HVCCG Adult Asthma Switch and Step Down Algorithms - Approved by Hertfordshire Medicines Management Committee June 2016 Page 1 of 6 Adult Summary flowchart for Asthma Switch and Step Down to preferred inhaler choices MDI: Metered dose inhaler DPI: Dry powder inhaler ICS: Inhaled corticosteroid LABA: Long acting β 2 -agonist Patient is currently being prescribed a combination ICS/LABA inhaler that is not a HVCCG preferred choice Assess if the patient is suitable to be considered for stepping DOWN treatment (see page 2) or if the patient can be switched to a corresponding strength of a HVCCG preferred inhaler choice Seretide Evohaler MDI [125/25 or 250/25 strengths] Symbicort Turbohaler DPI (budesonide /formoterol) [400/12 and 200/6 strengths] Sirdupla MDI (over 18 years old ONLY) [125/25 and 250/25 strengths] Branded generic that contains the same ICS and LABA ingredients and is therapeutically equivalent to corresponding strengths of Seretide Evohaler algorithm on page 3 Flutiform MDI (fluticasone/formoterol) [50/5, 125/5 and 250/10 strengths] Contains the same ICS dose to corresponding strengths of Seretide Evohaler but contains a different LABA ingredient (formoterol) algorithm on page 4 Fostair MDI (beclometasone /formoterol) [100/6 strength] Contains a different ICS (beclometasone) and LABA ingredient (formoterol) to Seretide Evohaler algorithm on page 5 DuoResp Spiromax DPI (budesonide /formoterol) [160/4.5 and 320/9 strengths] Branded generic that contains the same ICS and LABA ingredients and is therapeutically equivalent to corresponding strengths of Symbicort Turbohaler DPI algorithm on page 6 DuoResp Spiromax 320/9 provides a delivered dose of budesonide 320mg and formoterol 9mcg. This is therapeutically equivalent to Symbicort Turbohaler 400/12 metered dose of budesonide 400mcg and formoterol 12mcg which also provides a delivered dose of budesonide 320mg and formoterol 9mcg. DuoResp Spiromax 160/4.5 provides a delivered dose of budesonide 160mg and formoterol 4.5mcg. This is therapeutically equivalent to Symbicort Turbohaler 200/6 metered dose of budesonide 200mcg and formoterol 6mcg which also provides a delivered dose of budesonide 160mg and formoterol 4.5mcg.
HVCCG Adult Asthma Switch and Step Down Algorithms - Approved by Hertfordshire Medicines Management Committee June 2016 Page 2 of 6 How to step adult patients down algorithm Does the patient have an up to date asthma action plan? Has inhaler use (patient reported and Px history), inhaler technique, smoking status, adherence, trigger factors, medication side-effects and use of rescue medication been checked? Check expected use of inhaler against patient reported use. Has asthma been completely controlled for at least 3 months? LEVELS OF ASTHMA CONTROL - Assessment of current clinical control (preferably) over 4 weeks Characteristic Completely Controlled Partly Controlled Uncontrolled Daytime symptoms None (twice or less/week) >Twice/week Three or more RCP 3 Limitation on activities None Any features of Questions Nocturnal symptoms/awakening None Any partly Need for reliever/rescue treatment None (twice or less/week) >Twice/week controlled Lung Function (PEF or FEV 1 ) Normal <80% predicted or personal best (if known) asthma YES Does the patient have any exclusion criteria? Patient does not agree to step down Excacerbation, oral steroid course, GP/hospital visit due to worsening asthma in past 6 months Under respiratory specialist review or pregnant (only step down if agreed with specialist) Significant adverse outcomes from previous step down attempts. Consider 25% dose reduction if previously unable to step down by 50% Seasonal exacerbations. Reschedule step down review after season has ended Lifestyle considerations where stability crucial e.g. impending exam Maintenance and Reliever Therapy (MART) regime NO YES STEP the patient DOWN refer to HVCCG Adult Asthma Guidelines and Step DOWN/Switch Algorithms: - 1. Consider reducing add on therapies before reducing ICS 2. Identify the combination inhaler and dose the patient is currently being prescribed. Identify which step (3-5) this product and dose represents 3. Refer to the relevant Step DOWN/Switch algorithm for the ICS product 4. Consider using the HVCCG approved lower cost product when stepping down and where appropriate, switch to this product. Prescribe the dose that is suitable to the relevant step. Ensure the patient is trained and can demonstrate they can use any potential new device. 