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1 ASTHMA TREATMENT GUIDELINES Document Description Document Type Service Application Guidelines All healthcare professionals(hcps) caring for patients with asthma Version 4.0 Ratification date September 2016 Review date March 2018 Lead Author(s) Name Joanne Hamilton Dr M Hopkin Minesh Parbat Position within the Organisation Lead Nurse Respiratory DGNHFT GP & Respiratory Lead Prescribing Advisor Presented for discussion, approval and ratification to Core Policies and Procedures Group Change History Version Date Comments 0.1 Oct 09 First draft 0.2 Oct 09 Amended following comments from Pharmaceutical Adviser 0.3 Nov 09 Amended following comments from Core Policies 1 Jan 10 Final ratified edition. 1.1 March 10 Amendment on Theophylline Dosage 12+ Guidelines 1.2 May 10 Amendment on Montelukast micrograms to milligrams(mgs) 1.3 Feb 11 Addition of Fostair to adult guidelines at Step March 11 Change of layout at Step 3 and logos 1.5 January 12 Addition of Seretide 100 Accuhaler at Step 3 asthma

2 treatment guidelines 12 + years guidelines 1.6 January 12 Addition of Seretide 100 Accuhaler at Step 3 asthma treatment guidelines age 5 12 years 2.0 November September 2016 Change of Layout to guidelines Change of Layout to guidelines and treatment options 3.1 June 2017 Draft Updated : Symbicort Smart which is now licensed from the age of 12 years old (previously 18 years old). 4.0 June 2017 Final Ratified edition Updated : Symbicort Smart which is now licensed from the age of 12 years old (previously 18 years old). Link with Care Quality Commission Essential Standards of Quality & Safety Regulation 10, Outcome 16 Assessing & Monitoring the quality of services provision. Regulation13, Outcome 9 Management Of Medicines Link with Trust Purpose and Values statements These guidelines are aimed to improve the health and wellbeing of our local community. They link with values 1-11

3 Summary Sheet These treatment guidelines have been produced as a quick reference guide for HCPs who manage people with Asthma.. The guidelines are based on National Asthma Management Guidelines British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN), These treatment guidelines will help to ensure appropriate, cost effective prescribing for people of all ages, with asthma. The treatment guidelines will form part of an asthma education program. They support HCPs with prescribing and should be used in conjunction with the BTS/SIGN, These guidelines have been widely consulted on since March 2016, including: Dudley Respiratory Group Practice Nurse Mentors Prescribing and Medicines Management Team Presentations to Dudley GPs & Practice Nurses Nurse Consultant These guidelines will be reviewed at least every 2 years or sooner if indicated, by Dudley Respiratory Group or Area Clinical Effectiveness Committee.

4 ASTHMA TREATMENT GUIDELINES Definition: Asthma is a chronic inflammatory respiratory disease. It can affect people of any age, but often starts in childhood. It is characterised by attacks (also known as exacerbations) of breathlessness and wheezing, with the severity and frequency of attacks varying from person to person. The attacks are associated with variable airflow obstruction and inflammation within the lungs, which if left untreated can be life-threatening, however with the appropriate treatment can be reversible CONTROL OF ASTHMA, DEFINED AS: - No daytime symptoms - No limitations on activity including exercise - No night time awakening due to asthma - Normal lung function - No need for rescue medications - No asthma attacks With minimal side effects using the lowest effective doses BEST PRACTICE - Review patients regularly Considering Step Up & Down accordingly - A Spacer device is recommended when using a MDI- - Check Inhaler technique and compliance at each appointment and before starting any additional therapy - Use an in-check device to measure inspiratory effort - The least costly product that is suitable for an individual should be used - Consider total steroid load when reviewing patient - All patients should have a written self-management plan - Reconsider the diagnosis in patients who continue to have symptoms Asthma is not controlled at any step if using SABA: 3 times a week or more: having symptoms 3 times a week or more: waking at least once a week. Regular Inhaled Preventer Inhaled Corticosteroid (ICS) <12yrs Very Low Dose ICS 200mcgs 12yrs Low Dose ICS 400mcgs Initial Add on Therapy <5yrs 5yrs of age (or 6-11yrs >5yrs ADD in a Long Acting B 2 Agonist unable to use a DPI) (LABA) in a combination inhaler

