North Hampshire CCG Asthma Prescribing Guidelines June 2015 ASTHMA PRESCRIBING GUIDELINES FOR ADULTS AND CHILDREN OVER 12 These guidelines are based on the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network recommendations for Adults and Children over 12 years. An adaptable flow chart/quick reference guide is available at the end of this document for CCGs to insert local formulary choices. The primary objective of treatment is to achieve complete control of asthma, which is defined as: No daytime symptoms. No night-time awakening due to asthma. No need for rescue medicine. No asthma attacks. No limitations on activity including exercise. Normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best). Minimal side-effects. The Royal College of Physicians (RCP) '3 Questions' are widely used to measure clinical outcomes in asthma. Their use as part of a review for patients on the asthma register in the last 12 months is included in the Quality and Outcomes Framework (QOF) indicators in England. The questions ask: In the last month/week: 1. Have you had difficulty sleeping due to your asthma (including cough symptoms)? 2. Have you had your usual asthma symptoms (e.g. cough, wheeze, chest tightness, shortness of breath) during the day? 3. Has your asthma interfered with your usual daily activities (e.g. school, work, housework)? Note: One 'yes' indicates medium morbidity and two or three 'yes' answers indicate high morbidity. Key principles Start treatment at the step most appropriate to the initial severity of the patient s asthma. Advise the patient to monitor symptoms and return to the clinic if there is no improvement. Prescribe inhalers only after the patient has been trained in and is able to demonstrate adequate inhaler technique. Check concordance, adherence and reconsider diagnosis if response to treatment is unexpectedly poor. Aim of treatment is to achieve early control and maintain it at the lowest dose required, consider stepping up or down accordingly. Increased reliever usage is a sign of poor control. Step-up if ordering more than 2 short-acting beta agonist inhalers (SABA) per year (4 maximum if patient requires spare inhalers). Remember: airway hyperactivity can take up to 18 months to resolve. Asthma Prescribing Guidelines June 2015
North Hampshire CCG Asthma Prescribing Guidelines June 2015 Provide patients, parents or carers with a self-management plan that includes a personalised patient action plan supported by a regular professional review at least annually. Risk factors Rhinitis is a risk factor for the development and increasing severity of asthma. Consider asthma in all patients with rhinitis. Treat both conditions together; Patients who have been recently hospitalised should be closely monitored; Patients who do not attend for review; Patients who have no personalised asthma action plan. Action plans available via http://www.asthma.org.uk/sites/healthcare-professionals/pages/selfmanagement-materials; Use of more than 12 short acting bronchodilators over a 12 month period should be urgently assessed and measures taken to improve asthma control; Use of less than 12 inhaled corticosteroid containing inhalers over a 12 month period; The use of a long acting beta agonist (LABA) without an inhaled corticosteroid (ICS). Stepping up Think T T T Before initiating new treatment or stepping up, check: Adherence with Therapy Inhaler Technique Elimination of Trigger factors Stepping down Regularly review the need for treatment. Treatment should be at the minimum level required. Stepping down should be considered when control is stable for at least 3 months to prevent over treating. Stepping down inhaled steroids should be slow, 25 50% dose reduction every 3 months. After stepping down, review in 3 months and step patient up again if symptomatic. Advise patient to return to clinic before 3 months if symptoms return after stepping down. Advice on the management of chronic asthma is based on the recommendations of the British Thoracic Society and Scottish Intercollegiate Guidelines Network (updated October 2014). Updates available at www.brit-thoracic.org.uk High dose inhaled steroid in step 4 is defined as 800 2000mcg/day BDP or equivalent. NICE TA 138 http://guidance.nice.org.uk/ta138 Asthma Prescribing Guidelines June 2015
