High dose pMDI inhaled corticosteroid devices should be prescribed with a spacer to reduce risk of oral candidiasis. (see 3.1.5 Peak flow meters, inhaler devices and nebulisers).

For information on inhaled corticosteroid dose comparisons in asthma see here.

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.

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.

pMDI = Pressurised metered dose inhaler; BAI = Breath actuated inhaler; DPI = Dry powder 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.

Easyhaler Budesonide

(Budesonide)

• Dry powder inhaler 100micrograms/metered inhalation, 200micrograms/metered inhalation, 400micrograms/metered inhalation (DPI) (£17.71 = 200micrograms x 200 doses)

Indications and dose

• Asthma, adults and adolescents by inhalation of powder:
  • Aged ≥ 12 years: 100–800micrograms twice daily, dose to be adjusted as necessary
• Asthma, children by inhalation of powder:
  • 6 - 11 years: 100 - 400micrograms twice daily

Notes

1. COVID-19: Only use budesonide to treat COVID-19 as part of a clinical trial (NICE NG191 COVID-19 rapid guideline).
2. Refer to BNF or manufacturer's Summary of Product Characteristics (SPC) for once daily dosing regimen.
3. In adults with asthma, high dose ICS (such as Budesonide Easyhaler 400micrograms - 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
4. In children with asthma, medium dose ICS (such as Budesonide Easyhaler 400micrograms - 1 puff twice daily 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).

Pulmicort Turbohaler

(Budesonide)

• Dry powder inhaler 100micrograms/metered inhalation, 200micrograms/metered inhalation, 400micrograms/metered inhalation (DPI) (£14.25 = 200micrograms x 100 doses)

Indications and dose

• Asthma, adults and adolescents by inhalation of powder:
  • Aged > 12 years: 100–800micrograms twice daily, dose to be adjusted as necessary.
• Asthma, children by inhalation of powder:
  • 5 - 12 years: 100 - 400micrograms twice daily

Notes

1. COVID-19: Only use budesonide to treat COVID-19 as part of a clinical trial (NICE NG191 COVID-19 rapid guideline).
2. Refer to BNF or manufacturer's Summary of Product Characteristics (SPC) for once daily dosing regimen.
3. In adults with asthma, high dose ICS (such as Pulmicort Turbohaler 400micrograms - 2 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
4. In children with asthma, medium dose ICS (such as Pulmicort Turbohaler 400micrograms - 1 puff 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).

Budesonide

• Nebuliser liquid 500micrograms/2ml, 1mg/2ml (£39.41 = 20 x 1mg/2ml)

Kelhale

(BDP extrafine)

• Aerosol inhalation 50micrograms/metered inhalation, 100micrograms/metered inhalation, (pMDI) (£5.20 = 100micrograms x 200 doses)

Indications and dose

• Asthma, Adults:
  • 50–200micrograms twice daily, increased if necessary up to 400micrograms twice daily.

Notes

1. Prescribe by brand. BDP inhalers should be prescribed by brand since they are not all interchangeable. Kelhale and Qvar are extra-fine particle formulations and are therapeutically equivalent. They are both approximately twice as potent as Clenil Modulite.
2. In adults with asthma, high dose ICS (such as Kelhale 100micrograms - 4 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
3. Kelhale is not licensed for use in children under 18 years.
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.

Qvar

(BDP extrafine)

• Aerosol inhalation 50micrograms/metered inhalation, 100micrograms/metered inhalation (pMDI) (£17.21 = 100micrograms x 200 doses)
• Autohaler breath-actuated aerosol inhalation 50micrograms/metered inhalation, 100micrograms/metered inhalation (BAI) (£17.21 = 100micrograms x 200 doses)
• Easi-breathe breath-actuated aerosol inhalation 50micrograms/metered inhalation, 100micrograms/metered inhalation (BAI) (£16.95 = 100micrograms x 200 doses) (not licensed for use in children aged < 12 years)

Indications and dose

• Asthma, adults and adolescents:
  • Aged ≥ 12 years: 50–200micrograms twice daily; increased if necessary up to 400micrograms twice daily.
• Asthma, children:
  • Aged 5 years and older: 50-100micrograms twice daily (maximum daily dose 100micrograms twice daily) using Autohaler or pMDI

Notes

1. Prescribe by brand. BDP inhalers should be prescribed by brand since they are not all interchangeable. Qvar and Kelhale are extrafine particle formulations and are therapeutically equivalent. They are both approximately twice as potent as Clenil Modulite.
2. For new initiations of beclomethasone extrafine pMDI inhaler in adult patients, Kelhale pMDI is the preferred option due to its lower acquisition cost.
3. In adults with asthma, high dose ICS (such as Qvar 100micrograms - 4 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
4. Qvar is not licensed for use in children under 5 years.
5. Qvar Easi-breathe is not licensed for use in children under 12 years of age due to the lack of data.
6. pMDIs and BAIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the Environmental Impact of Inhalers). For this reason, pMDIs and BAIs (with the exception of salbutamol and ipratropium) are not generally considered first line options.

Clenil Modulite

(BDP)

• Aerosol inhalation 50micrograms/metered inhalation, 100micrograms/metered inhalation, 200micrograms/metered inhalation, 250micrograms/metered inhalation (pMDI) (£16.17 = 200micrograms x 200 doses)

Indications and dose

• Asthma, adults and adolescents:
  • Aged ≥ 12 years: 200–400micrograms twice daily, adjusted according to response
• Asthma, children 2-11 years:
  • 100–200micrograms twice daily.

Notes

1. Prescribe by brand. BDP inhalers should be prescribed by brand since they are not all interchangeable. Qvar and Kelhale are extrafine particle formulations and are both approximately twice as potent as Clenil Modulite.
2. In adults with asthma, high dose ICS (such as Clenil Modulite 250micrograms - 4 puffs twice a day; see Inhaled Corticosteroid Dose Comparison in Asthma) should only be used after referring the patient to secondary care.
3. Clenil Modulite 50 and 100 are licensed for use in children.
4. Clenil Modulite 200 and 250 are not licensed for use in children under 12 years.
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.

Flixotide Accuhaler

(Fluticasone propionate)

• Dry powder for inhalation 50micrograms/blister, 100micrograms/blister, 250micrograms/blister, 500micrograms/blister (DPI) (£25.51 = 250micrograms x 60 doses)

Indications and dose

• Asthma, adults:
  • Initially 100–500micrograms twice daily (max. per dose 1 mg twice daily), dose may be increased according to severity of asthma.
• Asthma, children:
  • Refer to Children's BNF and manufacturer's Summary of Product Characteristics (SPC)

Notes

1. The maximum licensed dose in children is 200micrograms twice daily.
2. Doses of 500micrograms twice daily, and above, should be initiated by a specialist.
3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers).

Flixotide Evohaler

(Fluticasone propionate)

• Aerosol inhalation 50micrograms/metered inhalation, 125micrograms/metered inhalation, 250micrograms/metered inhalation (pMDI) (£36.14 = 250micrograms x 120 doses)

Indications and dose

• Asthma, adults:
  • Initially 100–500micrograms twice daily (max. per dose 1 mg twice daily), dose may be increased according to severity of asthma.
• Asthma, children:
  • Refer to Children's BNF and manufacturer's Summary of Product Characteristics (SPC)

Notes

1. The maximum licensed dose in children is 200micrograms twice daily.
2. Doses of 500micrograms twice daily, and above, should be initiated by a specialist.
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.