5 ADD Leukotriene Low Dose ICS 6-11yr Very Low Dose ICS + LABA Receptor Antagonist 400mcgs/day in an MDI 200mcgs 12+ Low Dose ICS + LABA 400mcg Review after ONE MONTH <5yrs IF GOOD RESPONSE TO LTRA CONTINUE IF POOR OR NO RESPONSE RECONSIDER DIAGNOSIS REFER TO RESPIRATORY PAEDIATRICIAN 5yrs (or 6-11yrs unable to use a DPI) IF GOOD RESPONSE TO ICS CONTINUE >5yrs IF GOOD RESPONSE TO LABA - CONTINUE IF SOME RESPONSE OR NO RESPONSE THEN GO TO ADDITIONAL ADD ON THERAPY BELOW Additional Add on Therapy SOME RESPONSE to LABA EITHER INCREASE ICS in a combinations inhaler (ICS+LABA) 6-11yrs Low Dose (ICS+LABA) *400mcgs BDP 12+yrs Medium Dose (ICS+LABA) *800/*1000mcgs BDP OR CONTINUE WITH ICS+LABA (in a combination inhaler) and add a LTRA NO RESPONSE TO LABA STOP LABA in a combinations inhaler increase ICS alone (ICS+LABA) and 6 11 years 12+ years Low Dose ICS Medium Dose ICS 400mcgs BDP 800mcgs BDP 5yrs (or 6-11yrs unable to use a DPI) add in a LABA Low Dose ICS 400mcgs BDP (MDI + Spacer) <18yrs REFER TO RESPIRATORY PAEDIATRICIAN 18+ years Consider patients who may be suitable for Maintenance and Reliever therapy SMART/MART >18yrs CONSIDER TRIAL OF LAMA Long Acting Muscarinic Antagonist HIGH DOSE THERAPIES Consider trials of:- Addition of a 4 th drug LTRA

6 LAMA Increasing ICS up to 2000mcgs/day BDP 18+ years Refer to Respiratory Consultant Short Acting B2 Agonist (SABA) Prescribe as required Asthma is not controlled at any step if using SABA: 3 times a week or more: having symptom 3 times a week or more: waking at least once a week KEY: MDI Metered Dose Inhaler SABA Short Acting B 2 Agonist ICS Inhaled Corticosteroids DPI Dry Powder Inhaler BDP Beclometasone LTRA Leukotriene Receptor Antagonist LABA Long Acting B 2 Antagonist LAMA Long Acting Muscarinic Antagonist mcgs micrograms BTS British Thoracic Society SIGN The Scottish Intercollegiate Guidelines Network

7 MAINTENANCE & RELIEVER THERAPY The use of a single inhaler for both maintenance and reliever therapy in asthma Adult patients ( 18 years) use an adequate fixed maintenance dose and additional reliever inhalations of Symbicort/Fostair as required Symbicort 100/6 or 200/6 Turbohaler SMART (12+ years) One inhalation twice a day plus as required OR Two inhalations once daily plus as required OR Two inhalations twice a day plus as required A maximum of 12 inhalations per day (maintenance and reliever): The use of a separate reliever inhaler is NOT required Fostair 100/6 Metered Dose Inhaler MART (18+ years) One inhalation twice a day plus one as required A maximum of 8 inhalations per day (maintenance and reliever): The use of a separate reliever inhaler is NOT required Patients requiring frequent use of rescue inhalations daily should be strongly recommended to seek medical advice. Their asthma should be reassessed and their maintenance therapy should be reconsidered

