Inhaled Corticosteroid Dose Comparison in Asthma

First Line

Second Line

Specialist

Hospital Only

BDP = Beclometasone dipropionate; ICS = Inhaled corticosteroid; LABA = Long-acting beta-agonist; pMDI = Pressurised metered dose inhaler; BAI = Breath actuated (aerosol) inhaler; DPI = Dry powder inhaler

Kelhale and Qvar have extrafine BDP particles, and are more potent than traditional BDP CFC-containing inhalers; Kelhale and Qvar are approximately twice as potent as Clenil Modulite.

Fostair (pMDI), Fostair NEXThaler (DPI) and Luforbec (pMDI) have extrafine particles. The manufacturer states that 100 micrograms of BDP extrafine in these preparations is equivalent to 250 micrograms of BDP in a non-extrafine formulation.

Relvar Ellipta (DPI): fluticasone furoate in Relvar Ellipta has a higher potency compared to fluticasone propionate used in some other products; doses are not interchangeable. The manufacturer's S ummary of Product Characteristics (SPC) states that in patients with asthma, fluticasone furoate 100 micrograms once daily is approximately equivalent to fluticasone propionate 250 micrograms twice daily.

The dosage equivalents shown below are approximate and will depend on other factors such as inhaler technique. The very low, low, medium and high dose ICS categories have been taken from the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidance Network (SIGN) British guideline on the management of asthma (2019). Doses are presented in comparison to standard BDP equivalency per day.

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.

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

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200 micrograms BDP equivalent per day

ICS monotherapy inhaler

Budesonide

Easyhaler Budesonide (DPI) 100 micrograms – 1 puff twice a day
Pulmicort Turbohaler (DPI) 100 micrograms – 1 puff twice a day

Beclometasone dipropionate

Clenil Modulite (pMDI) 50 micrograms – 2 puffs twice a day

Fluticasone propionate

Flixotide Accuhaler (DPI) 50 micrograms – 1 puff twice a day
Flixotide Evohaler (pMDI) 50 micrograms – 1 puff twice a day

Combination ICS/LABA inhalers

Budesonide / formoterol

Symbicort Turbohaler (DPI) 100/6 – 1 puff twice a day

400 micrograms BDP equivalent per day

ICS monotherapy inhaler

Budesonide

Easyhaler Budesonide (DPI)
- 100 micrograms – 2 puffs twice a day
- 200 micrograms – 1 puff twice a day
Pulmicort Turbohaler (DPI)
- 100 micrograms – 2 puffs twice a day
- 200 micrograms – 1 puff twice a day

Beclometasone dipropionate

Kelhale (pMDI) (extrafine) 50 micrograms – 2 puffs twice a day
- Kelhale is licensed only for adults over 18 years of age
Qvar (pMDI or BAI) (extrafine) 50 micrograms – 2 puffs twice a day
Clenil Modulite (pMDI) 100 micrograms – 2 puffs twice a day

Fluticasone propionate

Flixotide Accuhaler (DPI) 100 micrograms – 1 puff twice a day
Flixotide Evohaler (pMDI) 50 micrograms – 2 puffs twice a day

Combination ICS/LABA inhalers

Budesonide / formoterol

Fobumix Easyhaler (DPI)
- 80/4.5 – 2 puffs twice a day
- 160/4.5 – 1 puff twice a day
- Note: Fobumix Easyhaler is licensed only for adults aged 18 years and above
Symbicort Turbohaler (DPI)
- 100/6 – 2 puffs twice a day
- 200/6 – 1 puff twice a day
DuoResp Spiromax (DPI) 160/4.5 – 1 puff twice a day
- Note: DuoResp Spiromax is included in the formulary only for adults aged 18 years and above

Fluticasone propionate / salmeterol

Seretide Accuhaler (DPI) 100/50 – 1 puff twice a day
Avenor (pMDI) 50/25 - 2 puffs twice a day

500 micrograms BDP equivalent per day

Combination ICS/LABA inhalers

Beclometasone dipropionate (extrafine) / formoterol

Fostair NEXThaler (DPI) 100/6 – 1 puff twice a day
- Note: Fostair NEXThaler is licensed only for adults aged 18 years and above
Luforbec (pMDI) 100/6 – 1 puff twice a day
- Note: Luforbec is licensed only for adults aged 18 years and above

Medium dose ICS should only be used in children aged 12 years and under after referring the patient to secondary care.

800 micrograms BDP equivalent per day

ICS monotherapy inhaler

Budesonide

Easyhaler Budesonide (DPI)
- 200 micrograms – 2 puffs twice a day
- 400 micrograms – 1 puff twice a day
Pulmicort Turbohaler (DPI)
- 200 micrograms – 2 puffs twice a day
- 400 micrograms – 1 puff twice a day

Beclometasone dipropionate

Kelhale (pMDI) (extrafine) 100 micrograms – 2 puffs twice a day
- Kelhale is licensed only for adults over 18 years of age
Qvar (pMDI or BAI) (extrafine) 100 micrograms – 2 puffs twice a day
Clenil Modulite (pMDI) 200 micrograms - 2 puffs twice a day

Combination ICS/LABA inhalers

Budesonide / formoterol

Fobumix Easyhaler (DPI)
- 160/4.5 – 2 puffs twice a day
- 320/9 – 1 puff twice a day
- Note: Fobumix Easyhaler is licensed only for adults aged 18 years and above
Symbicort Turbohaler (DPI)
- 200/6 – 2 puffs twice a day
- 400/12 – 1 puff twice a day
DuoResp Spiromax (DPI)
- 160/4.5 – 2 puffs twice a day
- 320/9 – 1 puff twice a day
- Note: DuoResp Spiromax is included in the formulary only for adults aged 18 years and above

1000 micrograms BDP equivalent per day

ICS monotherapy inhaler

Fluticasone propionate

Flixotide Accuhaler (DPI) 250 micrograms – 1 puff twice a day
Flixotide Evohaler (pMDI) 125 micrograms – 2 puffs twice a day

Combination ICS/LABA inhalers

Beclometasone dipropionate (extrafine) / formoterol

Note: BTS/SIGN classifies BDP 1000 micrograms equivalent/day as a high dose corticosteroid when given as Clenil Modulite but a medium dose corticosteroid when given as BDP extrafine in combination with formoterol as Fostair NEXThaler.

Fostair NEXThaler (DPI) 100/6 – 2 puffs twice a day
- Note: Fostair NEXThaler is licensed only for adults aged 18 years and above
Luforbec (pMDI) 100/6 – 2 puffs twice a day
- Note: Luforbec is licensed only for adults aged 18 years and above

Fluticasone propionate / salmeterol

Fusacomb Easyhaler (DPI) 250/50 – 1 puff twice a day
Seretide Accuhaler (DPI) 250/50 – 1 puff twice a day
Avenor (pMDI) 125/25 – 2 puffs twice a day

High dose ICS should only be used after referring the patient to secondary care.

High dose pMDI inhaled corticosteroid devices should be prescribed with a spacer to reduce risk of oral candidiasis.

1000 micrograms BDP equivalent per day

ICS monotherapy inhaler

Beclometasone dipropionate

Note: BTS/SIGN classifiees BDP 1000 micrograms equivalent/day as a high dose corticosteroid when given as Clenil Modulite but a medium dose corticosteroid when given as BDP extrafine in combination with formoterol as Fostair NEXThaler.

Formulary