CHARM ASTHMA TREATMENT GUIDELINE

NHS City and Hackney Prescribing Guidelines Adults ( 12 years of age) CHARM ASTHMA TREATMENT GUIDELINE Written by: Hetal Dhruve (Specialist Respiratory Pharmacist, City and Hackney CCG) Checked by: Prof Raj Rajakulasingam (Respiratory Consultant, Homerton University Hospital Foundation Trust) Debbie Roots, Cardiorespiratory Nurse Consultant, HUHFT Dr Meena Krishnamurthy, GP Respiratory Lead, City and Hackney Approved by: JPG City and Hackney and Homerton Hospital Date of approval: 13/02/2017 Date of Review: 13/02/18 Version: 3.5

Diagnosis Diagnostic Algorithm For patients with suspected Asthma, consider trial of low dose ICS and assess response BTS Asthma Guidelines 2016

Treatment algorithm for patients with confirmed diagnosis of Asthma All prescribing options to allow prescribing of most appropriate device. Also see inhaler standards and competency document to aid assessment of inhaler technique. Consider stepping up therapy if on review patient is using a reliever more than 3 times a week, has nocturnal symptoms and/or exacerbates frequently. Assess adherence to maintenance inhaler(s) and inhaler technique before stepping up. Reductions in ICS dose should be considered every 3 months in stable mild to moderate patients, reducing the dose by 25% - 50% each time. It is best practice to produce a written asthma action plan with each change of medication. Asthma suspected Consider monitored initiation of treatment with low-dose ICS pmdi: 1 st Clenil 100 2p DPI: 1 st Flixotide 100 1p Pulmicort 100 2p Easybreathe QVAR 50 2p Treat co-morbidities such as allergic rhinitis (see allergic rhinitis guidelines) and acid reflux, which may exacerbate symptoms Regular preventer Low dose ICS pmdi: 1 st Clenil 100 2p DPI: 1 st Flixotide 100 1p Pulmicort 100 2p Easybreathe QVAR 50 2p Improvement in symptoms Initial add-on therapy Add inhaled LABA to low dose ICS pmdi: 1 st Fostair 100/6 1p Seretide 50/25 2p DPI: 1 st Fostair 100/6 1p Symbicort 100/6 2p Symbicort 200/6 1p Spiromax Duoresp 160/4.5 1p Additional add-on therapies No response to LABA- stop LABA, consider increased dose of ICS (see table for doses) If benefit from LABA but not adequate, continue LABA and increase ICS (as below). If benefit from LAMA but control inadequate, consider LTRA, LAMA or SR Theophylline. pmdi: 1 st Fostair 100/6 2p Sirdupla 125/25 2p DPI: 1 st Fostair 100/6 2p Ellipta Relvar 92/22 T OD Symbicort 200/6 2p Spiromax Duoresp 160/4.5 2p LAMA: Spiriva Respimat 2.5 2p OD High dose therapies Consider trial of increasing ICS to high dose. Addition of fourth drug eg LTRA, LAMA or SR theophylline pmdi: 1 st Fostair 200/6 2p Sirdupla 250/25 2p DPI: 1 st Fostair 200/6 2p Ellipta Relvar 184/22 T OD Symbicort 400/12 2p Spiromax Duoresp 320/9 2p Refer to specialist care Continuous or frequent oral steroid use Use daily steroid at lowest dose providing control. Maintain high dose ICS Consider other treatment options Monitor bone density and blood sugar levels at least annually. Refer to specialist care Short acting beta-agonist as required; consider moving up if the patient if adherent to preventer medication & requiring use of SABA more than 3 times per week pmdi: Ventolin 100 Evohaler 1-2p PRN/Salamol 100 MDI 1-2p PRN, DPI: Ventolin 200 1p PRN or Bricanyl 500 1p PRN

Maintenance And Reliever Therapy (MART) In selected patients, using MART with ICS and LABA has been shown to be an effective treatment regime, reducing the risk of as thma attacks requiring oral corticosteroids in patients not well controlled on ICS alone. This is treatment regime is only licensed in adults over the age of 18 for the following inhalers: Fostair 100/6 MDI only The recommended maintenance dose is 1 inhalation twice a day. Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. The maximum dose is 8 inhalations per day. Patients requiring frequent use of rescue inhalations daily should be strongly advised to seek medical advice. Their asthma s hould be reassessed and their maintenance therapy should be reconsidered. Spiromax 160/4.5 or Symbicort 200/6 The recommended maintenance dose is 2 inhalations per day, with some patients requiring a maintenance dose of 2 inhalations twice a day. Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion. The maximum dose is 12 inhalations per day. If patients are requiring more than 8 inhalations per day, they should be strongly advised to seek medical advice, with reassessment of t heir maintenance therapy.

