HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE Date: 6 th September 2016

Transcription

1 HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE Date: 6 th September 2016 What are we bringing t HMMC? Updated Treatment Guidelines fr COPD withut asthma (Attach 6.2b) and supprting LAMA/LABA cmbinatin inhalers cmparisn data (Attach 6.2c) Why is this being brught t HMMC? Current treatment guidelines fr COPD withut asthma have been in place since Since the publicatin f the riginal guidelines new prducts (including LAMA/LABA cmbinatin inhalers) have been launched Sme LAMA/LABA cmbinatin inhalers were cnsidered by HMMC in 2014 and A nt recmmended decisin was made with a recmmendatin that the decisin will be reviewed when the lcal COPD guidelines are reviewed with lcal specialists t cnsider place in the pathway fr LAMA/LABA cmbinatin inhalers. Sme additinal evidence has been published fr LAMA/LABA cmbinatin inhalers since these recmmendatins were made NICE COPD guidelines were riginally published in Fllwing a review f the evidence in April 2016 the guidelines are being updated (publicatin date TBC) The Glbal Initiative fr Chrnic Obstructive Lung Disease (GOLD) guide t COPD diagnsis, management and preventin was updated in Sme lcal specialists have indicated a preference fr fllwing the treatment apprach within the GOLD guidelines Issues fr Cnsideratin Lcal specialists have expressed supprt fr prescribing LAMA/LABA cmbinatin inhalers The pharmaclgical treatment table in the guidelines is an adapted versin f the GOLD algrithm incrprating LAMA/LABA cmbinatin inhalers. Much f the supprting infrmatin within the lcal COPD guidelines have remained unchanged The inhaler chices table highlights current preferred treatment ptins. Previus GP feedback was t have cnsistency f inhaler chice between asthma & COPD guidelines where pssible Preferred LAMA/LABA cmbinatin inhaler chices are currently nt specified. The intrductin f LAMA/LABA cmbinatin inhalers may result in fewer patients being prescribed ICS (including as part f the highest cst triple therapy regime) which are assciated with adverse-effects including nn-fatal pneumnia Frm the cmments received there appears t be a clear cnsensus n having LAMA/LABA cmbinatins within the guidelines but nt n preferred chice. Sme have suggested having access t all but if restricted that the full prduct prtfli be available (eg availability f LAMA and LAMA/LABA in same device). The verall impact f the implementatin f these guidelines n prescribing csts is uncertain althugh it is anticipated t be at wrst cst neutral in the shrt term. A generic titrpium dry pwder inhaler equivalent t Spiriva Handihaler will be launched sn (Teva has cnfirmed expected >20% lwer cst than Handihaler with launch date Oct 2016). Current draft has cntact fr HVCCG cmmunity respiratry service. The ENHCCG cmmunity respiratry service cntact details will be added fr the ENHCCG versin Prpsed Recmmendatins and cnsideratins: T ratify the updated Treatment Guidelines fr COPD withut asthma but t cnsider: ptential impact f imminent launch f generic titrpium and if guideline ratificatin shuld be deferred preferred inhaler chices and recmmend an apprach t inhaler chice and if preferred prduct chices shuld remain as per current guidelines r be revised if a preferred LAMA/LABA cmbinatin inhaler prduct shuld be specified (nting that this may have an impact n prduct chice in the verall pathway) Guidelines t be reviewed when updated NICE COPD guidelines are published Respiratry prescribing items and csts t be mnitred t review impact f guidelines Prescribing cst impact f implementatin f updated guidelines The verall impact f the implementatin f these guidelines n prescribing csts is uncertain althugh it is anticipated t be at wrst cst neutral in the shrt term: Page 1 f 7