5. Reduce dose by 25% - 50%. The dose decrease is an individual clinical decision based on history of stability with respect to day to day symptoms, frequency of exacerbations and previous step down attempts. Consideration should be given to the current ICS dose and the inhaler product and strength that the patient is using. Keep the LABA dose the same when ICS dose when possible 6. Dose reductions of less than 50% may be complicated and may involve using combinations of separate inhalers. Further advice should be sought from the West Herts Community Respiratory Service Note: for patients at step 4 and 5: if also taking add-on therapies (e.g.montelukast, oral steroids), consider reducing/stopping these before attempting to reduce ICS dose. Seek further advice from specialist services. Check & reinforce inhaler technique + /- spacer Advise patient of importance of adherence Ensure patient has current asthma action plan Ensure patient understands if symptoms worsen when to increase dose and seek medical advice Agree a review date for 3 months time Patient review at 3 months Has the patient achieved complete asthma control in the last 3 months? (see Table 1) YES STEP the patient DOWN and repeat cycle If unclear, advise patient to complete peak flow diary and then re-assess NO NO DO NOT step patient down Consider reason for poor control or exclusion criteria. Action as appropriate. Consider STEP UP therapy for uncontrolled symptoms Considerations for Clinician Patients achieve complete asthma control at different rates. Discuss with the patient to decide whether to trial the current therapy for longer or to step upagain. Suggested discussion points with patient: 1. Any factor affecting adherence e.g. polypharmacy, social reasons or beliefs? 2. Any issues affecting ability to use inhaler e.g. dexterity? 3. Trigger factors e.g. smoking, pets, pollen, stress? 4. How long did it take the patient to achieve complete control last time? 5. What would be the potential consequences of an exacerbation and does the patient know what to do if this occurs? 6. What would the patient prefer to do? 7. Ensure patient has up to date selfmanagement/action plan. ACTION Clinicians should use their professional judgement to decide whether to continue trialling current therapy or to step up again. If continuing on current therapy, advise patient to monitor symptoms and reliever use and review again in one month. Advise patient to follow self-management plan if symptoms become problematic within this time. Refer to specialist service as necessary
HVCCG Adult Asthma Switch and Step Down Algorithms - Approved by Hertfordshire Medicines Management Committee June 2016 Page 3 of 6 Asthma Step DOWN/Switch Algorithm for Seretide Evohaler and Sirdupla in Adults (>18yrs) (devised from BTS/SIGN guidance and the relevant Summary of Product Characteristics) Sirdupla MDI is a therapeutically equivalent alternative to Seretide Evohaler. It is a HVCCG approved lower cost ICS/LABA fixed dose combination MDI for asthma. It is lower cost for patients on Seretide Evohaler to be switched to the equivalent corresponding strength Sirdupla MDI or, when stepping down treatment in suitable stable patients, for the lower strength Sirdupla MDI to be used. PRESCRIBE BY BRAND NAME - Addition of 4 th drug (e.g. montekukast, SR theophylline) } Consider reducing these - Addition of 5 th drug oral prednisolone [Step 5] } before reducing the ICS [400mcg BDP* equivalent/day] Seretide 250 Evohaler [MDI] 2 puffs bd ( 59.48) (2000mcg BDP* equiv/day Sirdupla 250 [MDI] 2 puffs bd ( 44.61) (2000mcg BDP* equiv./day Seretide 125 Evohaler [MDI] 2 puffs bd ( 35.00) (1000mcg BDP* equiv/day Sirdupla 125 [MDI] 2 puffs bd ( 26.25) (1000mcg BDP* equiv./day Seretide 50 Evohaler [MDI] 2 puffs bd ( 18.00) (400mcg BDP* equiv/day Flutiform 50 [MDI] (fluticasone/formoterol) 2 