Calculating Beclomethasone dipropionate (P) Equivalent These dosage equivalents are approximate and will depend on factors such as inhaler technique. Generic Brand Dose Daily P Low Dose Price/30 days License Beclomethasone Clenil MDI 100mcg 2p 400 4.45 Asthma-adults and children over 2 Beclomethasone QVAR autohaler 50mcg 2p 400 4.72 Asthma-adults and children over 12 Budesonide Pulmicort 100mcg 2p 400 7.10 Asthma-adults and children over 5 Fluticasone Flixotide Evohaler 50mcg 2p 400 5.44 Asthma-adults and children over 4 Fluticasone Flixotide 100mcg 1p 400 10.72 Asthma-adults and children over 4 Medium Dose Beclomethasone Clenil MDI 200mcg 2p 800 9.70 Asthma-adults and children over 12 Beclomethasone Clenil MDI 250mcg 2p 1000 9.77 Asthma-adults and children over 12 Beclomethasone QVAR autohaler 100mcg 2p 800 10.33 Asthma-adults and children over 12 Budesonide Pulmicort 200mcg 2p 800 14.21 Asthma-adults and children over 5 Fluticasone Flixotide Evohaler 250mcg 1p 1000** 18.07 Asthma-adults and children over 16 Fluticasone Flixotide Evohaler 125mcg 2p 1000 21.26 Asthma-adults and children over 16 Fluticasone Flixotide 100mcg 2p 800 21.44 Asthma-adults and children over 4 Fluticasone Flixotide 250mcg 1p 1000 25.51 Asthma-adults and children over 16 High Dose Fluticasone Flixotide Evohaler 250mcg 2p 2000 36.14 Asthma-adults and children over 16 Fluticasone Flixotide 500mcg 1p 2000 43.37 Asthma-adults and children over 16 Budesonide Pulmicort 400mcg 2p 1600 33.26 Asthma-adults and children over 12

Combination ICS (Inhaled Corticosteroid)/ LABA (Long Acting Beta Agonist) Inhalers Generic Brand Dose Daily P Low dose + LABA Price /30 days License Beclomethasone/formoterol Fostair MDI 100/6mcg 1p 500 14.66 Asthma-adults over 18 Beclomethasone/formoterol Fostair 100/6mcg 1p 500 14.66 Asthma-adults over 18 Fluticasone/salmeterol Seretide MDI 50/25mcg 2p 400 18.00 Asthma-adults and children over 5 Fluticasone/formoterol Flutiform MDI 50/5mcg 2p 400 14.40 Asthma-adults and children over 12 Fluticasone/salmeterol Budesonide/formoterol Seretide Symbicort 100/50mcg 1p 400 18.00 Asthma-adults and children over 5 100/6mcg 2p 400 33.00 Asthma-adults and children over 6 Medium dose + LABA Beclomethasone/formoterol Fostair MDI 100/6mcg 2p 1000 29.32 Asthma-adults over 18 COPD-adults over 18 Beclomethasone/formoterol Fostair 100/6mcg 2p 1000 29.32 Asthma-adults over 18 COPD-adults over 18 Fluticasone/formoterol Flutiform MDI 125/5mcg 2p 1000 28.00 Asthma-adults and children over 12 Fluticasone/salmeterol Sirdupla MDI 125/25mcg 2p 1000 26.25 Asthma-adults over 18 Fluticasone/salmeterol Seretide MDI 125/25mcg 2p 1000 35.00 Asthma-adults and children over 12 Fluticasone/salmeterol Seretide 250/50mcg 1p 1000 35.00 Asthma-adults and children over 12 Fluticasone/vilanterol Relvar Ellipta 92/22mcg 1p OD 1000 22.00 Asthma-adults over 18 COPD-adults over 18 Budesonide/formoterol Budesonide/formoterol Budesonide/formoterol Duoresp Spiromax Symbicort Symbicort 160/4.5mcg 2p 800 29.97 Asthma-adults over 18 COPD-adults over 18 200/6mcg 2p 800 38.00 Asthma-adults and children over 12 400/12mcg 1p 800 38.00 Asthma-adults and children over 12 High dose + LABA