2 LAMA/LABA cmbinatin inhalers are: generally higher cst than single cmpnent LABAs r LAMAs (but lwer cst than current 1 st chice mst cmmnly prescribed LAMA - titrpium Handihaler (nte imminent availability f generic titrpium) lwer cst than any cmbinatin f LABAs & LAMAs higher cst than 1 st line LABA/ICS chices (Fstair and DuResp) but lwer cst than 2 nd line chices (Seretide Accuhaler 500) The intrductin f LAMA/LABA cmbinatins may result in reduced prescribing f triple therapy which wuld reduce prescribing csts may lead t decreased use f LAMA inhalers which may increase prescribing csts in the lnger term (but nte will reduce csts if used instead f titrpium Handihaler) may lead t decreased prescribing f LABA/ICS which wuld increase prescribing csts Evidence Summary fr LAMA/LABA cmbinatin inhalers (als see Attach 6.2c) There are nw fur LAMA/LABA cmbinatin prducts licensed: Umeclidinium/vilanterl (Anr Ellipta ) Aclidinium/frmeterl (Duaklir Genuair ) Titrpium/ldaterl (Spilt Respimat ) Indacterl/glycpyrrnium (Ultibr Breezhaler ) These cmbinatin LAMA/LABA treatments may be an ptin fr patients currently indicated fr separate LABA and LAMA inhalers wh may benefit frm increased brnchdilatin and wh may nt be indicated fr LABA/ICS therapy as per NICE r GOLD as per NICE when ICS are declined r nt tlerated 1,2 as per GOLD when is preferred ptin ver LABA/ICS in patients at lw risk f exacerbatins ( 1 exacerbatin per year) but with significant symptms 3 where there is a risk f pneumnia with inhaled crticsterids in sme patients with COPD 9. The cmbinatins have nt been directly cmpared t ther LAMA/LABA cmbinatins althugh Astra Zeneca has perfrmed a netwrk meta-analysis 4 f three ut f the fur cmbinatins, which the SMC has accepted. This shwed that aclidinium /frmterl was bradly cmparable t indacaterl/glycpyrrnium, umeclidinium/vilanterl in terms f brnchdilatin, breathlessness, health status and safety. Studies have prvided evidence f benefits f dual brnchdilatin ver LABA r LAMA mntherapy, and that imprvements in lung functin and breathlessness are similar fr all the licensed LAMA/LABA cmbinatins. Hwever, it is unclear whether the cmbinatins have clinically imprtant benefits ver the individual cmpnents r whether it reduces exacerbatins by a clinically imprtant amunt 2,5,6. The NICE guidance n COPD recmmends that the chice f drug treatment shuld take int cnsideratin the persn s symptmatic respnse and preference and the drug s ptential t reduce exacerbatins 1. In light f the lack f clinical trial data which shws superirity f ne cmbinatin prduct ver the thers, patient preference and their ability t be able t use a specific inhaler shuld be strngly cnsidered. Availability f LABA and LAMA in a single device may cnfer imprved cmpliance. Sme peple with COPD may prefer t use a spacer; nne f the LAMA/LABA cmbinatins inhalers can be used with a spacer hence mn-cmpnents may need t be cnsidered in these situatins. Csts fr the 4 currently available LAMA/LABA inhalers are the same and als less cstly than prescribing the individual cmpnents 7 The NICE Surveillance Reprt n COPD 2 which assessed the need t update the existing clinical guidelines (cncluding that an update is required) selected : a netwrk meta-analysis by Oba et al. (2016) fr a full cmmentary because it cmpared dual brnchdilatr therapy (LAMA plus LABA) with LAMA r LABA mntherapy. It was cnsidered that these cmparisns may affect guideline recmmendatins. A number f strengths and limitatins f the meta-analysis were identified but cncluded that: The study prvides evidence f benefits f dual brnchdilatin ver LABA r LAMA mntherapy in patients with mderate t severe COPD. Tpic experts felt that the new evidence highlights advantages f using dual brnchdilatin ver mntherapy, in patients with mderate t severe