Croydon CCG Recommended Inhaler Devices Quick Reference Guide

Transcription

1 Croydon CCG Inhaler Devices Quick Reference Guide Name* Class Inhaler Type Licensed for Asthma <6 yrs 6-12 yrs yrs 18 yrs+ Licensed for COPD Salbutamol SABA MDI, & Easi-Breathe 4yrs + Terbutaline sulphate SABA 5yrs + Salmeterol (e.g. Serevent Evohaler ) LABA MDI 4yrs + Formoterol (e.g. Oxis Turbohaler ) LABA Ipratropium SAMA MDI 1m + Spiriva Handihaler (Tiotropium) LAMA Spiriva Respimat (Tiotropium) LAMA MDI ** Specialist Initiation Eklira Genuair (Aclidinium) LAMA Clenil Modulite ICS MDI Only Clenil 50mcg and 100mcg devices licensed for under 16yrs Pulmicort Turbohaler (Budesonide) ICS 5yrs + Flutiform (Fluticasone/Formoterol) ICS + LABA MDI Flutiform 250/10 licensed for adults only Sirdupla (Fluticasone/Salmeterol) ICS + LABA MDI Fostair (Beclometasone/Formoterol) ICS + LABA MDI Fostair 100/6 only DuoResp Spiromax (Budesonide/Formoterol) ICS + LABA Symbicort Turbohaler (Budesonide/Formoterol) ICS + LABA Seretide Evohaler (Fluticasone/Salmeterol) ICS + LABA MDI Only Symbicort 100/6 licensed for 6-11yrs Symbicort 400/12 - max 1 puff BD for yrs Only Seretide 50 Evohaler licensed for 4-11yrs Symbicort 200/6 and 400/12 only Seretide Accuhaler (Fluticasone/Salmeterol) ICS + LABA Only Seretide 100 Accuhaler licensed for 4-11yrs Seretide 500 Accuhaler only Duaklir Genuair (Aclidinium/Formoterol) LAMA + LABA ** Specialist Initiation *This list is not exhaustive. Refer to Summary of Product Characteristics and local/national guidelines for full information on available inhaler strengths, indications, doses and contraindications. ** for Secondary Care specialist inititation only licensed for this indication or age range Beclomethasone inhaler potencies vary, caution when switching between inhalers Product has shortened shelf life once opened. See product information for details Prepared by: Pharmaceutical Team, Croydon CCG Approved by: CPC March 2016; Review Due: March 2018 Page 1 Croydon CCG Inhaler Device Recommendations Version 1.2 (final) March 2016 Licensed = Dry Powder Inhaler, MDI = Metered Dose Inhaler, ICS = Inhaled Corticosteroid, SABA = Short Acting Beta-Agonist, LABA = Long Acting Beta-Agonist, SAMA = Short Acting Muscarinic Antagonist, LAMA = Long Acting Muscarinic Antagonist

2 Easyhaler (Formoterol) LABA Neovent (Salmeterol) LABA MDI Serevent Accuhaler (Salmeterol) LABA 4yrs + Vertine (Salmeterol) LABA MDI Atimos Modulite (Formoterol) LABA MDI Foradil (Formoterol) LABA Onbrez Breezhaler (Indacaterol) LABA Striverdi Respimat (Olodaterol) LABA MDI <6 yrs 6-12yrs 12-17yrs 18yrs+ Relatively small device, requires manual dexterity to operate, no significant Seebri Breezhaler (Glycopyrronium) LAMA advantage over Tiotropium Handihaler device Incruse Ellipta (Umeclidinium) LAMA Device not favoured by local secondary care specialist clinicians, rarely prescribed. Short in use shelf life (6 weeks) Easyhaler ICS Only one breath actuated device prioritised Easi-Breathe MDI chosen as Qvar ICS MDI most commonly prescribed device locally. Clenil chosen as 1st line over Breath-Actuated Qvar to help reduce confusion when switching between devices, due to Qvar Autohaler ICS MDI differences in potency. Breath-Actuated Qvar Easi-Breathe ICS MDI Only one prioritised. Turbohaler selected, as most commonly Easyhaler (Budesonide) ICS prescribed locally and relatively easy to use device. Only Flixotide 50mcg Evohaler, 50mcg Accuhaler and 100mcg Accuhaler Flixotide Evohaler/Accuhaler (Fluticasone) ICS MDI & licensed for 4-15yrs routinely prescribed Only one breath actuated device prioritised Easi-Breathe MDI chosen as Asmabec Clickhaler ICS most commonly prescribed device locally. Clenil chosen as 1st line over Qvar to help reduce confusion when switching between devices, due to Pulvinal ICS differences in potency. Budelin Novolizer (Budesonide) ICS Only one prioritised. Turbohaler selected, as most commonly prescribed locally and relatively easy to use device. Alvesco (Ciclesonide) ICS MDI ** Specialist ** Specialist Initiation Initiation For Secondary Care specialist initiation on a named patient basis only. Asmanex Twisthaler (Mometasone) ICS routinely prescribed Fostair and Duoresp Spiromax prioritised for local use. AirFluSal device AirFluSal Forspiro (Fluticasone/Salmeterol) ICS + LABA requires manual dexterity to operate. Fostair NEXThaler (Beclometasone/Formoterol) ICS + LABA Fostair 100/6 only Next haler not recommended, 1st line will be Duoresp. Next haler has short in use shelf life (6 months) Relvar Ellipta (Fluticasone/Vilanterol) ICS + LABA Relvar Ellipta CPC decision: recommended as no additional clinical or other benefits 92/22 only identified over existing inhalers. In use shelf life 6 weeks Ultibro Breezhaler (Glycopyrronium/Indacaterol) LAMA + LABA Spiolto Respimat (Olodaterol/Tiotropium) LAMA + LABA MDI Anoro Ellipta (Umeclidinium/Vilanterol) LAMA + LABA *This list is not exhaustive. Refer to Summary of Product Characteristics and local/national guidelines for full information on available inhaler strengths, indications, doses and contra-indications. e: Beclomethasone inhaler potencies vary, caution when switching between inhalers Croydon CCG Inhaler Devices Quick Reference Guide - 2nd and 3rd Line Options and - Name* Class Inhaler Type licensed for this indication age range Licensed for Asthma or Licensed Licensed for COPD Product has