8 12+ Years Recommended Asthma Treatment Choices - First Line 12 to Brand Name ICS LABA Dosage Regime Total Daily Dose ICS TDD BDP equivalent REGULAR PREVENTER (ICS) Clenil 100 MDI Beclometasone 2 Puffs twice a day 400mcgs = 400mcgs Budesonide 100 Easyhaler Budesonide 1 Puff twice a day 400mcgs = 400mcgs Pulmicort 200 Turbohaler Budesonide 1 Puff twice a day 400mcgs = 400mcgs INITIAL ADD ON THERAPY (ICS+LABA) Symbicort 100/6 Turbohaler Budesonide Formoterol 2 Puffs twice a day 400mcgs = 400mcgs Flutiform 50/5 MDI Fluticasone propionate Formoterol 2 Puffs twice a day 200mcgs = 400mcgs ADDITONAL ADD ON THERAPIES (ICS+LABA) ADDITIONAL ADD ON THERAPIES (ICS) Symbicort 200/6 Turbohaler Budesonide Formoterol 2 Puffs twice a day 800mcgs = 800mcgs Flutiform 125/5 MDI Fluticasone propionate Formoterol 2 Puffs twice a day 500mcgs = 1000mcgs Beclometasone x Fostair 100/6 MDI/Nexthaler Extrafine Formoterol 2 puffs twice a day 400mcgs = 1000mcgs Clenil 200 MDI Beclometasone 2 Puffs twice a day 800mcgs = 800mcgs Budesonide 400 Easyhaler Budesonide 1 Puff twice a day 800mcgs = 800mcgs Pulmicort 400 Turbohaler Budesonide 1 Puff twice a day 800mcgs = 800mcgs HIGH DOSE THERAPY (ICS+LABA) x Flutiform 250/10 MDI Fluticasone propionate Formoterol 2 Puffs twice a day 1000mcgs = 2000mcgs Beclometasone x Fostair 200/6 MDI/Nexthaler Extrafine Formoterol 2 Puffs twice a day 800mcgs = 2000mcgs Low Dose ICS Medium Dose ICS High Dose!CS TDD - Total Daily Dose BDP - Beclometasone ICS - Inhaled Corticosteroid LABA - Long Acting Beta Agonist

9 12+ Years - Other Asthma treatment choices - 2nd Line 12 to Brand Name ICS LABA Dosage Regime Total Daily Dose ICS TDD BDP equivalent REGULAR PREVENTER Qvar 50 MDI Beclometasone Extrafine 2 Puffs twice a day 200mcgs = 500mcgs INITIAL ADD ON THERAPY (ICS + LABA) Seretide 50/25 MDI Fluticasone propionate Salmeterol 2 Puffs twice a day 200mcgs = 400mcgs Seretide 100/50 Accuhaler Fluticasone propionate Salmeterol 1 Puff twice a day 200mcgs = 400mcgs ADDITIONAL ADD ON THERAPIES (ICS+LABA) Seretide 125/25 MDI Fluticasone propionate Salmeterol 2 Puffs twice a day 500mcgs = 1000mcgs Seretide 250/50 Accuhaler Fluticasone propionate Salmeterol 1 Puff twice a day 500mcgs = 1000mcgs ADDITIONAL ADD ON THERAPIES (ICS) Qvar 100 MDI Beclometasone Extrafine 2 Puffs twice a day 400mcgs = 1000mcgs HIGH DOSE THERAPIES (ICS+LABA) Seretide 250/25 MDI Fluticasone propionate Salmeterol 2 Puffs twice a day 1000mcgs = 2000mcgs Seretide 500/50 Accuhaler Fluticasone propionate Salmeterol 1 Puff twice a day 1000mcgs = 2000mcgs Low Dose ICS Medium Dose ICS High Dose!CS TDD - Total Daily Dose BDP - Beclometasone ICS - Inhaled Corticosteroid LABA - Long Acting Beta Agonist