Beclomethasone/formoterol Fostair MDI 200/6mcg 2p 2000 29.32 Asthma-adults over 18 Beclomethasone/formoterol Fostair 200/6mcg 2p 2000 29.32 Asthma-adults over 18 Fluticasone/formoterol Flutiform MDI 250/10mcg 2p 2000 45.56 Asthma-adults over 18 Fluticasone/salmeterol Sirdupla MDI 250/25mcg 2p 2000 44.61 Asthma-adults over 18 Fluticasone/salmeterol Seretide MDI 250/25mcg 2p 2000 59.48 Asthma-adults and children over 12 Fluticasone/salmeterol Seretide 500/50mcg 1p 2000 40.92 Asthma-adults and children over 12 Fluticasone/vilanterol Relvar Ellipta 184/22mcg 1p OD 2000 29.50 Asthma-adults over 18 Budesonide/formoterol Duoresp Spiromax 320/9mcg 2p 1600 59.94 Asthma-adults over 18 Budesonide/formoterol Symbicort 400/12mcg 2p 1600 76.00 Asthma-adults over 18 # First line option in green- all else in no particular order. Inhaler to be chosen based on device and inhaler technique. ** Most cost effective option for ingredient/device/dose Prices correct at time of update on 13/02/17. References: MIMS online and SPC.

Steroids All patients on high dose ICS (>1000P) should receive a steroid card. For patients receiving high dose ICS for a prolonged period and/or has frequently prescribed oral prednisolone, bone protection should be considered. Gradual withdrawal of Prednisolone - Should be considered for the following patients - Received more than 40mg of prednisolone daily for more than 1 week - Been given repeat doses in the evening, - Recently received repeated courses (particularly if taken for longer than 3 weeks), - Taken a short course within 1 year of stopping long-term therapy Self Management All patients should be given a self management plan detailing the following: - PEF 80-100% of annual best: As per usual prescription - PEF 60-80% of annual best: increase the dose of ICS to double, and if symptoms do not resolve/pef is not back to >75% of annual best within 48 hours, to consult GP/practice Nurse - PEF <60% of annual best take 40mg prednisolone daily for 5 days. **Continue use of salbutamol 1-2 puffs via spacer. Maximum dose of 10 puffs every 2 hours** Antibiotics in asthma Most patients with asthma do NOT require antibiotics. Please see PHE antibiotic guidelines if infection is suspected.

Theophylline Theophylline is a xanthine used as a bronchodilator in asthma. Once initiated, patients should remain on the same brand as the rates of absorption from modified-release preparations can vary between the brands. Theophylline available brands: Nuelin SA tablets: 175-350mg every 12 hours. Nuelin SA 250 tablets: 250-500mg every 12 hours Slo-Phyllin capsules: 250-500mg every 12 hours Uniphyllin Continus tablets: 200mg 400mg every 12 hours according to response. May be appropriate to give larger evening or morning dose to optimise therapeutic effect when symptoms are most severe. In patients whose night or daytime symptoms persist despite adherence to other therapy, who are not currently receiving theophylline, total daily requirement may be added as single evening or morning dose. Aminophylline available brands: - Phyllocontin Continus tablets: 225mg T then increase to 450mg if necessary, according to plasma concentration levels. - Phyllocontin Forte tablets: 350mg then increase to TT D if necessary (this brand should be prescribed to smokers and other patients with shorter theophylline half life). Therapeutic levels: Target range 10-20mg/L. Levels should be taken 5 days after starting oral treatment and at least 3 days after any dose adjustment. A sample should be taken 4-6 hours after an oral dose. Thereafter, levels should be taken every 6-12 months if the patient remains stable. More frequent monitoring may be required if the result was out of range, there is a newly initiated medication that interacts with theophylline or if you are querying adherence. Common interactions with Theophylline which may warrant more frequent monitoring: - levels are reduced in smoker and with high alcohol consumption - increased levels in patients with heart failure, hepatic impairment, viral infections and in the elderly For a full list of drug interactions see BNF or Stockleys Drug Interactions Pharmaceutical Press.

Guidance to support the stepwise review of asthma patients There are a large number of patients receiving high dose inhaled corticosteroids but are not adhering to the prescribed treatment and/or have poor inhaler technique. For every patient reviewed, levels of adherence must be confirmed using the GP records. In general, patients collecting 10 out of 12(>80%) inhalers per annum (based on a 30 day refill), are considered to be adherent. Patients collecting less than this amount, may not be adherent and the usage of their medication should be questioned. Using this information, work out the approximate daily P in relation to their QoL (using the ACT), and use this as a guide to prescribe the appropriate daily dose. Check inhaler technique and trigger factors to aid decision-making. For patients who are fully adherent, complete asthma control need to be achieved for at least 12 weeks before attempting to step patient s down 1. If asthma is controlled with a combination ICS/LABA, the preferred approach is to reduce the ICS by approximately 25-50% whilst continuing the LABA at the same dose. If control is maintained after stepping down, further reductions in the ICS should be attempted until a low dose is reached, when the LABA may be stopped 2. ** Adapted from Barking and Dagenham, Havering and Redbridge CCG. 1 British Thoracic Society. Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised 2 Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2012 update.