shortened shelf life once opened. See product information for details Reason for Exclusion from Inhaler Recommendations List Device rationalisation. Only one and one MDI prioritised. Most commonly prescribed devices selected, along with those licensed for widest age range. CAUTION: Neovent and Vertine should not be prescribed for patients with Peanut/Soya allergies Olodaterol/Indacaterol excluded as only licensed for COPD. Respimat has short in use shelf life (3 months). Only one combination LABA/LAMA device recommended. F SECONDARY CARE SPECIALIST INITIATION ONLY. Currently no clear guidance on place in therapy. Decision made based on ease of use of device. Spioloto Respimat and Anoro Elipta have short in use shelf life (3 months and 6 weeks respectively). = Dry powder inhaler, MDI = Metered dose inhaler, ICS = Inhaled corticosteroid, SABA = Short acting beta-agonist, LABA = Long acting beta-agonist, SAMA = Short acting muscarinic antagonist, LAMA = Long acting muscarinic antagonist Prepared by: Pharmaceutical Team, Croydon CCG Approved by: CPC March 2016; Review Due: March 2018 Page 2 Croydon CCG Inhaler Device Recommendations Version 1.2 (final) March 2016

3 Croydon CCG Primary Care Management of STABLE COPD: February 2016 Update ALL COPD PATIENTS STILL SMOKING, REGARDLESS OF AGE, SHOULD BE ENCOURAGED TO STOP, AND OFFERED HELP TO DO SO AT EVERY OPPTUNITY. Contact the NHS Croydon Stop Smoking Service on Tel: Consider the use of regular CO monitoring as a motivational tool for smokers BREATHLESSNESS AND EXERCISE LIMITATION Assess symptoms, severity and disability and manage as below (see overleaf for more details) Short-acting beta agonist (SABA) - Salbutamol 100mcg, 2 puffs PRN Short-acting muscarinic antagonist (SAMA) Ipratropium 20mcg, 2 puffs PRN If patient does not demonstrate satisfactory technique: Add spacer device or change device e.g. Easyhaler Salbutamol 100mcg FEV 1 50% FEV 1 < 50% Exacerbations or persistent breathlessness Add long acting bronchodilator Either Long acting muscarinic antagonist (LAMA) (stop ipratropium) Tiotropium (Spiriva Handihaler) 18mcg, once daily If patient does not demonstrate satisfactory technique: Tiotropium (Spiriva Respimat ) 2.5mcg two puffs once daily Aclidinium (Eklira Genuair) 375mcg twice daily Long acting β2 agonist (LABA) Formeterol (e.g. Oxis Turbohaler 12mcg twice daily Salmeterol (e.g. Serevent Evohaler ) 50mcg twice daily If patient remains breathless or has exacerbations Consider combination LABA/inhaled corticosteroid (ICS) (stop LABA) Beclometasone/Formoterol (Fostair ) 100mcg/6mcg, two puffs twice daily via spacer Budesonide/Formoterol (Duoresp Spiromax ) 320mcg/9mcg, one puff twice daily Exacerbations or persistent breathlessness Add long acting bronchodilator Either Long acting muscarinic antagonist (LAMA) (stop ipratropium) Tiotropium (Spiriva Handihaler) 18mcg, once daily If patient does not demonstrate satisfactory technique: Tiotropium (Spiriva Respimat ) 2.5mcg two puffs once daily Aclidinium (Eklira Genuair) 375mcg twice daily Combination Long acting β2 agonist (LABA)/inhaled corticosteroid (ICS) Beclometasone/Formoterol (Fostair ) 100mcg/6mcg, two puffs twice daily via spacer Budesonide/Formoterol (Duoresp Spiromax ) 320mcg/9mcg, one puff twice daily Offer tiotropium (Spiriva ) in addition to Fostair 100/6 or Duoresp Spiromax 320/9 to people with COPD who are still symptomatic If still symptomatic consider theophylline. Caution in elderly patients and smokers due to pharmacokinetic differences. Prescribe by brand only. Monitor drug interactions and plasma levels (every 6 12 months and after dose adjustment stable patients) (see BNF appendix 1) NOTE: If ICS declined or not tolerated, consider referral to respiratory specialist for potential trial of combination LAMA + LABA Aclidinium/Formoterol (Duaklir Genuair ) 340mcg/12mcg one puff twice daily (For Respiratory Specialist initiation ONLY) This guideline is in line with NICE COPD Clinical Guidelines June 2010 (CG101) Drug choice should take into account the patient s symptomatic response and preference, side effects, potential to reduce exacerbations and cost. Inhalers should only be prescribed after patients have received training in use of the device and have shown satisfactory technique. Inhaler technique should be checked prior to any change in medication. The Duoresp Spiromax device must be used within 6 months of opening, Fostair MDI must be used within 20 months of opening and Duaklir Genuair within 60 days of opening. To reduce wastage, patients should be encouraged to use only one inhaler device at a time and ensure their current device is finished before opening a new inhaler. Chronic cough/sputum production Consider a trial of carbocisteine 750mg tds for 6-8 weeks then 375mg qds if there is an improvement in sputum production and reduction in viscosity. Continue if symptoms improve. Do not use mucolytic drugs routinely for the prevention of exacerbations in stable COPD. e: Antitussives should not be used to manage COPD. Vaccination Pneumococcal vaccination and influenza vaccination should be offered to all patients with COPD. Oral antibiotics Oral antibiotics are recommended for exacerbations causing purulent sputum. Prophylactic antibiotics are not recommended in the management of stable COPD. See Croydon CCG Management of infections - Guidance for Primary care (available via Croydon CCG Intranet). Pulmonary rehabilitation should be available to all appropriate patients with COPD, including those recently hospitalised with an acute exacerbation and those who consider themselves functionally disabled by COPD (usually MRC grade 3 and above). Contact the Pulmonary Rehab Service for information: Tel: Page 1 of 4 Croydon CCG Primary Care Management of Stable COPD Version 2.4 Approved by: CPC March 2016; Review date: March 2018

