Appendix 3F – Guidance on Management of COPD

Inhaled therapy

ASSESS TECHNIQUE BEFORE CHANGE IN STEP/THERAPY

All patients

All patientsBronchodilator as needed or on regular basis to prevent / reduce worsening symptoms

Short acting β2 agonist asDPI needed Easyhaler® or on regular basis to prevent / reduce worseningShort acting symptoms

Short acting β2 agonistMDI Salbutamol MDI Salbutamol Short acting anticholinergic DPI Easyhaler® Salbutamol Further treatment Ipratropium bromide Dependent on whether increasing breathlessness or increasing risk of Further treatmentexacerbations dominates clinical presentation. Dependent on whether increasing breathlessness or increasing risk of exacerbations dominatesC: Severe/Very clinical severe presentation. D: Severe/Very severe (FEV1<50% predicted) (FEV1<50% predicted)

C: Severe/Very severeLess symptoms of breathlessnessD: Severe/Very severeMore symptoms of breathlessness

(FEV1<50% predicted)High risk of exacerbations (>2/yr)(FEV 1<50% predicted)High risk of exacerbations (>2/yr) Less symptoms of breathlessness More symptoms of breathlessness Therapy: ICS+LABA Therapy: ICS+LABA and LAMA High risk of exacerbations (>2/yr) High risk of exacerbations (>2/yr) Once daily dosing Twice daily dosing Once daily dosing Twice daily dosing Therapy: ICS+LABADry powder inhaler MeteredTherapy: dose inha ICS+ler LABADry powder and LAMA inhaler Metered dose inhaler

Once daily dosing RelvarTwice Ellipta® daily dosing FostairOnce 100/6 daily pMDI dosing® TrelegyTwice Ellipta® daily dosing Trimbow 87/5/9 Frequentexacerbations Dry powder inhaler 92/22mcg*Metered dose inhaler Dry powder inhaler 92/22Metered/55mcg dose inhalerpMDI ® quentexacerbations A: Mild/Moderate B: Mild/Moderate

Relvar Ellipta® Fostair 100/6 pMDI® Trelegy Ellipta® Trimbow 87/5/9 Fre

Less symptoms of breathlessness More symptoms of breathlessness 92/22mcg* 92/22/55mcg pMDI® Low risk of exacerbations (<2/yr) Low risk of exacerbations (<2/yr)

A: Mild/ModerateTherapy: LAMA or LABA B: Mild/ModerateTherapy: LAMA+LABA Less symptoms of breathlessness More symptoms of breathlessness Once daily dosing Once daily dosing Low risk of exacerbations (<2/yr) Twice dailyLow dosing risk of exacerbations (<2/yr) Twice daily dosing Dry powder inhaler or Dry powder inhaler Dry powder inhaler Dry powder inhaler Therapy: consider adding ICS LAMA orFine LABA mist Therapy: LAMA+Lor ABAfine mist Incruse Ellipta® or Eklira Genuair® or Once daily dosing Twice daily dosing Once daily dosing AnoroTwice Ellipta® daily dosing or Spiriva Respimat Easyhaler® Duaklir Genuair® Dry powder inhaler Dry powder inhaler Dry powder inhaler SpioltoDry powderRespimat inhaler

Increasing risk of acute exacerbations, exacerbations, Increasing acute of risk Infrequent Infrequent exacerbations Eklira Genuair® Incruse Ellipta® or Low symptoms High Symptom N.B. no once daily Anoro Ellipta® Duaklir Genuair® Easyhaler® LABA Infrequent Infrequent exacerbations formoterol Low symptomsIncreasing symptoms of breathlessness,High add Symptommore bronchodilator ASSESS INHALER TECHNIQUE BEFORE CHANGE IN STEP/THERAPY * card required for doses of 800mcg of equivalent or more. ** Trimbow pMDI contains the equivalent dose of ICS/LABA as Fostair pMDI, but expressed differently as metered verses delivered dose i.e. 87/5/9mcg equivalent to 100/6/10 ICS – Inhaled ; LABA – Long acting beta2 agonist; LAMA – Long acting

Inhaler Device Contains Relvar Ellipta® 92/22mcg furoate 92/ trifenatate 22mcg Fostair ® 100/6mcg pMDI Beclometasone 100mcg/formoterol 6mcg Incruse Ellipta® 55mcg 55mcg Eklira Genuair® 375mcg 375mcg Easyhaler® formoterol 12mcg Formoterol 12mcg Spirivia Respimat® 2.5mcg monohydrate 2.5mcg Spiolto Respimat® 2.5/2.5mcg Tiotropium bromide monohydrate 2.5mcg/ hydrochloride 2.5mcg Anoro Ellipta® 55/22mcg Umeclidinium bromide 55mcg/ vilanterol trifenatate 22mcg Duaklir Genuair® 12mcg Aclidinium bromide 375mcg /formoterol 12mcg Trelegy Ellipta® 92/22/55mcg 92mcg/vilanterol trifenatate 22mcg /umeclidinium bromide 55mcg Trimbow 87/5/9 pMDI® Beclometasone 100mcg/formoterol 6mcg /glycopyrronium bromide9mcg N.B. Due to variation between devices, all should be prescribed by brand name only (except salbutamol MDI). Date: August 2020 Review Date: August 2021 Approved on behalf of NHS Fife by the Fife Area Drugs & Therapeutics Committee Date: August 2020