Doncaster & Bassetlaw Medicines Formulary

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1 Doncaster & Bassetlaw Medicines Formulary Section 3.2: Corticosteroids Beclometasone 50, 100 and 250micrograms/dose Clickhaler Clenil Modulite (Beclometasone CFC free) 50, 100, and 250micrograms/dose MDI Qvar (Beclometasone CFC free) 50 and 100micrograms/ dose MDI Qvar (Beclometasone CFC free) 50 and 100micrograms/ dose Autohaler Qvar (Beclometasone CFC free) 50 and 100micrograms/ dose Easi- Breathe Budesonide 100, 200 and 400micrograms/dose Turbohaler Budesonide 500micrograms and 1mg Nebules Fluticasone CFC Free 50, 125 and 250micrograms/dose MDI Fluticasone 100, 250 and 500micrograms/dose Accuhaler Compound Preparations Symbicort 100/6 Turbohaler (budesonide 100micrograms and formoterol 6micrograms) Symbicort 200/6 Turbohaler (budesonide 200micrograms and formoterol 6micrograms) Symbicort 400/12 Turbohaler (budesonide 400micrograms and formoterol 12micrograms) Seretide 100 Accuhaler (fluticasone 100micrograms and salmeterol 50micrograms) Seretide 250 Accuhaler (fluticasone 250micrograms and salmeterol 50micrograms) Seretide 500 Accuhaler (fluticasone 500micrograms and salmeterol 50micrograms) Seretide 50 Evohaler (fluticasone 50micrograms and salmeterol 25micrograms) Seretide 125 Evohaler (fluticasone 125micrograms and salmeterol 25micrograms) Seretide 250 Evohaler (fluticasone 250micrograms and salmeterol 25micrograms) Sirdupla 125 MDI (fluticasone 125micrograms and salmeterol 25micrograms) Sirdupla 250 MDI (fluticasone 250micrograms and salmeterol 25micrograms) Duoresp Spiromax 160/4.5 (budesonide 160micrograms and formoterol 4.5micrograms) Duoresp Spiromax 320/9 (budesonide 320micrograms and formoterol 9micrograms) Approved by Drug and Therapeutics Committee: December 2014 Review Date: May 2015 KEY: [UL] Unlicensed Preparation; Drug first line choice; Drug hospital only; Drug Amber (TLS), Drug Red (TLS), see

2 Doncaster & Bassetlaw Hospitals NHS Foundation Trust Medicines Formulary Section 3.2: Corticosteroids (cont.) Flutiform 50/5 MDI (fluticasone 50micrograms and formoterol 5micrograms) Flutiform 125/5 MDI (fluticasone 125micrograms and formoterol 5micrograms) Flutiform 250/10 MDI (fluticasone 250micrograms and formoterol 10micrograms) Relvar Ellipta 92/22 (fluticasone 92micrograms and vilanterol 22micrograms) Fostair 100/6 MDI (beclometasone 100micrograms and formoterol 6micrograms) Prednisolone 1mg and 5mg Tablets Hydrocortisone sodium succinate Injection 100mg Approved by Drug and Therapeutics Committee: December 2014 Review Date: May 2015 Prescribing Guidance: Prescribers should be familiar with the following guidelines (click to access): BTS guidelines for the Management of Asthma NICE Guidance for the Management of COPD BEFORE INITIATING A NEW DRUG THERAPY PRACTITIONERS SHOULD CHECK COMPLIANCE WITH EXISTING THERAPIES, INHALER TECHNIQUE AND ELIMINATE TRIGGER FACTORS INHALED CORTICOSTEROIDS Asthma Inhaled corticosteroids should be considered for asthmatic patients with any of the following: Exacerbations of asthma in the last 2 years Using inhaled β 2 agonist 3 times a week or more Symptomatic 3 times a week or more, or waking 1 night a week

3 Equivalence of CFC-free inhaled corticosteroids: Beclometasone should be used as first-line inhaled corticosteroid in asthma. Beclometasone and budesonide are approximately equivalent in clinical practice, although there may be variations with different delivery devices. At present a 1:1 ratio should be assumed when changing between beclometasone and budesonide. Fluticasone provides equal clinical activity to Beclometasone and budesonide at half the dosage Due to variations in bioavailability, CFC free beclometasone should be prescribed by brand name, as advised by the MHRA (August 2006). Clenil modulite CFC free inhalers can be considered to be interchangeable with CFC containing inhalers, whereas Qvar can be considered to be twice as potent (see below). Qvar (Beclometasone CFC free): When transferring a patient from a CFC-containing inhaler (asthma well controlled), initially a 100µg metered dose of Qvar should be substituted for: 200 to 250µg metered dose beclometasone or budesonide 100µg metered dose fluticasone When transferring a patient from a CFC-containing inhaler (asthma poorly controlled), initially a 100µg metered dose of Qvar should be substituted for: COPD: 100µg metered dose beclometasone, budesonide or fluticasone For management of inhaled therapies in COPD, see Formulary Guidance for Management of COPD Patients ORAL CORTICOSTEROIDS Steroid tablets are as effective as injected steroids, provided tablets can be swallowed and retained. Plain prednisolone tablets should be used in preference to the enteric coated preparation, given the significant cost-saving and lack of a proven reduction in gastrointestinal tolerability.

4 Asthma Steroid tablets reduce mortality, relapses, subsequent hospital admissions and requirement for β 2 agonist therapy. The earlier they are given in an acute asthma attack the better the outcome. Following recovery from an acute exacerbation of asthma steroid tablets can be stopped abruptly and doses do not need tapering provided the patient receives inhaled steroids. COPD In the absence of significant contraindications, oral corticosteroids should be used, in conjunction with other therapies, in all patients admitted to hospital with an exacerbation of COPD. Maintenance use of oral corticosteroid therapy in COPD is not usually recommended. Some patients with advanced COPD may require oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroid should be kept as low as possible. Dosage: Exacerbation of COPD: 30mg prednisolone orally for 5 to 7 days It is recommended that a course of corticosteroid treatment should not be exceed 7 days as there is no advantage in prolonged therapy Exacerbation of Asthma: 40 to 50mg prednisolone orally for at least 5 days or until recovery, ideally guided by an action plan In the treatment of COPD and asthma, oral prednisolone should be prescribed as a single daily dose to be given in the morning. Prevention and Treatment of Long-term Corticosteroid Therapy Side Effects: Patients treated with long term oral corticosteroid therapy and those requiring frequent short courses (ie. 3 or 4 within the last 12 months) should be monitored for the development of osteoporosis and given appropriate prophylaxis (via National Osteoporosis Society website) Patients over the age of 65 years should be started on prophylactic treatment without monitoring Withdrawal of corticosteroids: The CSM has recommended that gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have: Received more than 40mg daily prednisolone (or equivalent) for more than one week Been given repeat doses in the evening Received more than 3 weeks treatment

5 Recently received repeated courses (particularly if taken for longer than 3 weeks) Taken a short course within one year of stopping long-term therapy Other possible causes of adrenal suppression Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and who have received treatment for 3 weeks or less and who are not included in the patient groups described above. During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5mg daily) and then reduced more slowly. Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur. PARENTERAL CORTICOSTEROIDS Intravenous hydrocortisone may be necessary for acute severe asthma if the patient is very ill or unable to swallow. Dosage: Hydrocortisone sodium succinate 100 to 200mg by slow IV bolus every 4 to 6 hours. It should not be given by infusion as this is less effective.

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