4 GRADATION OF SEVERITY OF AIRFLOW OBSTRUCTION Disease severity is assessed according to the degree of airflow obstruction, disability and frequency of exacerbations. Record as per current QOF indicators (NB NICE 2010 updated guidelines are now using GOLD classification). Post-bronchodilator FEV 1 /FVC FEV 1 Croydon CCG Primary Care Management of STABLE COPD: February 2016 Update READ Code Stage 1 Mild <0.7 80% (H36) Stage 2 Moderate < % (H37) Stage 3 Severe < % (H38) Stage 4 Very Severe <0.7 <30% (H39) POTENTIAL SAFETY ISSUES LONG ACTING BETA 2 AGONISTS In 2006 a meta-analysis identified the possibility of an increased risk of respiratory death with the use of short and long acting β2 agonists in patients with COPD. More recent data has been reassuring. In July 2009 the MHRA concluded that the overall balance of benefits and risks for LABAs in the treatment of COPD remains positive when used in line with current GOLD and BTS guidelines. Tolerability issues - Tremor, palpitations. STEROIDS Be aware of the potential risk of developing side effects (including non fatal pneumonia) in COPD treatment with high dose ICS and be prepared to discuss the risk with new patients. The potential risk of developing systemic side effects such as adrenal suppression and osteoporosis with high dose ICS should also be considered and prophylaxis provided if appropriate. Tolerability Issues - Hoarseness, bruising, oral candidiasis. TIOTROPIUM/IPRATROPIUM Tolerability Issues - Dry Mouth. MEDICATION REVIEW Mild/moderate COPD - review at least annually Severe COPD - review at least twice per year Inhaler technique should be assessed regularly by a competent healthcare professional and the correct technique should be re-taught/reinforced. If the patient is unable to use a particular device satisfactorily an alternative should be found. Where possible, aerosol inhalers should always be used with a spacer device to increase lung deposition and reduce oral side effects. Review symptom control and number of COPD exacerbations in last 12 months. Activities of daily living and exercise capacity should be reviewed using MRC dyspnoea scale. Patients should be given self-management advice that encourages them to respond promptly to the symptoms of an exacerbation. Appropriate patients should be given a course of antibiotics and oral steroids as a rescue strategy. LONG TERM OXYGEN THERAPY (LTOT) The need for oxygen should be assessed in: All patients with very severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, oxygen saturations 92% breathing air. Consider assessment in those with severe airflow obstruction (FEV % predicted). Refer patients to the Croydon Oxygen Assessment Service for assessment and review for appropriateness of oxygen therapy. Tel: e: Inappropriate oxygen therapy in people with COPD may cause respiratory depression. Page 2 of 4 Croydon CCG Primary Care Management of Stable COPD Version 2.4 Approved by: CPC March 2016; Review date: March 2018 MANAGEMENT OF EXACERBATIONS Refer to NICE COPD Guidelines June 2010 (CG101) to assess requirements for management at home or hospital BRONCHODILATS Increase frequency of bronchodilator use. AL CTICOSTEROIDS Indicated in patients who have an exacerbation with a significant increase in breathlessness which interferes with daily activities Prednisolone 30mg once daily for 7-14 days (non enteric coated) Patients should be made aware of the optimum duration of treatment and adverse effects of prolonged steroid therapy. Osteoporosis treatment should be offered to those patients who have frequent courses of corticosteroids. Routine use of oral steroids in stable COPD is NOT normally recommended. Maintenance therapy only on specialist advice. ANTIBIOTICS Give oral antibiotics if sputum purulent or there are signs of pneumonia Follow local antibiotic guidance for infected exacerbations of COPD Exacerbations without purulent sputum do not need an antibiotic unless consolidation on chest x-ray or clinical signs or pneumonia If sputum is sent for culture, review antibiotic treatment when sensitivity results are available. NEBULISERS The majority of patients can be taught to use handheld inhaler devices. However the few patients with distressing or disabling breathlessness despite maximal therapy with inhalers should be referred to the Respiratory Specialist Team for formal assessment and provision of compressor if appropriate. Nebulised therapy should be reviewed two weeks after initiation and only continued if there is proven benefit in line with NICE COPD Guidelines (section ). PALLIATIVE CARE (Involve multidisciplinary palliative care teams) Opiates can be used for the palliation of breathlessness in patients with end-stage COPD unresponsive to other medical therapy e.g. Oramorph 2.5mg prn (maximum 4 doses in 24 hours). Use benzodiazepines, tricyclic antidepressants, major tranquilisers and oxygen when appropriate. The respiratory consultant/specialist can provide advice.