puffs bd ( 14.40) (400mcg BDP* equiv./day + 20mcg formoterol/day) Clenil Modulite [MDI] 100mcg (beclometasone) 2 puffs bd ( 4.45) Qvar [MDI] 50mcg (fine particle beclometasone) 2 puffs bd ( 4.72) [NB Qvar twice as potent as Clenil ) Flixotide 50 Evohaler [MDI] (fluticasone) 2 puffs bd ( 5.44) (if the patient cannot tolerate a change in ICS from fluticasone) Step down to lower strength Sirdupla /Flutiform MDI Switch to equivalent strength Sirdupla / Flutiform MDI Step down to lower strength Seretide Evohaler (only if not possible to use Sirdupla eg cannot have alcohol or Flutiform eg intolerant to formoterol ) If the patient is at, further advice and guidance can be sought from the West Herts Community Respiratory Service on how to manage the step down process, particularly if a more gradual ICS dose reduction (<50%) is required than the combination devices in the above algorithm allows. This may involve using two agents in separate inhaler devices. There is not an equivalent strength Sirdupla inhaler for Seretide 50 Evohaler. Consider using Flutiform 50 MDI which contains the equivalent fluticasone dose as Seretide 50 Evohaler but a different LABA (formoterol) *Total daily dose inhaled corticosteroid (ICS), in terms of beclometasone dipropionate (BDP) equivalent All patients with asthma should have an up to date asthma action plan and be provided with a short-acting beta 2 agonist (salbutamol MDI or Easyhaler ) to aid in the event of an exacerbation.
HVCCG Adult Asthma Switch and Step Down Algorithms - Approved by Hertfordshire Medicines Management Committee June 2016 Page 4 of 6 Asthma Step DOWN/Switch Algorithm for Seretide Evohaler and Flutiform in Adults (>18yrs) (devised from BTS/SIGN guidance and the relevant Summary of Product Characteristics) Flutiform (fluticasone propionate/formoterol) is a HVCCG approved lower cost ICS/LABA fixed dose combination MDI for asthma. It contains the equivalent dose of fluticasone to Seretide Evohaler but contains a different LABA (formoterol). It is lower cost for patients on Seretide Evohaler to be switched to the equivalent strength Flutiform MDI or, when stepping down treatment in suitable stable patients, for the lower strength Flutiform MDI to be used. PRESCRIBE BY BRAND NAME - Addition of 4 th drug (e.g. montekukast, SR theophylline) } - Addition of 5 th drug oral prednisolone [Step 5] } [400mcg BDP* equivalent/day] Seretide 250 Evohaler [MDI] 2 puffs bd ( 59.48) (2000mcg BDP* equiv/day Flutiform 250/10 [MDI] 2 puffs bd ( 45.56) (2000mcg BDP* equiv./day + 40mcg formoterol/day) Seretide 125 Evohaler [MDI] 2 puffs bd ( 35.00) (1000mcg BDP* equiv/day Flutiform 125/5 [MDI] 2 puffs bd ( 28.00) (1000mcg BDP* equiv./day + 20mcg formoterol/day) Step down to lower strength Flutiform MDI Seretide 50 Evohaler [MDI] 2 puffs bd ( 18.00) (400mcg BDP* equiv/day Flutiform 50/5 [MDI] 2 puffs bd ( 14.40) (400mcg BDP* equiv./day + 20mcg formoterol/day) Switch to equivalent strength Flutiform MDI Clenil Modulite [MDI] 100mcg (beclometasone) 2 puffs bd ( 4.45) Qvar [MDI] 50mcg (fine particle beclometasone) 2 puffs bd ( 4.72) [NB Qvar twice as potent as Clenil ) Flixotide 50 Evohaler [MDI] (fluticasone) 2 puffs bd ( 5.44) (if the patient cannot tolerate a change in ICS from fluticasone) Step down to lower strength Seretide Evohaler (only when not possible to use Flutiform eg cannot use the device or if intolerant to formoterol) If the patient is at, further advice and guidance can be sought from the West Herts Community Respiratory Service on how to manage the step down process, particularly if a more gradual ICS dose reduction (<50%) is required than the combination devices in the above algorithm allows. This may involve using two agents in separate inhaler devices. * Total daily dose inhaled corticosteroid (ICS), in terms of beclometasone dipropionate (BDP) equivalent If patient is taking add-on therapiese.g. montelukast, oral prednisolone), consider reducing these before reducing the ICS. All patients with asthma should have an up to date asthma action plan and be provided with a short-acting beta 2 agonist (salbutamol MDI or Easyhaler ) to aid in the event of an exacerbation.
