3. Respiratory System

Transcription

1 1 3. Respiratory System Also see Appendix 3A Guidance on Management of Also see Appendix 3B Preferred Inhaler Devices for Adults Also see Appendix 3C Preferred Inhaler Devices for Adolescents (12-18 years) Also see Appendix 3D Preferred Inhaler Devices for Children (5-12 years) Also see Appendix 3E Preferred Inhaler Devices for Children less than 5 years old Also see Appendix 3F Guidance on Management of COPD Also see NHS Fife resource pack Also see NHS Fife COPD resource pack Also see BTS/SIGN British Guideline on the Management of (May 2008, revised Oct. 2014) Also see Respiratory Prescribing Strategy 2014 to 2016 Also see Appendix 4D NHS Fife Stop Smoking Prescribing Guidance Inhaler Devices The choice of device should be based on patient factors e.g. impaired dexterity, poor inspiratory flow, patient acceptability and cost. The cheapest device that the patient can use adequately should be prescribed. A metered dose inhaler (MDI) should be considered as first choice on cost grounds. For dry powder inhalers the Easyhaler range is the preferred Fife Formulary choice. Preferred Choice Inhaler Type 1st Choice MDI +/- spacer 2nd Choice Dry Powder Inhaler (DPI) - Easyhaler Other inhaler devices should be considered when the above devices have been ineffective or can not be used by the patient. Due to variation between devices it is recommended that all inhalers are prescribed by brand name only (except salbutamol MDI). Inhalers should only be prescribed after training in the use of a device and the patient is able to demonstrate a satisfactory technique. Where possible prescribe the same type of inhaler device if a patient is on multiple inhaled medicines. Combination inhalers are preferable to two separate devices to aid compliance e.g. ICS/LABA, LAMA/LABA. Always check compliance and inhaler technique before switching to an alternative device, changing the medication or increasing the dose. When switching to an alternative device, any changes to inhaler technique or dosage should be communicated to the patient. All patients prescribed an MDI should have a spacer device available for use in an acute exacerbation. High dose inhaled therapy via a spacer device can be as effective as nebulised therapy.

2 Bronchodilators Adrenoceptor agonists Selective beta 2 agonists Short-acting (SABA) Metered dose inhaler (MDI) Salbutamol Dry powder inhaler (DPI) Easyhaler Salbutamol The patient should be advised to seek medical advice when the prescribed dose of beta 2 agonist fails to provide the usual degree of symptomatic relief because this usually indicates a worsening of the asthma and the patient may require a prophylactic drug such as an inhaled corticosteroid. Patients with asthma using a short-acting beta 2 agonist bronchodilator, three times or more per week or those using more than one inhaler device per month should be identified and have their asthma control reassessed urgently. Liquid formulations of SABAs are not recommended for use in children. Use an appropriate inhaler instead. Long-acting (LABA) MDI Formoterol (Atimos Modulite ) DPI Easyhaler Formoterol LABAs should only be prescribed in asthmatic patients who are inadequately controlled with regular use of an inhaled corticosteroid i.e. at Step 3. Combination inhalers that contain a long-acting beta 2 agonist and a corticosteroid ensure that long-acting beta 2 agonists are not used without concomitant corticosteroids and may also aid compliance (See section 3.2) Other adrenoceptor stimulants Adrenaline (Epinephrine) Antimuscarinic bronchodilators Short-acting (SAMA) Ipratropium Long acting (LAMA) COPD Aclidinium (Eklira Genuair ) (twice daily administration) Umeclidinium (Incruse Ellipta ) (once daily administration)

3 3 Combination Preparations Aclidinium/formoterol (Duaklir Genuair ) (twice daily administration) Umeclidinium/vilanterol (Anoro Ellipta ) (once daily administration) Also see Appendix 3F Guidance on Management of COPD COPD Ipratropium can be used for short-term relief in mild COPD. Tiotropium (Spiriva Respimat ) - Step 4 A LAMA is preferred to ipratropium in stable COPD patients who remain breathless or have exacerbations despite using short-acting bronchodilators and a decision has been made to continue with an antimuscarinic agent. LAMAs must not be given in combination with ipratropium. LAMAs should be trialled for a 3 month period and only continued if there is improvement in symptoms. If no improvement switch to a LABA. If the intial LAMA is effective in providing symptom control but is not well tolerated, switching to an alternative LAMA should be considered. The choice of LAMA should be based on ease of use of inhaler device and if a once daily or twice daily preparation will control symptoms. Combination inhalers are preferable to two separate devices to aid compliance e.g. ICS/LABA, LAMA/LABA. Ipratropium may be used in infants under 1 year if salbutamol is ineffective in relieving wheeze. Tiotropium via the Respimat device is approved for use as an option at Step 4 in the mangement of adult patients with asthma who have experienced one or more severe exacerbations in the previous year. Tiotropium should only be considered when montelukast is ineffective or considered inappropriate Theophylline Theophylline products are used in COPD and in asthma at Step 4. Theophylline (preferred brand for oral products is Uniphyllin ) H Aminophylline i.v. In asthma, Theophylline should only be considered when montelukast and tiotropium Respimat are considered to be ineffective or unsuitable. Theophylline products should be prescribed by brand name due to differences in bioavailability. Theophylline products can interact with a range of drugs which can alter theophylline levels. Refer to BNF or Summary of Product Characteristics for possible interactions. Routine therapeutic monitoring of theophylline is not required unless checking for toxicity or assessing adherence.

