Before prescribing for COPD management, the patient should have had appropriate assessment, including spirometry, as per NICE guidelines.

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1 Formulary Guidance for Management of COPD patients Before prescribing for COPD management, the patient should have had appropriate assessment, including spirometry, as per NICE guidelines. For inhaler therapy, choice of treatment is based on assessment of inhaler technique and patient preference. Treatment options are listed in order of preference. The guidelines below assume that any inhaler can be successfully used. Initial treatment Either a short-acting beta agonist (SABA) or a short acting muscarinic antagonist (SAMA) should be given as required SABA choice Salbutamol Terbutaline SAMA choice Ipratropium 20microg 2 puffs qds prn For patients with FEV1 >50% predicted with zero to one exacerbation(s) requiring antibiotics and / or steroids within the last 12 months at presentation Choose either a

2 Long acting Beta Agonist (LABA) OR Long-acting Muscarinic Antagonist (LAMA) LABA choice 1. Formoterol 12 micrograms (one puff twice daily) 2. Indacaterol 150microg Breezhaler (one puff once daily) 3. Salmeterol 50 micrograms twice daily (either two puffs twice daily or one blister twice daily) LAMA choice 1. Tiotropium 18 micrograms handihaler (one inhalation once daily) 2. Aclidinium 400micrograms Genuair (one puff twice daily) 3. Glycopyronnium 50micrograms Breezhaler (one puff once daily) 4. Tiotropium 2.5 micrograms Respimat (two puffs once daily). Please note, respimat should only be used where no other inhaler device is appropriate. For patients with FEV1 >50% predicted with more than one exacerbation requiring antibiotics and / or steroids within last 12 months at presentation Choose Tiotropium 18 microgram handihaler (one inhalation once daily)

3 For patients with FEV1 > 50% predicted who are on either a LABA or a LAMA who continue to have symptoms but have had zero or one exacerbations requiring antibiotics and / or steroids Give LAMA PLUS LABA Anoro (vilanterol / umeclidinium) via Ellipta device one puff once daily Or use individual components as listed above. Consider once or twice daily dosing issues with both inhalers as well as technique. For patients with FEV1 > 50% predicted who continue to have symptoms (or exacerbations) despite regular treatment with a LABA + LAMA Discontinue LABA (but continue LAMA) AND ADD LABA/ICS (Long-acting beta agonist / Inhaled Corticosteroid) 1. Symbicort 400/12 turbohaler (one puff twice daily) or Symbicort 200/6 turbohaler (two puffs twice daily) 2. Seretide 500 accuhaler (one puff twice daily) or Relvar Ellipta 92/22 microg (one puff ONCE daily) 3. Fostair 100/6 MDI inhaler (two puffs twice daily) if a MDI is necessary *Note Seretide 250 evohaler is not licensed for COPD. Use Fostair instead of Seretide 250 evohaler. For relative costings see table below

4 *Note Relvar Ellipta 92/22microg is a new product to market containing a potent steroid equivalent to 250mcg fluticasone propionate twice daily *All inhaled corticosteroids carry a small, but significant risk of pneumonia SAFETY INFORMATION Relvar Ellipta is packaged in a pale blue livery which may be confused with a salbutamol inhaler. The patient must be explicitly informed that this inhaler is not to be used more than once a day because it contains a potent steroid. For patients with FEV1 <50% predicted with or without exacerbations Choose LAMA 1. Tiotropium 18microgram handihaler (one puff once daily) 2. Aclidinium 400microgram Genuair (one puff twice daily) 3. Glycopyronnium 50microgram Breezhaler (one puff once daily) For patients with FEV1 <50% predicted who continue to be symptomatic after a 3 month trial of LAMA Add LABA/ICS 1. Symbicort 400/12 turbohaler (one puff twice daily) or Symbicort 200/6 turbohaler (two puffs twice daily) 2. Seretide 500 accuhaler (one puff twice daily) or Relvar Ellipta 92/22 microg (one puff once daily) 3. Fostair 100/6 MDI (two puffs twice daily)

5 Inhaler / device Cost (BNF Feb 2014) Tiotropium handihaler Aclidinium Genuair Glycopyrronium Breezhaler Formoterol Indacaterol Breezhaler Salmeterol 25 MDI Tiotropium Respimat Relvar Ellipta 92/ Symbicort 200/6 turbohaler Symbicort 400/12 turbohaler Seretide 500 accuhaler Seretide 250 evohaler Flutiform 250 MDI Fostair 100/6 MDI Review For secondary care, patients under the care of a respiratory consultant should be reviewed in outpatients clinic at appropriate intervals until such time that the patient is discharged from clinic to be managed in primary care. For primary care, it is suggested that the patient is reviewed annually to ensure inhaler technique / adherence is satisfactory and the patient is benefiting from continued treatment. Review should be more frequent if the patient exacerbates or continues to experience ongoing symptoms of breathlessness etc with the option to refer into the care of a respiratory consultant where appropriate. Community pharmacists should check inhaler technique after every change of device.

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