North Hampshire CCG Asthma Prescribing Guidelines June 2015 Prescribers need to consider the BDP equivalence of each inhaler before switching devices. Equivalence to beclometasone dipropionate (BDP) 400mcg Clenil 200mcg Qvar 200mcg Fostair 400mcg budesonide 200mcg fluticasone propionate (FP) 200mcg mometasone 200-300mcg ciclesonide 400mcg BDP 400mcg BDP 500mcg BDP 400 mcg BDP 400 mcg BDP 400 mcg BDP 400 mcg BDP BTS/SIGN did not review the evidence for Relvar Ellipta (fluticasone furoate & vilanterol) in the 2014 update of their asthma guidelines and this product is difficult to fit into the asthma treatment pathway due to the conflicting statements on the SPC and the lack of a comparable BDP equivalent dose. Because fluticasone furoate is a new ICS, more information about its effect on cortisol suppression relative to other inhaled corticosteroids is needed. The product comparisons for Relvar Ellipta are: Relvar Ellipta 92/22 inhaler 1 puff od (500 mcg fluticasone propionate) Relvar Ellipta 184/22 inhaler 1 puff od (1000mcg fluticasone propionate) Key to pricing on table below 0.00-4.99 5.00-9.99 10.00-19.99 20.00-29.99 30.00-39.99 40.00 + Costs are for 28 days treatment at the specified dose and exclude spacers. When required (PRN) doses are costed per device. * BDP equivalent [equiva lences] expressed in brackets Key to spacer devices Cost per annum Drug Tariff online September 2015. Based on 2 devices per annum. a - Volumatic ( 7.62) or AeroChamber Plus ( 8.02) b - AeroChamber Plus ( 8.02) c - Volumatic ( 7.62) Other spacer device to consider: A2A Spacer standard device plus mask (S or M) ( 6.68) Able Spacer ( 7.16) Optichamber Diamond ( 8.98) Pocket Chamber ( 7.49) Space Chamber Plus with mask ( 6.98) As the use of a spacer device with an MDI may increase drug delivery to the lungs, it should be noted that this could potentially lead to an increase in the risk of systemic effects. Consider step down treatment where appropriate. Asthma Prescribing Guidelines June 2015
North Hampshire CCG Medicines Management Adults and children over 12 years: Asthma quick reference guide Key points Ensure patient has a personal asthma action plan which includes warning signs of poor asthma control and what to do during an attack. Start treatment at the step most appropriate to initial severity of their asthma. Patients should receive training for each device prescribed, and be able to demonstrate satisfactory technique. Try to limit number of different devices a patient has. Check concordance and reconsider diagnosis if response to treatment is unexpectedly poor. Perform yearly asthma review. Consider a spacer device for patients prescribed a metered dose inhaler (MDI) who are: o o Having difficulty co-ordinating actuation and inhalation. Receiving high doses of inhaled corticosteroid (ICS) (>800 mcg of beclometasone or equivalent daily). Indicators associated with increased risk of death (from NRAD report) Recent hospitalisation Previous severe attacks Non-attenders for planned review LABA monotherapy without ICS Using more than 12 reliever inhalers per year Using less than 12 preventer inhalers per year.
Stepping UP? Think T T T Adherence with Therapy Technique Trigger factors 3 Respiratory System 3.1.1.1 Selective beta₂agonists short acting Long acting Maintenance and reliever therapy - Consider for patients on Step 3 with a personal asthma plan able to manage their own treatment. Caution can become expensive and needs closer monitoring of patient/prescriptions. Use Preferred List Devices Salbutamol aerosol inhaler 100mcg as Ventolin Evohaler or Salbutamol inhaler Salbutamol dry powder for inhalation 100mcg as Easyhaler Terbutaline dry powder inhaler 500mcg as Bricanyl Turbohaler Salmeterol aerosol inhaler 25mcg Salmeterol dry powder for inhalation 50mcg as Serevent Accuhaler Formoterol dry powder for inhalation 6mcg, 12mcg as Easyhaler Formoterol 3.1.2 Antimuscarinic bronchodilators Aclidinium bromide 375mg as Eklira Genuair Glycopyrronium inhalation powder, hard capsule 50mcg as Seebri Breezhaler (50mcg delivers 44mcg of glycopyrronium)
Tiotropium inhalation powder, hard capsule 18mcg for use with Handihaler device 3.1.3 Theophylline Nuelin SA 175mg Nuelin SA-250 175mg Slo-Phyllin 60mg, 125mg, 250mg Uniphyllin Continus M/R tablets 200mg, 300mg, 400mg 3.1.5 Drug delivery devices Aerochamber Plus spacer device, standard, child, infant Volumatic spacer device Volumatic spacer device with paediatric face mask 3.2 Corticosteroids Beclometasone Clenil Modulite aerosol inhalation 50mcg, 100mcg, 200mcg, 250mcg Qvar aerosol inhalation 50mcg, 100mcg, breath-actuated aerosol inhalation as Easi-breathe 50mcg, 100mcg Easyhaler Beclometasone dry powder for inhalation 200cmg Beclometasone/formoterol Fostair aerosol inhalation 100/6 Beclometasone/formoterol Fostair NEXThaler for Asthma only Budesonide/formoterol Symbicort turbohaler 100/6, 200/6 to remove if approved by DPC DUOResp Spiromax 160/4.5 DPI, 320/9 DPI
Fluticasone/formoterol Flutiform aerosol inhalation 50/5, 125/5 Fluticasone/salmeterol Seretide dry pwder for inhalation Accuhaler 100/50, 250/50, 500/50 Fluticasone furoate/vilanterol Relvar Elipta dry powder inhaler 92mcg/22mcg 3.3 leukotriene receptor antagonist Montelukast tablets 10mg, chewable tablets 4mg, 5mg 3.4 Antihistamines Chlorphenamine tablets 4mg, oral soln. 2mg/5ml Cetirizine tablets 10mg, oral soln. 5mg/5ml Loratadine tablets 10mg, syrup 5mg/5ml Hydroxyzine tablets 10mg, 25mg, syrup 10mg/5ml 3.4.3 Anaphylaxis Adrenaline auto-injector device as EpiPen Jr Auto-injector 0.15mg, EpiPen Auto-injector 0.3mg, Jext 150mcg, 300mcg or Emerade 150mcg, 300mcg 3.7 Mucolytics Carbocisteine capsules 375mg as Mucodyne Stepping DOWN? - Reduce ICS dose slowly - Aim to use the lowest effective ICS dose - Consider a treatment review every 12 weeks