5 Croydon CCG Primary Care Management of STABLE COPD: February 2016 Update Appendix A: Diagnosing COPD Think of the diagnosis of COPD for patients who are over 35 smokers or ex-smokers have any of these symptoms: o exertional breathlessness o chronic cough o regular sputum production o wheeze o frequent winter bronchitis and have no clinical features of asthma (See table 1 below) Perform spirometry if COPD seems likely Airflow obstruction is defined as post-bronchodilator: FEV 1 /FVC < 0.7 Spirometric reversibility testing is not usually necessary as part of the diagnostic process or to plan initial therapy. If still in doubt about diagnosis consider the following pointers: Asthma may be present if: - There is a >400 ml response to bronchodilators - Serial peak flow measurements show significant diurnal or day to day variability - There is a >400 ml response to 30mg prednisolone daily for 2 weeks Clinically significant COPD is not present if FEV 1 and FEV 1 /FVC ratio return to normal with drug therapy Refer to more detailed investigations/respiratory specialist advice if needed. If still in doubt, make a provisional diagnosis and start empirical treatment If in no doubt, diagnose COPD and start treatment Table 1: Clinical features differentiating COPD and Asthma COPD Asthma Smoker or ex-smoker Nearly all Possibly Symptoms under age 35 Rare Common Chronic productive cough Common Uncommon Breathlessness Persistent and progressive Variable Night-time waking with breathlessness and/or wheeze Uncommon Common Significant diurnal or day-to-day variability of symptoms Uncommon Common Table 2: MRC Dyspnoea scale Reassess diagnosis in view of response to treatment Grade Degree of breathlessness related to activities 1 troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100 metres or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing or undressing Reference: NICE COPD 2010 guidelines Page 3 of 4 Croydon CCG Primary Care Management of Stable COPD Version 2.4 Approved by: CPC March 2016; Review date: March 2018

6 Croydon CCG Primary Care Management of STABLE COPD: February 2016 Update Management of Chronic Obstructive Pulmonary Disease Structured Abstract Aim(s) What this guideline does not cover: I. To summarise the NICE guidance into a format which can be used as an easy reference at the point of consultation by clinicians to ensure the appropriate diagnosis and management of COPD patients. II. To augment the NICE Chronic Obstructive Pulmonary Disease (COPD) guidelines by promoting locally agreed first-line cost effective drug choices for the management of stable COPD in Croydon. This guideline includes a summary of the NICE guidelines for the treatment and diagnosis of COPD. Please refer to the full guidance for more detailed information. These guidelines represent current recommended practice in Croydon. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Outcome Measures (For Audit Purposes, NSF & GMS) References Authors & Approving Committees QOF, COPD001: The contractor establishes and maintains a register of patients with COPD QOF, COPD002: The percentage of patients with COPD (diagnosed after 1 April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 12 months after entering on to the register QOF, COPD003: Percentage of COPD patients who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 12 months QOF, COPD004: The percentage of patients with COPD a record of FEV 1 in the preceding 12 months QOF, COPD007: Percentage of patients with COPD who have had influenza immunisation in the preceding 1 August to 31 March QOF SMOK002: Percentage of patients with any conditions e.g. COPD whose notes record smoking status in the preceding 12 months QOF SMOK005: Percentage of patients with any conditions e.g. COPD who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months NICE Chronic Obstructive Pulmonary Disease guidelines July 2010 British National Formulary No 60 September 2010 MeReC bulletin Vol. 19 No 4. April 2009 BTS Clinical Guidelines for Oxygen Assessment Nov 2005 (Layout adapted from NHS Surrey COPD Guidelines June 2010 with permission) Margaret Haastrup Principal Primary Care Pharmacist Victoria MacGregor Senior Practice Support Pharmacist Dr Roshan Siva Respiratory Consultant, Croydon University Hospital Croydon COPD Strategy Group Croydon Prescribing Committee Date of Review March 2018 Page 4 of 4 Croydon CCG Primary Care Management of Stable COPD Version 2.4 Approved by: CPC March 2016; Review date: March 2018

7 Prepared by Pharmaceutical Team, Croydon CCG March 2016, Approved by: CPC March 2016; Review Due: March 2018 Croydon CCG Chronic Asthma Management Guidelines Summary of Stepwise Management and Preferred Inhaler Devices in ADULTS and Children Over 12 years of age Start treatment at the step most appropriate to the initial severity, medication should be titrated against clinical response to ensure optimum efficacy. Move up to improve control as needed Move down to find and maintain lowest controlling step STEP 1 Mild Intermittent Asthma Inhaled short acting β2 agonist (SABA) as required (to be continued in all steps) Consider stepping up therapy if: - Requiring SABA 3 or more times per week or symptomatic 3 or more times per week -Asthma attack requiring oral corticosteroid in past 2 years -Nocturnal symptoms one or more nights per week * Beclometasone dipropionate or equivalent Easi-Breathe Salbutamol 100mcg Easi-Breathe 1-2 puffs QDS prn Terbutaline sulphate 500mcg Turbohaler 1 puff QDS prn STEP 2 Regular preventer therapy Add inhaled corticosteroid (ICS) mcg/day* Start at dose of ICS appropriate to severity of disease 400mcg/day* is an appropriate starting dose for many patients Titrate dose to the lowest effective dose that maintains asthma control. Easi-Breathe Qvar 50mcg Easi-Breathe ** 2 puffs BD Pulmicort 100mcg Turbohaler (Budesonide) 2 puffs BD STEP 3 Initial add-on therapy Add inhaled long-acting β2 agonist (LABA) N.B. LABA s should not be used without inhaled corticosteroids, combination ICS&LABA inhalers are therefore recommended Assess control of asthma: Good response to LABA continue LABA Some benefit from LABA but control still inadequate - continue LABA and increase ICS dose to 800mcg/day* (if not already on this dose) No response