COPD, and suggested that there is a need t review the algrithm fr inhaled therapy a netwrk meta-analysis by Tricc et al. (2015) fr a full cmmentary because it prvides cmparative evidence f different lng-acting inhaled therapies (LAMA r LABA mntherapy versus dual brnchdilatr therapy with r withut ICS) that may impact n guideline recmmendatins. A number f strengths and limitatins f the meta-analysis were identified but cncluded that: The study prvides strng evidence that dual brnchdilatr therapy (specifically, glycpyrrnium plus indacaterl) is mre effective than LAMA r LABA mntherapy and LABA plus ICS therapy in reducing the risk f mderate-t-severe COPD exacerbatins. Tpic experts agreed with the evidence and suggested that dual brnchdilatin prduces greater imprvements in FEV1 and Page 2 f 7

3 Attach 6.2a dyspnea than LABA plus ICS cmbinatins in patients with severe COPD. Hwever, new intelligence suggested that sme LABA plus ICS cmbinatins are becming cheaper due t expiring patents. A review f the clinical and cst effectiveness f inhaled therapies may be needed t identify whether recmmendatins in the guideline shuld remain. Ptential disadvantages f LAMA/LABA Althugh LABA/LAMA is licensed fr dual therapy fr patients nt n ICS, in the majrity f the trials patients remained n ICS 4,5,6,9. In clinical trials, patients with cardivascular disease were excluded frm studies s all fur LABA/LAMA cmbinatins are cautined in cardivascular disease t different degrees. Cmpared with established LABAs & LAMAs the lng-term safety f LAMA/LABA cmbinatins is unclear 7,8. Each f the cmbinatins are black triangle drugs as they cntain newly licensed agents. References: (1) NICE CG101 (2010) Chrnic Obstructive Pulmnary Disease in ver 16s: diagnsis and management (2) NICE Surveillance Reprt 6 Apr 2016 Chrnic bstructive pulmnary disease in ver 16 s; diagnsis and management (3) GOLD- Glbal Strategy fr the Diagnsis, Management and Preventin f COPD updated (4) Scttish Medicines Cnsrtium; aclidinium/frmterl fumarate dihydrate 340/12 micrgrams inhalatin pwder (Duaklir Genuair ) SMC N. (1034/15) (5) Oba Y et al. Efficacy and safety f lng acting beta-agnist/lng-acting muscarinic antagnist cmbinatins in COPD; a netwrk meta-analysis; Thrax 2016; 71: (6) Calzetta L et al. A systematic review with meta-analysis f dual brnchdilatin with LAMA/LABA fr the treatment f stable COPD; Chest 2016; 149(5): (7) PrescQIPP; Inhaled therapy in chrnic bstructive pulmnary disease (COPD): Bulletin 109; Dec 2015 (8) NICE evidence summaries; chrnic bstructive pulmnary disease (as referenced n the cmparatr dcument) (9) Wedzicha J et al. Indacterl-Glycpyrrnium versus Salmeterl-Fluticasne fr COPD; NEJM; 374: ; June 2016 Cmments Received (amendments t guidelines agreed as specified in blue text) Dr Matthew J Knight Cnsultant in Respiratry and Internal Medicine WHHT Cmments n initial draft 27/07/2016 I nte the cncerns re drug escalatin. I think that an increasing bdy f evidence wuld supprt the use f LAMA and LABA cncurrently (nt necessarily the same device althugh I imagine csts and cmpliance wuld supprt single device) and I d feel that if we cntinue t advcate a try ne, then try the ther and then finally try all cmbined apprach that we d ur patients a disservice. I am cncerned that the GOLD ABCD apprach has t many variables in it n the B and C stages which is pen t cnfusin ( fr example changing Seretide MDI t Sirdupla caused a large number f ur patients wh were stable n the 500 accuhaler t be switched inapprpriately t MDI and has been the cause f quite a number f telephne calls and letters t me and clleagues). I think an apprach that fllws the belw is very acceptable, but I believe that increasingly we will be encuraged t skip 2 and g straight t 3 and d wnder whether at least fr the mre breathless/ GOLD stage