3.1.4 Combination inhalers

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.

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 CCG Medicines Optimisation Team, please contact: d-ccg.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

Fostair® NEXThaler®

(combination of BDP (extrafine) and formoterol fumarate)

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

Indications and dose

  • Asthma, adults (aged ≥ 18 years);
    • 100 micrograms / 6 micrograms: one or two inhalations twice daily
    • 200 micrograms / 6 micrograms: two inhalations twice daily
  • Chronic obstructive pulmonary disease (100 micrograms / 6 micrograms):
    • Aged ≥ 18 years: 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 100 micrograms of BDP extrafine in Fostair® NEXThaler® are equivalent to 250 micrograms 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)
Fostair®

(combination of BDP (extrafine) and formoterol fumarate)

  • Aerosol inhalation 100 micrograms / 6 micrograms / metered dose (pMDI) (£29.32 = 120 doses)
  • Aerosol inhalation 200 micrograms / 6 micrograms / metered dose (pMDI) (£29.32 = 120 doses)

Indications and dose

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

Notes

  1. Fostair® contains extrafine beclometasone particles and is more potent than traditional beclometasone dipropionate CFC-free inhalers (Clenil®)
  2. The manufacturer states that 100 micrograms of BDP extrafine in Fostair® are equivalent to 250 micrograms of BDP in a non-extrafine formulation.
  3. Fostair® 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® 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. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)

Budesonide and formoterol fumarate

Duoresp® Spiromax®

(combination of budesonide and formoterol fumarate)

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

Indications and dose

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

Notes

  1. Duoresp® Spiromax® is licensed for patients 18 years and over and currently 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)
Symbicort® Turbohaler®

(combination of budesonide and formoterol fumarate)

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

Indications and dose

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

Fluticasone furoate and vilanterol

Relvar® Ellipta®

(combination of fluticasone furoate and vilanterol)

  • Dry powder inhalation 92 micrograms / 22 micrograms / delivered dose (DPI) (£22.00 = 30 doses)
  • Dry powder inhalation 184 micrograms / 22 micrograms / 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 100 micrograms once daily is approximately equivalent to fluticasone propionate 250 micrograms twice daily; fluticasone furoate 200 micrograms once daily is approximately equivalent to fluticasone propionate 500 micrograms 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® 184 micrograms / 22 micrograms 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 for inhalation 500 micrograms/ 50 micrograms/ 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)
Seretide® Accuhaler®

(combination of fluticasone propionate and salmeterol)

  • Dry powder inhalation 100 micrograms / 50 micrograms / blister dose (DPI) (£18.00 = 60 doses)
  • Dry powder inhalation 250 micrograms / 50 micrograms / blister dose (DPI) (£35.00 = 60 doses)

Indications and dose

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

Notes

  1. 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.
  2. The maximum licensed dose of fluticasone propionate delivered by Seretide® Accuhaler® in children aged 4 years and above is 100 microgram twice daily
  3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
AirFluSal® MDI

(combination of fluticasone propionate and salmeterol)

  • Aerosol inhalation 125 micrograms / 25 micrograms / metered dose (pMDI) (£16.42 = 120 doses)
  • Aerosol inhalation 250 micrograms / 25 micrograms / metered dose (pMDI) (£20.52 = 120 doses)

Indications and dose

Notes

  1. AirFluSal® MDI is not licensed for the management of COPD
  2. AirFluSal® is licensed for use in adults aged 18 years and above
  3. In adults with asthma, high dose ICS (such as AirFluSal® 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.
  4. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)
Seretide® Evohaler®

(combination of fluticasone propionate and salmeterol)

  • Aerosol inhalation 50 micrograms / 25 micrograms / metered dose (pMDI) (£18.00 = 120 doses)

Indications and dose

Notes

  1. Seretide® Evohaler® 50 micrograms/ 25 micrograms remains in the formulary for use in children aged 4 years and above
  2. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)

Fluticasone propionate and formoterol fumarate

Flutiform® (fluticasone /formoterol)
  • 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 maleate and glycopyrronium bromide

Ultibro® Breezhaler®

(combination of indacaterol maleate and glycopyrronium bromide)

  • Dry powder inhalation 85 micrograms / 43 micrograms / 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

Spiolto® Respimat®

(combination of tiotropium bromide and olodaterol hydrochloride)

  • Solution for inhalation 2.5 micrograms / 2.5 micrograms / 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)

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

Trelegy® Ellipta®

(combination of fluticasone furoate, umeclidinium bromide and vilanterol trifenatate)

  • Dry powder inhalation 92 micrograms / 55 micrograms / 22 micrograms / 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®

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

  • Pressurised inhalation, solution 87 micrograms / 5 micrograms / 9 micrograms / 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 100 micrograms of BDP extrafine in Trimbow® are equivalent to 250 micrograms 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)
Last updated: 13-11-2019

 

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