4 4 Smoking cessation may increase theophylline levels Peak flow meters, inhaler devices and nebulisers Peak Flow Meters Standard Range Medi Low Range Medi Measurement of peak flow is particularly helpful for patients who are poor perceivers and hence slow to detect deterioration in their asthma, and for those with moderate or severe asthma. Standard-range peak flow meters are suitable for both adults and children; low-range peak flow meters are appropriate for severely restricted airflow in adults and children. Patients must be given clear guidelines as to the action they should take if their peak flow falls below a certain level. Spacer Devices A variety of spacers to compliment different types of MDI are available. Large-volume spacer devices should be used for administering inhaled corticosteroids in children under 5 years; they are also useful in older children and adults if high doses of corticosteroids are required. Advise patients - Do Not clean spacer devices more often than once per month. Clean with water and washing-up liquid and allow to air dry. Spacer devices should be replaced every 6-12 months. Spacer Device Compatible MDI AeroChamber Plus All MDIs Volumatic Atimos Modulite, Clenil Modulite, Seretide, Nebulisers Also see NHS Fife Respiratory MCN Nebuliser Guidelines Nebulisers should only be initiated by specialists. A spacer device + high dose inhaler should be tried before considering the use of nebules. Single formulations of nebules are preferable to combination preparations Corticosteroids 1st Choice 2nd Choice MDI Beclometasone (Clenil Modulite, Qvar ) Also see Appendix 3A Guidance on Management of DPI Easyhaler Beclometasone Easyhaler Budesonide An inhaled corticosteroid (ICS) is used regularly for prophylaxis of asthma when patients require a beta 2

5 5 agonist three times or more per week; if symptoms disturb sleep more than once a week or if the patient has suffered exacerbations in the last 2 years requiring a systemic corticosteroid or a nebulised bronchodilator i.e. Step 2 of BTS/SIGN Guidance. Corticosteroid inhalers must be used regularly for maximum benefit; alleviation of symptoms usually occurs 3 to 7 days after initiation. Review asthma patients on high doses of ICS once symptoms are under control. Reduce dose of ICS where appropriate. High doses of ICS should be continued only if there is clear benefit over the lower dose. In asthma, the dose of inhaled steroid should be titrated to the lowest effective dose. Beclometasone CFC-free inhalers are not bioequivalent and should be prescribed by brand name only. Qvar is approximately twice as potent as Clenil Modulite. The risk of oral candidiasis can be reduced by using a spacer device with the corticosteroid inhaler (at doses of 800mcg of beclometasone or equivalent); rinsing the mouth with water (or cleaning teeth) after inhalation of a dose may also be helpful. Patients using high doses of inhaled corticosteroids (> or equal to 800mcg of beclometasone or equivalent) should be given a steroid card. Patients requiring long-term high dose inhaled corticosteroids ( 2000mcg beclometasone equivalent) should be monitored for adrenal suppression and should be referred for a DXA scan. If over the age of 65, they should have bone protection without the need for a DXA scan. (See Appendix 6A). In adults, at the time of an exacerbation of asthma doubling the dose of inhaled steroids has not been shown to be effective. Add in a short term course of oral steroids instead. Paediatrics Also see Appendix 3D Preferred Inhaler Devices for Children (5-12 years) Also see Appendix 3E Preferred Inhaler Devices for Children less than 5 years old COPD High doses of inhaled corticosteroids used for prolonged periods can induce adrenal suppression. Inhaled corticosteroids have been associated with adrenal crisis and coma in children; excessive doses should be avoided. Children taking high doses of inhaled corticosteroids should have their height monitored and plotted on a centile chart at least on an annual basis. Specific written advice on steroid replacement in the event of severe intercurrent illness should be available for all children treated with 800 micrograms of beclometasone dipropionate or equivalent. Clenil Modulite is licensed for use in children. A Volumatic spacer device must be used in all patients aged < or equal to 15 years. Whereas Qvar is not licensed for use in children 12 years or younger. Large-volume spacer devices should be used for administering inhaled corticosteroids in children less than 5 years; they are also useful in older children and adults, particularly if high doses of corticosteroids are required. Also see Appendix 3F Guidance on Management of COPD ICS should not be used in the treatment of COPD unless co-prescribed with a LABA. (see combination preparations below).