II and abve patients we culd advcate prgressin straight t LAMA LABA cmbinatin 1. SABA +- SAMA; 2. LAMA; 3. LAMA LABA cmbinatin; 4. LAMA LABA ICS; 5. Add n Chice f LABA/LAMA Indacaterl/Glycpyrrnium (Ultibr Breezhaler) As is quicker nset f actin and nce day dse Umeclidinium/vilanterl (Anr Ellipta) nce daily dse Nt chsen Aclidinium/frmterl (Duaklir Genuair) inhalatin twice daily Nt chsen Titrpium/ldaterl (Spilta Respimat Sft Mist) as lng insipiratry time needed In additin cmbined LABA/LAMAs are cheaper than individual cmpnents used separately and all cst the same ( 32.50), and nte Chest meta-analyses and trial data attached n efficacy. 02/08/2016 cmments n full draft guidelines: (Guidelines) Lk fine- I think sme talks n the 3 binary scales (MRC, GOLD spir and exac) will be needed as I am cncerned thse withut a chest interest will get cnfused with the ABCD apprach. I still think that the current evidence base wuld suggest that always being n a LAMA LABA rather than a LAMA r LABA is beneficial. Gd selectin f devices. I d wnder thugh- shuld we take Symbicrt and Seretide MDI 250 ff as we have very gd alternatives and there appears t be quite a difference in cst in these devices. Ptential cnflicts f interest- I have met drug reps frm all f the cmpanies that make pretty much all f the drugs listed (except DuResp and Sirdupla). I really like the dcument 18/08/2016 Page 3 f 7

4 Evidence base wuld suggest that LAMA LABA superir t LAMA alne, but as f yet n significant signal f any difference between them. Given that the cst is the same the mre devices available the better, s that patient chice determines. My persnal preferences are fr Anr Ellipta device fr simplicity, and Ultibr fr the quicker nset f actin f Glyc in it which has sme benefit fr thse wh find getting ging in the mrning a bit f a challenge. Prblem with Duaklir is it is twice daily admin, which is mre f a nuisance. There is n need t adjust the dse fr renal impairment with ANORO. There is n need t adjust Ultiibr with renal failure, althugh the manufacture advises against use in the dialysis ppulatin (althugh yu culd argue that that ppulatin is a high CVS risk and all LAMA shuld be used carefully) unless benefits utweigh risks. Likewise n adjustments are needed with Duakalir All LAMA shuld be used with sme degree f cautin with patients with clsed angle glaucma and cardivascular disease Dr She Lk, Clinical Directr Respiratry Medicine, ENHT Thanks fr the draft guidelines fr cmments which are essentially based n the GOLD guidance. There is a tendency twards patient tailred treatment dependent n whether the issue is symptm cntrl, exacerbatin reductin r bth. T reflect this we d need access t the varius cmbinatin f inhalers and imprtant that we d have access t the cmbinatin brnchdilatrs. At the same time I als feel we need t relk at the different inhalers available. It is imprtant fr cst effective evidence based prescribing but at the same time it needs t be patient directed. It is n pint t have a limited number f inhalers with limited devices if the patient can nly use a device that is nt n the frmulary and at the same time if the patient is use t a particular device we d nt want t g changing it because the cmbinatin we are after with the apprpriate device is nt n the frmulary. The guidelines yu have drafted gives the pprtunity t make inhaler prescribing mre rbust. As mentined n the varius s there is n real difference with the different brnchdilatr cmbinatin available s I d nt have a particular preference. My decisin wuld be swayed by the devices available. Speaking with the nurses the ellipta device is straightfrward and similar t the accuhaler. The respimat device shuld als be available as a nn-dpi which sme may prefer. Whichever, cmbinatin is decided upn the varius inhalers in that prtfli