400/12 are licensed for use in asthma patients aged 12 years and older.
  3. Symbicort Turbohaler 200/6 and 400/12 strengths are licensed for use in COPD patients aged 18 years and older.
  4. Symbicort Turbohaler 200/6 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details.
  5. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
DuoResp Spiromax

(combination of budesonide and formoterol fumarate dihydrate)

  • Dry powder inhalation 160micrograms/4.5micrograms/delivered dose (DPI) (£27.97 = 120 doses)
  • Dry powder inhalation 320micrograms/9micrograms/delivered dose (DPI) (£27.97 = 60 doses)

Indications and dose

  • Asthma, adults (maintenance therapy, aged ≥ 18 years):
    • 160micrograms/4.5micrograms: one or two inhalations twice daily
    • 320micrograms/9micrograms: one inhalation twice daily
  • Chronic obstructive pulmonary disease:
    • 160micrograms/4.5micrograms: two inhalations twice daily
    • 320micrograms/9micrograms: one inhalation twice daily

Notes

  1. DuoResp Spiromax is included in the formulary for patients aged 18 years and over and is available in two strengths: 160/4.5 and 320/9. These strengths are equivalent to the Symbicort Turbohaler 200/6 and 400/12 preparations respectively. DuoResp Spiromax strengths refer to the delivered dose whereas the Symbicort Turbohaler strengths refer to the total dose contained in each actuation.
  2. DuoResp Spiromax 160/4.5 may be used as regular maintenance treatment and as needed in response to asthma symptoms (MART regimen), refer to Asthma - adult treatment guidance, Initial add on therapy for further details.
  3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).

Fluticasone furoate and vilanterol trifentate

Relvar Ellipta

(combination of fluticasone furoate and vilanterol trifenatate)

  • Dry powder inhalation 92micrograms/22micrograms/delivered dose (DPI) (£22.00 = 30 doses)
  • Dry powder inhalation 184micrograms/22micrograms/delivered dose (DPI) (£29.50 = 30 doses)

Indications and dose

Notes

  1. Relvar Ellipta inhaler has an in-use shelf life of 6 weeks.
  2. Prescribe by brand.
  3. Fluticasone furoate in Relvar Ellipta has a higher potency compared to fluticasone propionate; doses are not interchangeable.
  4. In patients with asthma, fluticasone furoate 100micrograms once daily is approximately equivalent to fluticasone propionate 250micrograms twice daily; fluticasone furoate 200micrograms once daily is approximately equivalent to fluticasone propionate 500micrograms twice daily.
  5. In adults with asthma, high dose ICS (such as Relvar Ellipta 184/22 – 1 puff once daily; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
  6. The routine commissioning of Relvar Ellipta combination inhaler is accepted in Devon for the regular treatment of asthma in adults and adolescents aged 12 years and older (see Commissioning Policy for more details).
  7. The routine commissioning of Relvar Ellipta combination inhaler is accepted in Devon for the symptomatic treatment of adults with chronic obstructive pulmonary disease (COPD) and an exacerbation history despite regular bronchodilator therapy (see Commissioning Policy for more details).
  8. The Relvar Ellipta 184micrograms/22micrograms is not licensed for patients with chronic obstructive pulmonary disease.
  9. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).

Fluticasone propionate and salmeterol

AirFluSal Forspiro

(combination of fluticasone propionate and salmeterol)

  • Dry powder inhalation 500micrograms/50micrograms/inhalation (DPI) (£29.97 = 60 doses)

Indications and dose

Notes

  1. AirFluSal Forspiro dry powder inhaler is not recommended for new initiations, consider alternative ICS/LABA combinations; existing patients who are stable on treatment may continue to have AirFluSal Forspiro prescribed.
  2. In adults with asthma, high dose ICS (such as AirFluSal Forpsiro 500/50 - 1 puff twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
  3. AirFluSal Forspiro dry powder inhaler side chamber will gradually fill up with used strip. There should never be more than 2 sections of foil strip in the side chamber as they may cause the inhaler to jam. The strip should be torn away carefully as shown in SPC or patient information leaflet..
  4. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
Fusacomb Easyhaler

(combination of fluticasone propionate and salmeterol)

  • Dry powder inhalation 250micrograms/50micrograms/metered dose (DPI) (£21.50 = 60 doses)

Indications and dose

Notes

  1. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
Seretide Accuhaler

(combination of fluticasone propionate and salmeterol)

  • Dry powder inhalation 100micrograms/50micrograms/blister dose (DPI) (£17.46 = 60 doses)
  • Dry powder inhalation 250micrograms/50micrograms/blister dose (DPI) (£33.95 = 60 doses) (see note 1)

Indications and dose

  • Asthma, adults:
    • Aged ≥ 12 years: one inhalation twice daily
  • Asthma, children (100micrograms/50micrograms):
    • Aged ≥ 4 years: one inhalation twice daily

Notes

  1. For new initiations of fluticasone propionate 250micrograms / salmeterol 50micrograms DPI in patient aged ≥ 12 years, Fusacomb Easyhaler is the preferred option due to its lower acquisition cost.
  2. In children, medium dose inhaled corticosteroid (ICS) (see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
  3. The maximum licensed dose of fluticasone propionate delivered by Seretide Accuhaler in children aged 4 years and above is 100microgram twice daily.
  4. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
Avenor