6 6 Combination preparations COPD MDI Fostair 100/6 (extra-fine beclometasone + formoterol) DPI 1 st choice: Relvar Ellipta 92 mcg/22 mcg (fluticasone furoate + vilanterol) 2 nd choice: Symbicort Turbohaler 400/12 (budesonide+formoterol) Also see Appendix 3F Guidance on Management of COPD Inhaled corticosteroids in COPD should only be considered in patients with severe COPD with an FEV 1 of 50% predicted or less, who have two or more exacerbations leading to hospital admission and two or more exacerbations needing treatment with antibiotics or oral steroids in the last year. Only combination products containing an ICS and a LABA should be prescribed in the treatment of COPD. Single agent ICS inhalers should not be prescribed. Patients using high doses of inhaled corticosteroids (> or equal to 800mcg of beclometasone or equivalent) should be given a steroid card. High doses of inhaled corticosteroid have been associated with pneumonia and other significant side effects, particulary in older patients with chronic obstructive pulmonary disease. (5-12 yrs) (12-17 yrs) Adults MDI Seretide 50 Evohaler (fluticasonepropionate+salmeterol) +/- spacer Flutiform (fluticasone propionate + formoterol) Fostair 100/6, 200/6 (extra-fine beclometasone + formoterol) DPI Symbicort Turbohaler (>6 years) (budesonide+formoterol) Relvar Ellipta (fluticasone furoate + vilanterol) 92 mcg/22 mcg, 184 mcg/22 mcg Symbicort Turbohaler (budesonide+formoterol) Relvar Ellipta (fluticasone furoate + vilanterol) 92 mcg/22 mcg, 184 mcg/22 mcg Symbicort Turbohaler (budesonide+formoterol) Preparations that combine a corticosteroid with a long-acting beta 2 agonist may be helpful, at Step 3 of the

7 7 BTS/SIGN guidance, for patients stabilised on the individual components in the same proportion. Combination inhalers ensure that long-acting beta 2 agonists are not used without concomitant corticosteroids and may also aid compliance. Fostair contains extra-fine particles of beclometasone. When switching patients from other beclometasone dipropionate and formoterol fumarate inhalers, Fostair 100/6 can be prescribed for patients already using Clenil Modulite 250 micrograms. The dose of Fostair should be adjusted according to response. In addition to their regular use for the prophylaxis of asthma, both Fostair MDI and Symbicort can be used as a reliever (instead of a short-acting beta- 2 agonist). Patients must be carefully chosen and be instructed on the appropriate dose (see BNF) and also be instructed on how to manage exacerbations before initiating this reliever therapy. Patients using Fostair or Symbicort as a reliever once daily or more frequently should have their treatment reviewed regularly. Relvar Ellipta is a once daily dry powder inhaler. Prescribers should be aware that fluticasone furoate 100 micrograms once daily is approximately equivalent to fluticasone propionate 250 micrograms twice daily. Patients using high doses of inhaled corticosteroids (> or equal to 800mcg of beclometasone or equivalent) should be given a steroid card. Paediatrics Also see Appendix 3D Preferred Inhaler Devices for Children (5-12 years) Also see Appendix 3E Preferred Inhaler Devices for Children less than 5 years old Seretide 50 Evohaler is licensed for use from the age of 5. Symbicort 100/6 Turbohaler is licensed for use from the age of 6. Children requiring doses of fluticasone/budesonide >500mcg/ day should be referred to secondary care for further assessment and monitoring. Children taking high doses of inhaled corticosteroids should have their height monitored and plotted on a centile chart at least on an annual basis. Specific written advice on steroid replacement in the event of severe intercurrent illness should be available for all children treated with 800 micrograms of beclometasone dipropionate or equivalent Leukotriene receptor antagonists Montelukast In asthma, montelukast should be considered at Step 3/4 in addition to inhaled steroid therapy (see BTS/SIGN Guideline). Montelukast should be considered in patients who present with asthma + uncontrolled rhinitis. When a leukotriene receptor antagonist is initiated, symptoms and peak expiratory flow should be monitored and treatment stopped if there is no benefit after 12 weeks Antihistamines, hyposensitisation and allergic emergencies Antihistamines Non-sedating 1st Choice Cetirizine 2nd Choice Loratadine 3rd Choice R Desloratadine, Fexofenadine, Levocetirizine Sedating Chlorphenamine Hydroxyzine