to LABA stop LABA and increase ICS to 800mcg/ day*. If still inadequate, institute trial of other therapies e.g. leukotriene receptor antagonist or SR theophylline DuoResp Spiromax 160/4.5mcg (18 years+ only) (Budesonide/Formoterol) 1 puff BD Symbicort 200/6mcg Turbohaler (12 years and over) (Budesonide/Formoterol) 1 puff BD 1 STEP 4 Persistent Poor Control Consider trial of: Increasing ICS up to 2000mcg/day* Addition of fourth drug e.g. leukotriene receptor antagonist, SR theophylline If trial of add on therapy ineffective, stop the drug/reduce to original dose of corticosteroid Refer to respiratory specialist STEP 5 Frequent use of oral steroids Use lowest dose of daily oral corticosteroid for adequate control Maintain high dose ICS at 2000mcg/day* Consider other treatments to minimise use of oral corticosteroid Refer to respiratory specialist ALL PATIENTS SHOULD RECEIVE TRAINING AND ASSESSMENT IN INHALER TECHNIQUE BEFE STARTING ANY NEW INHALER TREATMENT Refer patients who smoke to an accredited Croydon Stop Smoking Advisor/service before offering step up therapy. Patients should be advised that smoking reduces the effectiveness of therapy. Higher doses Check adherence to existing therapies, ensure patients are able to use their inhalers and spacer devices correctly and triggers have been eliminated before stepping up therapy of inhaled corticosteroids may be needed in patients who are smokers or ex-smokers Consider referring patients to their Community Pharmacist for Medicines Use Reviews and Ensure that all patients issued with a corticosteroid MDI are also issued with a spacer and know how to the New Medicines Service to support adherence and assess inhaler technique use it correctly. Preferred spacers - Volumatic or Aerochamber Plus Explore any beliefs the patient may have about their treatment, which may be acting as a Where possible ensure that patients receive treatment with similar devices barrier to inhaler use. STEP 1 Inhaler Choices STEP 2 Inhaler Choices STEP 3 Inhaler Choices STEP 4/5 Inhaler Choices Flutiform 125/5mcg (12 years and over) Clenil Modulite 100mcg** Flutiform 125/5mcg (12 years and over) (Fluticasone/Formoterol) 2 puffs BD via spacer Salbutamol 100mcg (Fluticasone/Formoterol) 1 puff BD via spacer Flutiform 250/10mcg (18 years+ only) 1-2 puffs QDS prn 2 puffs BD via spacer (Fluticasone/Formoterol) 1-2 puffs BD via spacer Sirdupla 125/25mcg (18 years+ only) Sirdupla 250/25mcg (18 years+ only) (Fluticasone/Salmeterol) 1 puff BD via spacer (Fluticasone/Salmeterol) 1-2 puffs BD via spacer To reduce wastage, patients should be encouraged to use only one inhaler device at a time and ensure all doses have been used in their current device before opening a new inhaler. Duoresp Spiromax must be used within 6 months of opening and Flutiform within 3 months, see product information for further details. DuoResp Spiromax 360/9mcg (18 years+ only) (Budesonide/Formoterol) 1-2 puffs BD Symbicort 400/12mcg Turbohaler (12 years and over) (Budesonide/Formoterol) 1 puff BD Respiratory Specialist recommended only Spiriva Respimat 2.5mcg (18 years+ only) (Tiotropium) 2 puffs OD Only preferred products are shown. If a patient cannot use, or declines the listed inhalers then alternative products within the recommended classes are available. Choice of product class should be based on the BTS/SIGN asthma guideline. It is recommended that combination ICS/LABA inhalers are prescribed by BRAND name. **NB: Beclometasone inhaler potencies vary, caution required when switching between inhalers

8 Inhaled short acting β2 agonist (SABA) as required (to be continued in all steps) Consider stepping up therapy if: - Requiring SABA 3 or more times per week or symptomatic 3 or more times per week - Asthma attack requiring oral corticosteroid in past 2 years -Nocturnal symptoms one or more nights per week Croydon CCG Chronic Asthma Management Guidelines Summary of Stepwise Management and Preferred Inhaler Devices in CHILDREN aged 5 to 12 years Start treatment at the step most appropriate to the initial severity, medication should be titrated against clinical response to ensure optimum efficacy. Move up to improve control as needed Move down to find and maintain lowest controlling step STEP 1 Mild Intermittent Asthma STEP 2 Regular preventer therapy STEP 3 Initial add-on therapy STEP 4 Persistent Poor Control STEP 5 Frequent use of oral steroids Add inhaled corticosteroid (ICS) mcg/day* Start at dose of ICS appropriate to severity of disease 200mcg/day* is an appropriate starting dose for many patients Titrate dose to the lowest effective dose that maintains asthma control. Reconsider diagnosis if response to treatment is unexpectedly poor Periodically re-visit diagnosis as a proportion of patients will grow out of their asthma Add inhaled long-acting β2 agonist (LABA) N.B. LABA s should not be used without inhaled corticosteroids, combination ICS&LABA inhalers are therefore recommended Assess control of asthma: Good response to LABA continue LABA Some benefit from LABA but control still inadequate - continue LABA and increase ICS dose to 400mcg/day* (if not already on this dose) No response to LABA stop LABA and increase ICS to 400mcg/ day*. If still inadequate, institute trial of other therapies e.g. leukotriene receptor antagonist or SR theophylline Consider trial of: Increasing ICS up to 800mcg/day* If trial of increased therapy ineffective, reduce to original dose of corticosteroid Refer to paediatrician Use lowest dose of daily oral corticosteroid for adequate control Maintain high dose ICS at 800mcg/day* Refer to paediatrician * Beclometasone dipropionate or equivalent ALL PATIENTS SHOULD RECEIVE TRAINING AND ASSESSMENT IN INHALER TECHNIQUE BEFE STARTING ANY NEW INHALER TREATMENT Ensure that all patients issued with a corticosteroid MDI are also issued with a spacer and Consider referring patients to their Community Pharmacist for Medicines Use Reviews and New know how to use it correctly. Preferred spacers - Volumatic or Aerochamber Plus Medicines Service to support adherence and assess inhaler technique Where possible ensure that patients receive treatment with similar devices Explore any beliefs the patient and parent/carers may have about their treatment, which may