(combination of fluticasone propionate and salmeterol)

  • Aerosol inhalation 50micrograms/25micrograms/metered dose (pMDI) (£12.99 = 120 doses)
  • Aerosol inhalation 125micrograms/25micrograms/metered dose (pMDI) (£10.33 = 120 doses)
  • Aerosol inhalation 250micrograms/25micrograms/metered dose (pMDI) (£13.66 = 120 doses)

Indications and dose

Notes

  1. In children with asthma, medium dose ICS (such as Avenor MDI 125/25 – 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care
  2. In adults with asthma, high dose ICS (such as Avenor MDI 250/25 - 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
  3. Avenor pMDI is not compatible with the Volumatic spacer device; patients prescribed Avenor pMDI who require a spacer should use an AeroChamber Plus spacer device.
  4. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers). For this reason, pMDIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.

Fluticasone propionate and formoterol fumarate dihydrate

Flutiform (fluticasone / formoterol fumarate dihydrate)
  • The routine commissioning of Flutiform is not accepted in Devon for the treatment of asthma in adults and children over 12 years (see Commissioning Policy for more details).

Combination inhalers (Long-acting beta2 agonists (LABA) + Long-acting muscarinic antagonists (LAMA))

Indacaterol and glycopyrronium

Ultibro Breezhaler

(combination of indacaterol and glycopyrronium )

  • Dry powder inhalation 85micrograms/43micrograms/delivered dose hard capsule (DPI) (£32.50 = 30 capsules and device)

Indications and dose

Notes

  1. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).

Tiotropium bromide and olodaterol hydrochloride

Spiolto Respimat

(combination of tiotropium bromide and olodaterol hydrochloride)

  • Solution for inhalation 2.5micrograms/2.5micrograms/dose (SMI) (£32.50 = cartridge and device with 60 doses)

Indications and dose

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
    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. The routine commissioning of Tiotropium bromide monohydrate and olodaterol hydrochloride (Spiolto Respimat) combination inhaler is accepted in Devon for chronic obstructive pulmonary disease (COPD) (see Commissioning Policy for more details).
  3. SMIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).

Umeclidinium and vilanterol trifenatate

Anoro Ellipta

(combination of umeclidinium and vilanterol trifenatate)

  • Dry powder inhalation 55micrograms/22micrograms (DPI) (£32.50 = 30 doses)

Indications and dose

Notes:

  1. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)

Glycopyrronium and formoterol fumarate dihydrate

Bevespi Aerosphere

(combination of glycopyrronium and formoterol fumarate dihydrate)

  • Pressurised inhalation, suspension 7.2micrograms/5micrograms/delivered dose (pMDI) (£32.50 = 120 doses)

Indications and dose

Notes

  1. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers). For this reason, pMDIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.

Triple combination inhaler (Inhaled corticosteroid (ICS) + Long-acting beta2 agonists (LABA) + Long-acting muscarinic antagonists (LAMA))

Trelegy Ellipta

(combination of fluticasone furoate, umeclidinium and vilanterol trifenatate)

  • Dry powder inhalation 92micrograms/55micrograms/22micrograms/delivered dose (DPI) (£44.50 = 30 doses)

Indications and dose

Notes

  1. Licensed for maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or a combination of a long-acting beta2-agonist and a long-acting muscarinic antagonist.
  2. The routine commissioning of Trelegy Ellipta is accepted in Devon for maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) (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).
Trimbow NEXThaler

(combination of BDP (extrafine), formoterol fumarate dihydrate, and glycopyrronium)

  • Inhalation powder 88micrograms/5micrograms/9micrograms/delivered dose (DPI) (£44.50 = 120 dose unit)

Indications and dose

Notes

  1. Licensed for maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or a combination of a long-acting beta2-agonist and a long-acting muscarinic antagonist.
  2. The aerosol particles of Trimbow are on average much smaller than the particles delivered in non-extrafine formulations. For BDP, this results in a more potent effect than formulations with a non-extrafine particle size distribution; the manufacturer states that 100micrograms of BDP extrafine in Trimbow are equivalent to 250micrograms of BDP in a non-extrafine formulation.
  3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).
Trimbow pMDI

(combination of BDP (extrafine), formoterol fumarate dihydrate, and glycopyrronium)

  • Pressurised inhalation, solution 87micrograms/5micrograms/9micrograms/delivered dose (pMDI) (£44.50 = 120 dose unit)

Indications and dose

Notes

  1. Licensed for maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or a combination of a long-acting beta2-agonist and a long-acting muscarinic antagonist.
  2. The aerosol particles of Trimbow are on average much smaller than the particles delivered in non-extrafine formulations. For BDP, this results in a more potent effect than formulations with a non-extrafine particle size distribution; the manufacturer states that 100micrograms of BDP extrafine in Trimbow are equivalent to 250micrograms of BDP in a non-extrafine formulation.
  3. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers). For this reason, pMDIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.
Trixeo Aerosphere

(combination of formoterol fumarate dihydrate, glycopyrronium, and budesonide)

  • Pressurised inhalation, solution 5micrograms/7.2micrograms/160micrograms/delivered dose (pMDI) (£44.50 = 120 dose unit)

Indications and dose

Notes

  1. Licensed for maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or combination of a long-acting beta2-agonist and a long-acting muscarinic antagonist.
  2. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers). For this reason, pMDIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.
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