shuld als be available fr the reasn mentined abve. Prfessr Thida Win, Cnsultant Respiratry and General Medicine Physician, ENHT I am in ttal supprt f Dr Lk cmment, and appreciate variety f inhalers available t prescribe. Dr Patryk Szulakwski, Cnsultant in Respiratry and Sleep Medicine, ENHT I ttally agree with She. I wuld pt fr having a chice f fur LABA/LAMA inhalers (Ultibr, Spilt, Anr, Duaklir). The price f all f them is the same. There is evidence that they all imprve FEV1, dyspnea index, QL and exacerbatin rate. Hwever the bdy f evidence is the strngest in the case f Ultibr (Studies: SHINE, ILLUMINATE, SPARK, FLAME). In case we cannt have all f them n ur frmulary my rating is as fllws: 1. Ultibr, 2. Spilt, 3. Anr, 4. Duaklir Kevin Hazelwd, Cnsultant Pharmacist - Emergency Medicine, ENHT Happy t agree with guidelines. With regard t chice I t like the Ellipta range, which wuld mean we include Relvar and Incruse and btain the significant savings ffered there, hwever what little differential evidence there is fr LABA/LAMA favurs Ultibr (as (Patryk states). Assuming we wuld like patients t stay with this device this raises the ptin f Seebri ver Spiriva Handihaler first line (better device than handihaler, lwer inspiratry rate, cmparable evidence t ti??). Frm a secndary care CIP perspective we ften get patients cming int hspital withut their inhalers and n ne at hme able t bring them in. Seebri ffers a 6 day hspital pack (cmplete with device) at 5.50 which wuld accmmdate a lt f ur admissins rather than having t give them a mnths wrth f a n ther LAMA. Newly initiated patients r new placements/ict etc wuld get the full cntract amunt (>2/52 r ne whle mnth pack). I have prpsed this ptin previusly fr patients admitted fr ther cnditins nt related t respiratry prblems with verbal supprt frm Dr Lk - I'd welcme any ther cmments. (Ultibr als ffers a 12 day hspital pack which wuld als save us mney n a similar basis) Fr thse wh prefer a mdi then Spiriva Respimat is mst cst effective with benefit f Spilt in same device if dual brnchdilatr preferred. I understand there is sme resistance frm ur respiratry nurses Page 4 f 7

5 wrt Respimat device as sme patients find it difficult t lad/prime - I thught cmmunity pharmacists were happy t d this if asked? Dr Wha-Yng Lee, Cnsultant in Respiratry Medicine, ENHT I wuld agree t having all 4 LABA/LAMA's n the frmulary. This wuld be beneficial especially with ICS assciated pneumnias, thse wh dn't have recurrent exacerbatins r severe COPD n FEV1 and lung functins. I d find the current GOLD guidelines are better than the previus as it des take int cnsideratin the clinical factrs and nt just spirmetry but als the disease curse which is mre specific in the management fr COPD patients. As Patryk and She pinted ut there is rbust evidence fr them all but inhaler suitability, cmpliance, and critical errrs are imprtant in the chice. If there was a chice, I wuld prefer a DPI and an MDI n the frmulary. Fr the DPI, I'd prefer (inrder f preference) Anr Ellipta, Ultibr breezehaler, Duaklir Genuair. And fr the MDI Spilt respimat nly. Dr Alisn McMillan, Cnsultant Respiratry Physician,and Dr Wha-Yng Lee, Cnsultant in Respiratry Medicine ENHT (summary ntes f PMOT frm NDF (final ntes awaited)): Agree with guidelines in general but have sme cmments. D nt believe there are any clinical differences between the LAMA/LABAs. Chice wuld be 1. Anr Ellipta, 2. Spilt Respimat, 3. Duaklir Genuair, 4. Ultibr Breezhaler but will liaise with the department and prvide cmments n guidelines and cnfirm preferred chices by 2 nd September. Glenda Esmnd, Respiratry Nurse Cnsultant, Central Lndn Cmmunity Healthcare (West Herts) nil declaratin Thank yu fr all the hard wrk put int the COPD guidelines and verall I am in agreement with them. I have made sme