Greater Manchester Asthma Management Plan 2018 Inhaler therapy options for adult patients (18 and over) with asthma

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1 Greater Manchester Asthma Management Plan 2018 Inhaler therapy options for adult patients (18 and over) with asthma Non-pharmacological options for ALL patients, consider at ALL stages Make sure diagnosis is correct and consider alternative / additional problems Check inhaler technique: technique with pmdis is often less than ideal and a spacer is strongly recommended different DPIs have different priming and administration mechanisms CHECK CAREFULLY! Check adherence (prescription records), especially picking up sufficient ICS prescriptions Check reliever prescriptions (use of more than 6 per year suggests uncontrolled disease) Stop smoking: Be proactive, challenge patients who obviously smoke, offer support to stop. Follow recommendations in NICE NG92. Provide a written self-management plan Annual flu vaccination Important principles to guide treatment: Assess response to any change in therapy over 6 to 12 weeks Prescribe by BRAND and DEVICE Spacer device recommended for pmdis: e.g. A2A, Aerochamber Plus or Volumatic; check SPCs for device and spacer compatibility Consider and manage allergies especially nasal symptoms, e.g. hayfever Consider trigger factors including allergens and passive smoke exposure Consider occupational influences and refer if suspected Stop treatments after an unsuccessful trial (e.g. Step 4 options) Consider how to assess response to treatment. Options include o RCP 3 questions o Asthma Control Test o Exacerbation rate o Spirometry (if available) o Peak flow Step down inhaled corticosteroids as per BTS recommendation e.g. when stable for 3-6 months reduce corticosteroid dose by 25-50% but not to less than equivalent of beclometasone 200mcg daily. Criteria for referral to specialist care e.g. severe asthma service: Unclear diagnosis Two or more courses of oral steroids in a 12 month period Still exacerbating or symptomatic or uncontrolled after addition of add-on therapies

2 Regular preventer Low dose ICS Initial add-on therapy Add LTRA or inhaled LABA to ICS therapy Additional add-on therapies High dose therapies AND Refer to Specialist Centre Continuous or frequent use of oral steroids Should be managed in a specialist centre Inhaled corticosteroid: recommended starting dose should be equivalent to Clenil 400mcg daily or Qvar 200mcg daily allowing step down to half of these doses if well controlled. Inhaler options: Qvar Easi-Breathe 50 (or MDI +/- spacer) Clenil 100 MDI + spacer 2puffs bd Easyhaler budesonide 200 Add LTRA: montelukast 10mg daily in the evening OR* inhaled LABA, normally as a combination inhaler Inhaler options: Fostair 100/6 MDI (+/- spacer) Fostair NEXThaler 100/6 Fobumix Easyhaler 160/4.5 No response to LTRA / LABA: withdraw and try the other option (i.e. LABA / LTRA) Partial response to LTRA / LABA: continue and add the other option (i.e. LABA / LTRA) If benefit from LTRA ± LABA but control still inadequate: continue LTRA ± LABA and increase ICS to medium dose: Fostair 100/6 MDI (+/- spacer) Fostair NEXThaler 100/6 Fobumix Easyhaler 160/4.5 2 puff bd If once daily option preferred: Relvar 92/22 1 puff once daily If control still inadequate, consider trial of additional therapy : Tiotropium Respimat, 2 puffs once daily ICS only option if both LTRA/LABA of no benefit: Qvar Easi-Breathe 100 (or MDI +spacer) Easyhaler budesonide 200 Refer patient for specialist care Consider trial of: Increasing ICS up to high dose Fostair 200/6 MDI (+/- spacer) Fostair NEXThaler 200/6 Fobumix Easyhaler 320/9 If once daily option preferred: Relvar 184/22 1 puff once daily Addition of a third / fourth drug: Uniphyllin 200mg bd (measure levels 5 days after starting treatment and adjust dose as necessary) Refer patient for specialist care. Following steps to be initiated only by specialist: Consider daily steroid tablet in lowest dose providing adequate control Maintain high dose ICS Consider other treatments to minimise use of steroid tablets Provide a steroid warning card. Inhaled short-acting beta agonist option to be used at all stages: 1-2 puffs as required: Salbutamol pmdi (Ventolin); Easyhaler Salbutamol; Salamol EasiBreathe. Match with ICS device if possible.

3 Notes These treatment recommendations are suitable for newly diagnosed asthma patients. For asthma patients already established on treatment, then the recommendations here may also be used in cases where symptoms and / or exacerbations require a change in treatment, or cost reduction is being considered. This list of inhaler therapy options is not intended to be used to change therapy if it is working well nor to completely rule out any device. Certain devices not in the Plan above may be more suitable for persons with problems of dexterity. These treatment recommendations are suitable for newly diagnosed asthma patients or where symptoms and / or exacerbations require a change in treatment. This list of inhaler therapy options is not intended to be used to change therapy if it is working well nor to completely rule out any device eg. certain devices not in the Plan above may be more suitable for persons with problems of dexterity. Promote use of regular ICS preventer in newly diagnosed individuals. * - Initial add on therapy options: Consider montelukast where: Consider ICS / LABA combination inhaler where: Patient willing to take a tablet as well as an inhaler. N.B. must be confident patient will not substitute the tablet for the Requires relief from tight / wheezy chest with excessive use of SABA especially where due to poor lung function e.g. FEV1 < 80% predicted. inhaled corticosteroid. Allergic rhinitis Don t wish to take a tablet Exercise-induced asthma Extra prescription charge presents a financial burden These choices should be discussed carefully with the patient and agreement reached as to the best initial add-on therapy. British Thoracic Society (BTS) 2016 guideline on the management of asthma does not recommend Maintenance and Reliever Therapy regimens (MART / SMART) although NICE NG does. These may be suitable for some patients and some of the inhalers which may be used are: Fobumix Easyhaler 80/4.5 Fobumix Easyhaler 160/4.5 Fostair 100/6 MDI Symbicort Turbohaler 100/6 Symbicort Turbohaler 200/6

4 The Rightbreathe website contains a wealth of information regarding inhalers and videos demonstrating correct use.

5 List of abbreviations ICS inhaled corticosteroids LABA long-acting beta-agonist LTRA leukotriene receptor antagonist MDI metered dose inhaler pmdi pressurised metered dose inhaler RCP 3 questions UK Royal College of Physicians 3 Questions screening tool