HVCCG Adult Asthma Switch and Step Down Algorithms - Approved by Hertfordshire Medicines Management Committee June 2016 Page 5 of 6 Asthma Step DOWN/Switch Algorithm for Seretide Evohaler and Fostair in Adults (>18yrs) (devised from BTS/SIGN guidance and the relevant Summary of Product Characteristics) Fostair (beclometasone/formoterol) is a HVCCG approved lower cost ICS/LABA fixed dose combination MDI for asthma and COPD. It is lower cost for patients on Seretide Evohaler to be switched to the equivalent BDP strength Fostair MDI. For stable patients suitable to be stepped down, it is also recommended to change from Seretide Evohaler to the appropriate lower BDP strength Fostair MDI when stepping. PRESCRIBE BY BRAND NAME - Addition of 4 th drug (e.g. montekukast, SR theophylline) - Addition of 5 th drug oral prednisolone [Step 5] [400-500mcg BDP* equivalent/day] Seretide 250 Evohaler 2 puffs bd ( 59.48) (2000mcg BDP* equiv/day Step down to lower BDP strength Fostair MDI Seretide 125 Evohaler 2 puffs bd ( 35.00) (1000mcg BDP* equiv/day Fostair 100/6 MDI (beclometasone/formeterol) [1 puff = 250mcg BDP equiv. + 6 mcg formoterol] 2 puffs bd ( 29.32) (1000mcg BDP* equiv./day + 24mcg formoterol/day) Seretide 50 Evohaler 2 puffs bd ( 18.00) (400mcg BDP* equiv/day Fostair 100/6 MDI (beclometasone/formeterol) [1 puff = 250mcg BDP equiv. + 6 mcg formoterol] 1 puff bd ( 14.66) (500mcg BDP* equiv./day + 12mcg formoterol/day) Switch to equivalent BDP strength Fostair MDI Clenil Modulite [MDI] 100mcg (beclometasone) 2 puffs bd ( 4.45) Qvar [MDI] 50mcg (fine particle beclometasone) 2 puffs bd ( 4.72) [NB Qvar twice as potent as Clenil ) Flixotide 50 Evohaler [MDI] (fluticasone) 2 puffs bd ( 5.44) (if the patient cannot tolerate a change in ICS from fluticasone) Step down to lower strength Seretide Evohaler (only when not possible to use Fostair eg cannot use the device or if intolerant to beclometasone/formoterol) If the patient is at, further advice and guidance can be sought from the West Herts Community Respiratory Service on how to manage the step down process, particularly if a more gradual ICS dose reduction (<50%) is required than the combination devices in the above algorithm allows. This may involve using two agents in separate inhaler devices. * Total daily dose inhaled corticosteroid (ICS), in terms of beclometasone dipropionate (BDP) equivalent If patient is taking add-on therapies (e.g. montelukast, oral prednisolone), consider reducing these before reducing the ICS. All patients with asthma should be provided with a shortacting beta 2 agonist (salbutamol MDI or Easyhaler ) to aid in the event of an exacerbation.
