Appendix 3B – Asthma Treatment in Adults

Patients should be reviewed on a regular basis. Once symptoms are under control, the patient should be stepped down to the lowest effective step that maintains asthma control. Refer to BNF for recommended doses

ASSESS INHALER TECHNIQUE BEFORE CHANGE IN STEP/THERAPY

BTS/SIGN Metered Dose Inhaler Options Dry Powder Device Options Step (+/- spacer*) Step 1:Mild

intermittent ® Short-acting 2- Salbutamol 100mcg Easyhaler salbutamol 100mcg agonist as required

Step 2: 1st choice: Regular 1st choice: Easyhaler® Beclometasone 200mcg, preventer Clenil Modulite® 100mcg or Add regular ICS 2nd choice: Easyhaler® Budesonide 100mcg Stop separate ICS, switch to combination device Step 3: Add ® on therapy Fostair 100/6mcg: Relvar® 92/22mcg*, or Add LABA**,  ® ICS dose to one puff twice daily*** Symbicort 200/6mcg 800mcg/d

® Fostair 100/6mcg 2 puffs twice daily* Relvar® 184/22mcg* or Step 4: increasing to Symbicort® 400/12mcg* or Persistent Fostair 200/6mcg 2 puffs twice daily * add montelukast. poor control or add montelukast. If no response/intolerant to  ICS up to If no response/intolerant to 2000mcg/d (high montelukast, change to strength) montelukast, change to Move up and down steps as necessary as steps down and up Move Spiriva Respimat® 2.5mcg Spiriva Respimat® 2.5mcg

® Step 5: Relvar 184/22mcg* or Maintain high Fostair 200/6mcg 2 puffs twice daily * Symbicort® 400/12mcg* dose ICS at plus low dose daily steroid tablets 2000mcg/d plus low dose daily steroid tablets Continue plus specialist referral/care additional plus specialist referral/care therapies

* Spacers available are Volumatic® and Aerochamber®. Whilst different inhalers are licensed for use with particular spacers, consideration should be given to which spacer will be most acceptable for patient/carer use. * Steroid card required for doses greater than or equal to 800mcg of beclometasone equivalent ** Long Acting Beta2 Agonists (LABAs) should not be prescribed alone for asthma *** Fostair contains extrafine beclometasone particles, 100mcg is equivalent to 250mcg non-extrafine beclometasone (as contained in Clenil)

Inhaler Device Contains Clenil Modulite®, Qvar® Beclometasone diproprionate Fostair® Beclometasone diproprionate/formoterol fumarate Symbicort Turbohaler® Budesonide/ formoterol fumarate Relvar Ellipta® Fluticasone furoate/ vilanterol trifenatate Spiriva Respimat® Tiotropium bromide monohydrate N.B. Due to variation between devices, all inhalers should be prescribed by brand name only (except salbutamol MDI).

Author: Respiratory MCN Date: November 2015 Version:2 Review Date: Nov. 2018 Approved on behalf of NHS Fife by the Fife Area Drugs & Therapeutics Committee Date: December 2015