suggestins which I have attached and included within this is my thughts n chice f LAMA/LABA cmbinatin based n the cmprehensive review that Sapana prvided. Once they have been apprved I think we need t think abut implementatin very carefully particularly in relatin t LAMA/LABA. Educatin abut COPD & Treatment changes agreed Separate nutritinal and exercise as hw it reads it lks like that the exercise is related t weight management. Wuld suggest: Give initial advice n nutritin / weight management Advice n physical activity/exercise t prevent decnditining Pulmnary Rehabilitatin changes agreed The psitining f pulmnary rehabilitatin makes it lk like it is the last treatment that needs t be cnsidered. It wuld be better t mve pulmnary rehab bx t tp f 2 nd clumn befre inhaled therapy. Replace MRC scre 3 with MRC dyspnea scre 3 TREATMENT TABLE MRC Dyspnea scale changes agreed Bth the MRC Dyspnea scale and the mdified MRC dyspnea scale are being used within the guideline which is likely t cause cnfusin. The descriptins are the same but the nly difference is that the mmrc starts at 0 and ges t 4 whereas the riginal MRC starts at 1 and ges t 5. I think that the GP templates will have MRC s suggest that it is changed t: MRC 1 2 (mmrc 0 1) MRC 3 (mmrc 2) Spirmetric classificatin nt agreed - descriptr already specified in table Add descriptrs under numbers s this relates t QOF cding 1 (mild) 2 (mderate) 3 (severe) 4 (very severe) Classificatin & assessment changes agreed Need t add MRC dyspnea scre as well as mmrc NICE classificatin is used fr cding s suggest add ref t NICE against mild, mderate, severe & very severe. Oral Therapy t add when agreed by HVCCG pharmacy team Des the type f preparatin need t be added fr Carbcisteine s it is clear that capsules are 1 st line and then sachet 2 nd line and liquid nly used fr PEG feeds. Maybe this can be added t the list f medicatin chice At review & Fllw-up changes agreed Assess fr anxiety & depressin and act upn results (add this as separate line) Wuld suggest that example f c-mrbidities wuld be heart failure rather than anxiety Cnsider referral t respiratry specialist changes agreed Page 5 f 7

6 Think this is a bit difficult t fllw and als definitin f respiratry specialist needs t be defined as where there is a cmmunity respiratry service need t be clear this is where the referrals are sent. Hw it reads it culd be interpreted as acute referral which wuld be a backward step in West Herts. The evidence fr lng term nebulisers is weak and therefre wuld nt want t have this n the list f reasns fr respiratry specialist referral. Any significant haemptysis wuld be n 2 week pathway Cr-pulmnale is usually caused by hypxia and they wuld have clinical decline s nt sure needs t be mentined specifically Disrdered breathing wuld be picked up as symptms wuld be disprprtinate t lung functin s nt sure need t be mentined specifically My thughts n this bx is: Cnsider referral t respiratry specialist: Diagnstic uncertainty Frequent exacerbatins f COPD Clinical symptms disprprtinate t lung functin tests Rapid clinical r FEV 1 decline Prblematic withdrawal f sterids symptm nset at age <40 years, r a family histry f alpha1-antitrypsin deficiency Cmplex COPD patients requiring specialist MDT review Pulmnary rehabilitatin Lng term xygen therapy (fr hypxia, if SpO2 92% breathing air during clinical stability. Haemptysis (fllw 2 week pathway) NB. HVCCG respiratry specialist referrals t be sent t the Cmmunity Respiratry Service (Fax: ) Inhaled Therapy and Preferred Inhaler Chices still widespread primary care prescribing s t remain SAMA Ipratrpium 20micrgrams is nt really used as it is qds and als if a LAMA is added wuld need t be stpped and SABA added. D we want t keep it in the lcal guidelines as it is s rarely used fr stable disease but yu