be acting Check adherence to existing therapies, ensure patients are able to use their inhalers and as a barrier to inhaler use. spacer devices correctly and triggers have been eliminated before stepping up therapy STEP 1 Inhaler Choices STEP 2 Inhaler Choices STEP 3 Inhaler Choices STEP 4/5 Inhaler Choices Salbutamol 100mcg 1-2 puffs QDS prn via spacer Seretide 50/25mcg Evohaler (Fluticasone/Salmeterol) 1 puff BD via spacer Easi-Breathe Salbutamol 100mcg Easi-Breathe 1-2 puffs QDS prn Terbutaline sulphate 500mcg Turbohaler 1 puff QDS prn Clenil Modulite 50mcg** 1 puff BD via spacer Pulmicort 100mcg Turbohaler (Budesonide) 1 puff BD Symbicort 100/6mcg Turbohaler (Budesonide/Formoterol) 1 puff BD Seretide 100/50mcg Accuhaler (Fluticasone/Salmeterol) 1 puff BD Referral to paediatrician recommended Specialist referral required because the use of combination inhalers at higher steroid doses is unlicensed Only preferred products are shown. If a patient cannot use, or declines the listed inhalers then alternative products within the recommended classes are available. Choice of product class should be based on the BTS/SIGN asthma guideline. It is recommended that combination ICS/LABA inhalers are prescribed by BRAND name. **NB: Qvar (beclometasone dipropionate) inhalers are not licensed in the under 12s. Refer patients aged 0-18 years to the Croydon Children s Asthma Service who have poorly controlled asthma, who have frequent A&E attendances for asthma/wheeze or who require asthma management education to avoid further emergency department attendances. Tel: or mhn-tr.chahasthma@nhs.net Prepared by Pharmaceutical Team, Croydon CCG March 2016, Approved by: CPC March 2016; Review Due: March

9 Croydon CCG Chronic Asthma Management Guidelines Consider stepping up therapy if: - Requiring SABA 3 or more times per week or symptomatic 3 or more times per week -Nocturnal symptoms one or more nights per week For under 1s and those with difficult or uncertain diagnosis consider referring to respiratory paediatrician Summary of Stepwise Management and Preferred Inhaler Devices in CHILDREN aged less than 5 years Start treatment at the step most appropriate to the initial severity, medication should be titrated against clinical response to ensure optimum efficacy. Move up to improve control as needed Move down to find and maintain lowest controlling step STEP 1 Mild Intermittent Asthma STEP 2 Mild Persistent Asthma STEP 3 Moderate Persistent Asthma STEP 4 Persistent Poor Control Inhaled short acting β2 agonist (SABA) as Add inhaled corticosteroid (ICS) 200- required 400mcg/day* (to be continued in all steps) Or leukotriene receptor antagonist if ICS cannot be used Start at dose of ICS appropriate to severity of disease Titrate dose to the lowest effective dose that maintains asthma control. Reconsider diagnosis if response to treatment is unexpectedly poor Periodically re-visit diagnosis as a proportion of patients will grow out of their asthma In children taking inhaled corticosteroid mcg/day consider addition of leukotriene receptor antagonist In those children taking a leukotriene receptor antagonist alone reconsider addition of an inhaled corticosteroid mcg/day In children under 2 years of age refer to paediatrician Refer to paediatrician * Beclometasone CFC or equivalent ALL PATIENTS & CARERS SHOULD RECEIVE TRAINING AND ASSESSMENT IN INHALER TECHNIQUE BEFE STARTING ANY NEW INHALER TREATMENT Ensure all patients issued with a corticosteroid MDI are also issued with a spacer and know how to use it correctly. Preferred spacers - Volumatic with paediatric mask or AeroChamber Plus with infant mask Explore any beliefs the parent/carers and patients may have about their treatment which Easi-breathe or breath actuated and dry powder inhaler devices are UNSUITABLE for this age may be acting as a barrier to inhaler use group STEP 1 Inhaler Choices STEP 2 Inhaler Choices STEP 3 Inhaler Choices STEP 4/5 Inhaler Choices Check adherence to existing therapies and ensure patients are able to use their inhalers and spacer devices correctly before stepping up therapy Salbutamol 100mcg Inhaler 1-2 puffs QDS prn via spacer Clenil Modulite 50mcg Inhaler (Beclometasone dipropionate) 2 puffs BD via spacer Clenil Modulite 100mcg Inhaler 2 puffs BD via spacer If no response after 6 weeks refer to paediatrician Referral to paediatrician recommended Specialist referral required because the use of combination inhalers at higher steroid doses is unlicensed Only preferred products are shown. If a patient cannot use, or declines the listed inhalers then alternative products within the recommended classes are available. Choice of product class should be based on the BTS/SIGN asthma guideline. It is recommended that combination ICS/LABA inhalers are prescribed by BRAND name. **NB: Qvar (beclometasone dipropionate) inhalers are not licensed in the under 12s. Refer patients aged 0-18 years to the Croydon Children s Asthma Service who have poorly controlled asthma, who have frequent A&E attendances for asthma/wheeze or who require asthma management education to avoid further emergency department attendances. Tel: or mhn-tr.chahasthma@nhs.net Prepared by Pharmaceutical Team, Croydon CCG March 2016, Approved by: CPC March 2016; Review Due: March

10 Croydon CCG Chronic Asthma Management Guidelines DIAGNOSING ASTHMA Diagnosis is based on the recognition of features that, together with spirometry, increase or decrease the probability of asthma. HIGH probability of asthma - give a trial of treatment for 2-3 months. If patient does not respond, assess compliance and inhaler technique and consider further investigation and/or referral. Continue treatment if patient is responsive. LOW probability of asthma and other diagnosis is likely, investigate and treat other condition accordingly. Reconsider the diagnosis of asthma in those who do not respond The preferred approach in patients with an INTERMEDIATE probability of having asthma, and where other diagnosis is uncertain, is to treat as follows: If evidence of airways obstruction - assess for reversibility and/or give a trial of treatment If no evidence of airways obstruction - carry out further investigations and consider referral If unable to perform airway obstruction tests - give trial of treatment and assess response Clinical features that increase probability of asthma More than one of the following symptoms: wheeze, breathlessness, chest tightness and cough, particularly if: o They re worse at night and in the early morning o They re frequent and recurrent o They occur in response to exercise, allergen exposure and cold air o They occur when the patient doesn t have a cold o They occur after taking aspirin or beta blockers History of atopic disorder Family history of asthma and/or atopic disorder Widespread bilateral wheeze heard on auscultation of the chest Prolonged expiration and/or increased respiratory rate Otherwise unexplained low forced expiratory volume (FEV 1 ) or peak expiratory flow rate (PEF) in adults (historical or serial readings are unreliable for diagnosis in children) Otherwise unexplained peripheral blood eosinophilia Clinical features that lower the probability of asthma Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough in the absence of wheeze or breathlessness Repeatedly normal physical examination of chest when symptomatic Voice disturbance Moist cough Symptoms with colds only Significant smoking history (i.e. >20 pack-years) Cardiac disease Normal PEF or spirometry when symptomatic in adults (NOTE: A normal spirogram, when not symptomatic, does not exclude the diagnosis of asthma. Repeated measurements of lung function are often more informative than a single assessment) 4 Prepared by Pharmaceutical Team, Croydon CCG March 2016, Approved by: CPC March 2016; Review Due: March 2018

11 Croydon CCG Chronic Asthma Management Guidelines STRUCTURED ANNUAL REVIEW (or more frequently as clinically required for non-stable patients) 1. Check asthma control using an accredited tool e.g. Royal College of Physicians 3 Questions for adults, or the Children s Asthma Control Test. i. In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms)? ii. Have you had your usual asthma symptoms (e.g. cough, wheeze, chest tightness, shortness of breath) during the day? iii. Has your asthma interfered with your usual daily activities (e.g. school, work, housework?) Where loss of control is identified, immediate action is required. Treatment may need to be changed and follow-up arrangements made. If control remains poor or is deteriorating consider referring to secondary care. 2. Confirm and document number of asthma attacks, oral corticosteroid use, hospital admissions and time off work/school since last assessment 3. Check patient s understanding of their condition, what their triggers are, the aims of treatment, potential side effects and different inhaler types i.e. preventer and reliever. 4. Offer patients self-management education that focuses on individual needs and reinforce with an age appropriate written Personalised Asthma Action Plan (PAAP). Template plans are available for adults and children here: 5. Review compliance and inhaler technique with patients and ensure spacers are used. Training videos are available at to reinforce this if needed. If technique remains unsatisfactory consider trialling an alternative device. 6. Assess, and document in the clinical record, patient s lung function by spirometry and/or by PEF. Review patient s previous spirometry and peak flow readings and frequency of symptoms to assess control. 7. If patient is a smoker and has not been offered smoking cessation in the last 12 months, refer patients who smoke to an accredited Croydon Stop Smoking Advisor/service (Tel: ) and reinforce benefits of smoking cessation. Assess children s exposure to tobacco smoke and offer smoking cessation to parents/carers as appropriate. 8. Offer annual influenza vaccine administration. Offer pneumococcal vaccine administration according to national guidance 9. In children with asthma monitor growth (height & weight centile) on an annual basis 10. Ensure that all adult patients using >1000mcg beclometasone dipropionate or equivalent per day or at step 4 or above of the treatment guidelines is issued a high dose inhaled steroid card (available via Croydon CCG Pharmaceutical Team or Tel: , 32.00/100 or 96.00/500) 11. Audit patient s use of inhalers: using 10 or more reliever inhalers per year or less than 80% uptake of repeat ICS inhalers per year indicates that a patient should be classified as high risk and should be invited for urgent review (Why asthma still kills: The National Review of Asthma Deaths (NRAD) Confidential Enquiry Report May 2014) 12. Ensure patients who have received treatment in hospital or through out of hours services for an acute exacerbation of asthma are followed up with their own GP within 2 working days (NICE Asthma quality standards [QS25] February 2013) Controlled asthma is defined as having all of the following: PEF or FEV 1 >80% predicted (or at personal best) Need for reliever therapy / rescue treatment less than three times per week Daytime symptoms less than three times per week No nocturnal symptoms / awakenings No limitation of activities If patient s asthma controlled: STEP DOWN If patient s asthma has been well controlled for 3 months or more, discuss with patient and consider stepping down therapy in line with the Croydon CCG Chronic Asthma Management Guidelines. Step down s (dependent on current step): Decrease dose of inhaled corticosteroid (either as combination ICS/LABA or ICS alone) by 25-50% Stop leukotriene receptor antagonist To step down off combination ICS/LABA inhalers: switch to ICS alone inhaler, ensuring equivalent ICS dose is maintained. Review after 3 months and continue to reduce ICS dose as tolerated. Ensure patient is given information on managing symptoms and action to be taken if asthma worsens. Review therapy again in 2 weeks (or sooner if clinically indicated) and regularly thereafter. Consider further step down if patient is well controlled for 3 months. 5 Prepared by Pharmaceutical Team, Croydon CCG March 2016, Approved by: CPC March 2016; Review Due: March 2018 If patient s asthma NOT controlled: consider the following 1. Is the patient using the treatment as directed i.e. using preventer inhaler BD? 2. Is the patient using the most suitable device for their needs and using it correctly? 3. Is the patient being exposed to exacerbating factors which can be eliminated? 4. Is the diagnosis of asthma correct? 5. Are there additional co-morbidities affecting control? If addressed then consider stepping up therapy as outlined in the Chronic Asthma Management guidelines on pages 1 to 3 of this document