10 <12 Years Asthma Inhaler Treatment Choices REGULAR PREVENTER INITIAL ADD ON PREVENTER (ICS + LABA) Total Daily TDD BDP <5 5 to 11 Brand Name ICS LABA Dosage Regime Dose ICS equivalent Clenil 50 MD! Beclometasone 2 Puffs twice a day 200mcgs = 200mcgs Pulmicort 100 Turbohaler Budesonide 1 Puff twice a day 200mcgs = 200mcgs 6+ Budesonide 100 Easyhaler Budesonide 1 Puff twice a day 200mcgs = 200mcgs 6+ Symbicort 100/6 Turbohaler Budesonide Formoterol 1 Puff twice a day 200mcgs = 200mcgs If 5years of age or 6-11yrs and unable to use Dry Powder Inhaler (Turbohaler) then: Clenil 100 MDI Beclometasone 2 puffs twice a day 400mcgs = 400mcgs ADDITIONAL ADD ON THERAPIES (ICS + LABA) 6+ Symbicort 100/6 Turbohaler Budesonide Formoterol 2 Puffs twice a day 400mcgs = 400mcgs Seretide 50/25 MDI Fluticasone propionate Salmeterol 2 Puffs twice a day 200mcgs = 400mcgs ADDITIONAL ADD ON THERAPIES (ICS) Clenil 100 MDI Beclometasone 2 Puffs twice a day 400mcgs = 400mcgs 6+ Budesonide 100 Easyhaler Budesonide 2 Puffs twice a day 400mcgs = 400mcgs Pulmicort 200 Turbohaler Budesonide 1 Puff twice a day 400mcgs = 400mcgs Flixotide 50 MDI Fluticasone 2 Puffs twice a day 200mcgs = 400mcgs HIGH DOSE THERAPIES (ICS + LABA) Clenil 100 Beclometasone 4 Puffs twice a day 800mcgs = 800mcgs Seretide 125/25 MDI Fluticasone propionate Salmeterol 2 Puffs twice a day 500mcgs = 1000mcgs Very low dose ICS Low Dose ICS Medium Dose ICS TDD - Total Daily Dose BDP - Beclometasone ICS - Inhaled Corticosteroid LABA - Long Acting Beta Agonist

11 SABA Short Acting B 2 Antagonist Short Acting Bronchodilators 12 to <5 5 to Brand Name SABA Dosing Regime 2 puffs as required up to a max of 4 times a Ventolin 100mcgs MDI Salbutamol day 2 puffs as required up to a max of 4 times a day Salamol Easibreathe 100mcgs MDI Salbutamol Bricanyl Turbohaler 500mcgs Terbutaline 1 puff as required up to a max of 4 times a day 2 puffs as required up to a max of 4 times a Salbutamol Easyhaler 100mcgs Salbutamol day NOTE: Asthma is not controlled at any step if using SABA: 3 times a week or more: having symptoms 3 times a week or more: waking at least once a week. LAMA Long Acting Muscarinic Antagonist Long Acting Muscarinic Antagonists (LAMA) 18+ Brand Name LAMA Dosage Regime Spiriva Respimat 2.5 micrograms Tiotropium 2 Puffs once daily (This is indicated as an add on bronchodilator treatment in adult patients with asthma who are currently treated with a maintenance combination inhaler (ICS+LABA) at 800mcgs/day BDP equivalent and who experienced one or more severe exacerbations in the previous year)

12 Leukotriene Receptor Antagonists (LTRA) 6 months to 5 years Once daily at night 6-14 years Once daily at night 15+ years Once daily at night LTRA - Leukotriene Receptor Antagonist Montelukast 4mg Chewtab or 4mg granules (do not mix with fluid but can be mixed with food) Montelukast 5mg Chewtab Montelukast 10mg tablet SPACER DEVICES Wash your spacer once a month using detergent, such as washing-up liquid. Don t scrub the inside of the spacer as this affects the way it works. Leave it to air-dry as this helps to prevent the medicine sticking to the sides of the chamber and reduces static Wipe the mouthpiece clean of detergent before you use it again. Don t worry if your spacer looks cloudy - that doesn t mean its dirty Your spacer should be replaced at least every year, especially if you use it daily, but some may need to be replaced sooner - ask your GP, asthma nurse or pharmacist if you re unsure Ensure the inhaler is compatible with the spacer device Aerochamber Infant Device with Mask (Orange) 0-18 months Aerochamber Child Device with Mask (yellow) 1 year 5 years Aerochamber plus with Mask (Blue) 5+ years Volumatic with Facemask 0+ years Volumatic 3+ years Aerochamber Plus (Blue) 5+ years