may have different prescribing data t supprt it remaining in guidelines. LAMA/LABA chice As there is nt a difference in cst I think that factrs that increase cncrdance with treatment is imprtant which includes nce daily and ease f use. Althugh there is little differential evidence t date there is mre evidence t supprt Ultibr. The shelf life nce pen is similar apart frm Spilt which is significantly lnger. Cst Once daily Ease f use Evidence (Duaklir Genuair ) (Ultibr Breezhaler ) (Spilt Respimat ) (Anr Ellipta ) Chice based n abve wuld be: 1 st Anr Ellipta All in ne inhaler and nce daily s easiest t use 2 nd Ultibr Breezhaler Once daily and mre published evidence but inhaler requires a degree f dexterity 3 rd Duaklir Genuair All in ne inhaler but twice daily 4 th Spilt Respimat Once daily but device difficult t use and n guarantee that the pharmacist pre-lads cartridge and als requires mre strength t prime and als t many things t d if nt used. Depending n which LAMA/LABA cmbinatin is chsen as 1 st / 2 nd line then need t cnsider if the LAMA chice is in line with this. It wuld appear that Glycpyrrnium (Seebri Breezhaler) is cheaper than Titrpium handihaler s if Ultibr is either 1 st r 2 nd chice it wuld appear sensible t mve Glycpyrrnium t be at least equal t titrpium handihaler. Gillian Austin Respiratry/Pulmnary Rehabilitatin Clinical Specialist Physitherapist HCT My nly cmment relates t the PR sectin (nt a surprise). Offer t patients with recent hspitalisatin/hspital at hme treatment fr acute exacerbatin if well enugh t benefit I wuld recmmend nt including the phrase if well enugh t benefit If yu ffer PR t thse pts they will pt ut if nt well enugh. That is usually enugh f a screening tl. If pts can get t us, then usually that means they are well enugh t benefit and if referred we will cntact them and then keep them n ur bks until they are ready t attend. change agreed Dr Saha, GP prescribing lead, Stevenage, ENHCCG I d believe the cmbinatin f LABA/LAMA will have its place in the COPD pathway where ICS are nt Page 6 f 7

7 tlerated r indicated. The ptins f nce daily may attract better cmpliance. Im nt sure hw much f an issue it will be that nne f them can be used with a spacer. There des nt seem t be any cst difference r clinical differences f effect between the 4. In COPD, a clinical utcme f imprved breathlessness wuld be a strng enugh reasn t try a new device even if there was n evidence f imprvement in the number f exacerbatins in my pinin. We need t think carefully abut the nes we will prmte as it will have a knck n effect n the use f ther inhalers in that range and their use in asthma. Fr instance the Ellipta range has Relvar and Incruse at a lwer cst t the preferred equivalents Dr Sissu, GP prescribing lead, Dacrum, HVCCG I've gt t admit I fail t see any real clinical advantages f ne cmbi ver anther. Des anyne in the prescribing team feel differently? Dr Patel, GP prescribing lead, Three Rivers and Watfrd, HVCCG I wuld g fr Duaklir Genuair ver the thers. N issues with renal functin and having t calculate creatine clearances ptentially. There is a dse metre unlike sme which is useful fr patients. It requires the least inspiratry effrt than the ther (apart frm the MDI) LABA = Lng acting beta 2 agnist LAMA = Lng acting muscarinic antagnist LABA/ICS = cmbined lng acting beta 2 agnist & inhaled crticsterid inhaler LAMA/LABA = cmbined lng acting muscarinic antagnist & lng acting beta 2 agnist inhaler Triple therapy = Lng acting muscarinic antagnist inhaler + cmbined lng acting beta2 agnist & inhaled crticsterid inhaler MDI = pressurised Metered Dse Inhaler DPI = Dry Pwder Inhaler Prduced by Clin Sach, Lead Pharmaceutical Adviser, Pharmacy and Medicines Optimisatin Team, ENHCCG and Sapana Sheth, Pharmaceutical Adviser HVCCG Aug 2016 Page 7 f 7