12 Aim(s) What this guideline does not cover: Outcome Measures (For Audit Purposes, NSF & GMS) References Authors & Approving Committees Date of Review March 2018 Croydon CCG Chronic Asthma Management Guidelines STRUCTURED ABSTRACT I. To summarise the current BTS/SIGN guidance, into a format which can be used as an easy reference at the point of consultation by clinicians, to ensure the appropriate diagnosis and management of asthma patients. II. To augment the BTS asthma management guidelines by promoting locally agreed first-line cost effective drug choices for the management of chronic asthma in Croydon. This guideline includes a summary of the BTS/SIGN guidelines for the treatment and diagnosis of asthma. Please refer to the full guidance for more detailed information. These guidelines cover the management of chronic asthma and do not provide any guidance on the treatment of acute asthma, please refer to the BTS/SIGN guidance on this. These guidelines represent current recommended practice in Croydon. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. QOF AST001: The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months QOF AST002: The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or any time after diagnosis QOF AST003: The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions QOF AST004: The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months QOF SMOK002: Percentage of patients with any conditions e.g. Asthma whose notes record smoking status in the preceding 12 months QOF SMOK005: Percentage of patients with any conditions e.g. Asthma who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months - BTS/SIGN Asthma Guideline British National Formulary No 70 September Why asthma still kills: The National Review of Asthma Deaths (NRAD) Confidential Enquiry Report May London Children and Young People s Strategic Clinical Network asthma standards for Children and Young People July London Respiratory Network: Responsible Respiratory Prescribing Messages, March NICE Asthma quality standards [QS25] February 2013 (Layout adapted from NHS Southwark and Lambeth CCG Guidelines Nov 2013 with permission) Victoria MacGregor Senior Practice Support Pharmacist, Croydon CCG Margaret Haastrup Principal Pharmacist, Croydon CCG Dr Roshan Siva Respiratory Consultant, Croydon University Hospital Dr Tuck-Kay Loke Respiratory Consultant, Croydon University Hospital Croydon Respiratory Team Children s Hospital at Home team Croydon Health Services paediatricians Croydon Prescribing Committee 6 Prepared by Pharmaceutical Team, Croydon CCG March 2016, Approved by: CPC March 2016; Review Due: March 2018

13 Prepared by Pharmaceutical Team, Croydon CCG March 2016, Approved by: CPC March 2016; Review Due: March 2018 Croydon CCG Chronic Asthma Management Guidelines Summary of Preferred Inhaler Devices for Asthma Management Start treatment at the step most appropriate to the initial severity, medication should be titrated against clinical response to ensure optimum efficacy. Move up to improve control as needed Move down to find and maintain lowest controlling step STEP 1 INHALER CHOICES Mild Intermittent Asthma STEP 2 INHALER CHOICES Mild Persistent Asthma STEP 3 INHALER CHOICES Moderate Persistent Asthma STEP 4/5 INHALER CHOICES Persistent Poor Control ADULTS and children over 12 years of age Salbutamol 100mcg 1-2 puffs QDS prn Easi-Breathe Salbutamol 100mcg Easi-Breathe 1-2 puffs QDS prn Terbutaline sulphate 500mcg Turbohaler 1 puff QDS prn CHILDREN aged 5 to 12 years Salbutamol 100mcg Inhaler 1-2 puffs QDS prn via spacer Easi-Breathe Salbutamol 100mcg Easi-Breathe 1-2 puffs QDS prn Terbutaline sulphate 500mcg Turbohaler 1 puff QDS prn CHILDREN aged less than 5 years Salbutamol 100mcg Inhaler 1-2 puffs QDS prn via spacer Clenil Modulite 100mcg** 2 puffs BD via spacer Easi-Breathe Qvar 50mcg Easi-Breathe ** 2 puffs BD Pulmicort 100mcg Turbohaler (Budesonide) 2 puffs BD Clenil Modulite 50mcg** 1 puff BD via spacer Pulmicort 100mcg Turbohaler (Budesonide) 1 puff BD Clenil Modulite 50mcg Inhaler 2 puffs BD via spacer Flutiform 125/5mcg (12 years and over) (Fluticasone/Formoterol) 1 puff BD via spacer Sirdupla 125/25mcg (18 years+ only) (Fluticasone/Salmeterol) 1 puff BD via spacer DuoResp Spiromax 160/4.5mcg (18 years+ only) (Budesonide/Formoterol) 1 puff BD Symbicort 200/6mcg Turbohaler (12 years and over) (Budesonide/Formoterol) 1 puff BD Seretide 50/25mcg Evohaler (Fluticasone/Salmeterol) 1 puff BD via spacer Symbicort 100/6mcg Turbohaler (Budesonide/Formoterol) 1 puff BD Seretide 100/50mcg Accuhaler (Fluticasone/Salmeterol) 1 puff BD Clenil Modulite 100mcg Inhaler 2 puffs BD via spacer 7 Flutiform 125/5mcg (12 years and over) (Fluticasone/Formoterol) 2 puffs BD via spacer Flutiform 250/10mcg (18 years+ only) (Fluticasone/Formoterol) 1-2 puffs BD via spacer Sirdupla 250/25mcg (18 years+ only) (Fluticasone/Salmeterol) 1-2 puffs BD via spacer DuoResp Spiromax 360/9mcg (18 years+ only) (Budesonide/Formoterol) 1-2 puffs BD Symbicort 400/12mcg Turbohaler (12 years and over) (Budesonide/Formoterol) 1 puff BD Respiratory Specialist recommended only Spiriva Respimat 2.5mcg (18 years+ only) (Tiotropium) 2 puffs OD Referral to paediatrician recommended Specialist referral required because the use of combination inhalers at higher steroid doses is unlicensed Referral to paediatrician recommended Specialist referral required because the use of combination inhalers at higher steroid doses is unlicensed If no response after 6 weeks refer to paediatrician Only preferred products are shown. If a patient cannot use, or declines the listed inhalers then alternative products within the recommended classes are available. Choice of product class should be based on the BTS/SIGN asthma guideline. It is recommended that combination ICS/LABA inhalers are prescribed by BRAND name. **NB: Beclometasone inhaler potencies vary, caution required when switching between inhalers. Qvar (beclometasone dipropionate) inhalers are not licensed in the under 12s.