HVCCG Adult Asthma Switch and Step Down Algorithms - Approved by Hertfordshire Medicines Management Committee June 2016 Page 6 of 6 Asthma Step Down/Switch Algorithm for Symbicort quivalent/day Turbohaler in Adults (>18yrs) (devised from BTS guidance and the relevant Summary of Product Characteristics) DuoResp Spiromax is a HVCCG approved lower cost ICS/LABA fixed dose combination dry powder inhaler (DPI) for asthma. It is therapeutically equivalent to corresponding strengths of Symbicort Turbohaler. It is lower cost for patients on Symbicort Turbohaler to be switched to the equivalent strength DuoResp Spiromax DPI or, when stepping down treatment in suitable stable patients, for the lower strength DuoResp Spiromax DPI to be used. PRESCRIBE BY BRAND NAME - Addition of 4 th drug (e.g. montekukast, SR theophylline) - Addition of 5 th drug oral prednisolone [Step 5] [400mcg BDP* equivalent/day] Symbicort Turbohaler 400/12 [1 puff = 400mcg BDP equiv.] 2 puffs bd ( 76.00) (1600mcg BDP* equiv./day + 48mcg formoterol/day) DuoResp Spiromax 320/9 [1 puff = 400mcg BDP equiv. + 12 mcg formoterol] 2 puffs bd ( 59.94) Symbicort Turbohaler 400/12 [1 puff = 400mcg BDP equiv.] 1 puff bd ( 38.00) Symbicort Turbohaler 200/6 [1 puff = 200mcg BDP* equiv.] 2 puffs bd ( 38.00) (800mcg BDP* equiv./day + 24mcg formoterol/day) DuoResp Spiromax 320/9 [1 puff = 400mcg BDP equiv. + 12 mcg formoterol] 1 puff bd ( 29.97) DuoResp Spiromax 160/4.5 [1 puff = 200mcg BDP* equiv./6mcg formoterol] 2 puffs bd ( 29.97) (1600mcg BDP* equiv./day + 48mcg formoterol/day) (800mcg BDP* equiv/day + 24mcg formoterol/day) Prescribe by BRAND name Costs: 30 day costs (without a spacer) * Total daily dose inhaled corticosteroid (ICS), in terms of beclometasone dipropionate (BDP) equivalent Symbicort Turbohaler 100/6 2 puffs bd ( 33.00) (400mcg BDP* equiv/day + 24mcg formoterol/day) Symbicort Turbohaler 200/6 [1 puff = 200mcg BDP equiv.] 1 puff bd ( 19.00) (400mcg BDP* equiv./day + 12mcg formoterol/day) DuoResp Spiromax 160/4.5 [1 puff = 200mcg BDP equiv. + 6mcg formoterol] If patient is taking add-on therapies (e.g. montelukast, oral prednisolone), consider reducing these before reducing the ICS. 1 puff bd ( 14.99) (400mcg BDP* equiv./day + 12mcg formoterol/day) Easyhaler Beclometasone 200mcg [DPI] 1 puff bd ( 4.48) Qvar Easi-Breathe [B] 50mcg 2 puffs bd ( 4.64) Easyhaler Budesonide 200mcg [DPI] 1 puff bd ( 5.31) All patients with asthma should be provided with an up-date asthma action plan & a shortacting beta 2 agonist (salbutamol MDI or Easyhaler ) to aid in the event of an exacerbation. Step down to lower strength Symbicort Turbohaler Switch to equivalent strength DuoResp Spiromax Step down to lower strength DuoResp Spiromax If the patient is at, further advice and guidance can be sought from the West Herts Community Respiratory Service on how to manage the step down process, particularly if a more gradual ICS dose reduction (<50%) is required than the combination devices in the above algorithm allows. This may involve using two agents in separate inhaler devices.