8 8 Promethazine In treatment of allergic rhinitis, antihistamines reduce rhinorrhoea and sneezing but are usually less effective for nasal congestion. Although drowsiness is rare with non-sedating antihistamines patients should still be advised that it can occur and may affect performance of skilled tasks (e.g. driving); excess alcohol should be avoided. Loratadine can be considered in patients who develop sedation with cetirizine. R Desloratidine, fexofenadine, levocetirizine are accepted for restricted use in patients with allergic rhinitis or chronic idiopathic urticaria when cetirizine and loratadine are ineffective or inappropriate. Hydroxyzine is used to treat pruritus in adults and children. Due to the risk of QT prolongation the maximum adult dose is 100mg, 50mg in the elderly and 2mg per kg body weight for children up to 40kg in weight. Hydroxyzine should not be prescribed to people with a prolonged QT interval or at risk of QT interval prolongation. For further advise see MHRA Drug Safety Update April Due to its long half-life hydroxyzine may cause day time sleepiness. Promethazine is used to treat pruritus in adults and children and may be used as a sedative in adults. Management of Chronic Urticaria Patients should be initially be managed with a once daily dose of a non-sedating antihistamine. If necessary, the dose can be doubled (usually given at night, off-label use). In difficult to treat patients, the dose of desloratadine or levocetirizine can be increased in incremental steps up to 4x the normal licensed dose (off-label use). Leukotriene receptor antagonists, see above, may be used in combination with non-sedating antihistamines in difficult to treat patients especially if aspirin or NSAID induced urticaria or those with delayed-pressure or autoimmune urticaria There is little evidence for the addition of H 2- antihistamines e.g. cimetidine, ranitidine. They should not be used routinely for this indication Allergen Immunotherapy R- Omalizumab (Xolair ) R - Omalizumab (Xolair ) is approved for restricted hospital use in patients with severe, persistent confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy (a full trial of and, if tolerated, documented compliance with inhaled high-dose corticosteroids, long-acting beta 2 agonists, leukotriene receptor antagonists, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate) in people aged 6 years and older who need continuous or frequent treatment with oral corticosteroids (defined as 4 or more courses in the previous year). R - Omalizumab is also approved for restricted hospital use as add-on therapy for the treatment of chronic spontaneous urticaria in adult and adolescent (12 years and above) patients with inadequate response to combination therapy with maximum dose H 1 antihistamines and/or leukotriene receptor antagonists, used according to current treatment guidelines Allergic Emergencies Adrenaline (epinephrine) Epipen Chlorphenamine IV

9 9 Hydrocortisone IV H - C1-Esterase Inhibitor (Berinert P ) Individuals at considerable risk of anaphylaxis need to carry two adrenaline (epinephrine) autoinjectors at all times and need to be instructed in advance when and how to inject. Due to differences in injection techniques adrenaline autoinjectors should be prescribed by brand name. In general, no more than 4 autoinjector devices should be prescribed at any one time. Berinert P is approved for the symptomatic treatment of acute attacks of hereditary angiodema under expert supervision Respiratory stimulants and Pulmonary surfactants Respiratory Stimulants R- Caffeine citrate injection 20mg/ml (Peyona ) R- Doxapram (Dopram ) R - Caffeine citrate is approved for restricted use in the treatment of apnoea of prematurity. Neonatal specialist advice only. R - Doxapram is approved for restricted use is post-operative respiratory depression, acute respiratory failure or neonatal apnoea. Hospital use only Pulmonary surfactants R- Poractant alfa (Curosurf ) R - Poractant alfa is approved for restricted use in the treatment of respiratory distress syndrome or hyaline membrane disease in neonates. Consultant paediatrician use only Mucolytics Carbocisteine S - Dornase Alfa (Cystic fibrosis) H Nebulised hypertonic sodium chloride 6% S - Nebulised sodium chloride 0.9% A 4 week trial of a mucolytic agent should be considered in COPD patients chronically troubled by sputum production. Only continue if symptoms improve Cough Preparations Also see NHS Fife Respiratory MCN Guidelines on Management of Chronic Cough Cough Suppressants Pholcodine Demulcent and expectorant cough preparations

10 10 Simple Linctus The benefit of demulcent cough preparations in dry irritating cough is considered to be a placebo effect. Physiotherapy, hot drinks, breathing exercises and steam inhalation can aid expectoration Systemic nasal decongestants No products recommended due to limited clinical benefits. See section for topical products Antifibrotics H - Nintedanib (Ofev ) H - Pirfenidone (Esbriet ) Nintedanib and pirfenidone are approved for the treatment of mild to moderate idiopathic pulmonary fibrosis for use in patients with a predicted forced vital capacity less than or equal to 80%. Treatment should be in line with the NHS Fife idiopathic pulmonary fibrosis protocol. Patients should be monitored on a regular basis. The need for ongoing treatment should be reviewed after 3 months and 12 months. Due to different formulations of nintedanib being licensed for different indications prescribe by brand name only.