Respiratory Inhalers

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RESPIRATORY INHALERS

The correct administration of inhaled therapy is essential for successful, cost-effective and safe therapy. Everyone, including the patient needs to understand the importance of ensuring correct inhaler technique. Patients should be instructed on how to use their inhaler and supervised when they are first prescribed a new inhaler and their inhalation technique should be checked by observation at every opportunity.

To promote a consistent inhaler technique for patients, wherever possible, prescribe drugs in identical devices or, if this is not possible, use the same type of device i.e either aerosols or DPI devices rather than a mixture of the two.

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INHALED DEVICE COST USUAL DOSE PHARMACOLOGICAL RECOMMENDED THINGS TO NOTE MEDICINE OPTIONS ACTION PLACE IN UK www.medicines.org.uk or Common adverse effects, precautions 30 day treatment / PRACTICE Generic Name RED = per dose BNF for more details and key pharmacokinetic for use etc. DRY powder device profiles GUIDELINES based on BNF For children please confirm BLUE = Brand Name September 2014 licensed indication and dose AEROSOL device before prescribing

SHORT ACTING BRONCHODILATORS Short Acting Beta-2 agonist (SABA)

Salbutamol Easyhaler ® £3.31 $ 100 –200 micrograms when Mechanism of action: Relief of breathlessness SABA inhalers should ideally be prescribed Airomir ®o, AirSalb , MDI □,o £1.50 –£1.97 $ required • Bronchodilation and chest tightness in “PRN - when required ” as this helps to Salamol ®□ and Ventolin ®□ through activation of people with asthma and monitor control. Reliance on frequent use, Salamol ® Easi-Breathe ® £6.30 $ beta-2 receptors on the COPD (according to the or a sudden increase in dose, indicates Ventolin ® Accuhaler ® £6.00 $ airway smooth muscle British Asthma poorly controlled or deteriorating Airomir ® Autohaler £6.02 $ • Reduction of lung guideline 1 and NICE disease. Salbulin ® Novolizer ® £4.95 (refill £2.75) $ hyperinflation, resulting COPD guideline). 2 in increased inspiratory People with asthma using their SABA capacity inhaler three times a week or more is a Terbutaline marker of uncontrolled asthma and should Bricanyl ® Turbohaler ® £6.92 $ 500 micrograms when Onset of action: have their asthma control assessed. 1 Any required • within 5 minutes person with asthma identified as requesting twelve or more 3 SABA canisters over 12 Duration of action: months should be invited for a structured • approximately 4 to 6 review of their asthma. hours People with COPD may require more No clinical pharmacological regular use of SABA, as using prior to difference between movement/exercise may be beneficial. salbutamol and terbutaline For people using SABA regularly ensure other medicines are prescribed and optimised to reduce breathlessness as per NICE COPD guideline. 2

Side effects include: Fine tremor (particularly in hands), muscle cramps and tachycardia. High doses associated with hypokalaemia. Most side effects are dose related.

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SHORT ACTING BRONCHODILATORS continued Short Acting Muscarinic Antagonist (SAMA)

Ipratropium bromide Atrovent ® MDI £3.34 –£6.67 20 –40 micrograms three to Mechanism of action: Relief of breathlessness Side effects include: four times a day (there is • Bronchodilation in people with COPD Dry mouth (most common), dizziness, no benefit in using through antagonism at who have intermittent nausea, gastro-intestinal motility disorder >4 times a day, although muscarinic receptors on symptoms. (i.e. constipation or diarrhoea), cough and some patients may need airway smooth muscle headache. up to 4 puffs at a time to • Reduction of lung Relief of breathlessness, obtain maximum benefit) hyperinflation, resulting wheeze and chest Precautions for use: in increased respiratory tightness (in addition to Prescribe with caution in people with For dose in children capacity SABA treatment) in acute pre-existing bladder outflow obstruction or <12 years see BNF asthma exacerbations. prostatic hyperplasia, and those susceptible Onset of action: to angle-closure glaucoma. Studies have • within 20 minutes, suggested an increased risk of cardiovascular morbidity and mortality Duration of action: associated with the use of ipratropium • approximately 4 hours bromide. 4 Patients should be reminded not to exceed the recommended dose. Δ

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LONG ACTING BRONCHODILATORS Long Acting Beta-2 agonists (LABA)

Salmeterol MDI £29.26 Vertine ® MDI □ 50 micrograms twice a day Mechanism of action: Maintenance In people with asthma a LABA must be £23.40 • Bronchodilation Serevent ®□ MDI □ (higher doses not management of used in conjunction with an inhaled £29.26 through activation of Serevent ® recommended as evidence persistent asthma not corticosteroid (ICS). Data from a large Accuhaler £35.11 beta-2 receptors on ® for increased efficacy is controlled by inhaled clinical trial showed an increased risk of Neovent MDI* £29.26 airway smooth muscle ® limited) Soltel MDI* £19.95 • Reduction of lung corticosteroids series respiratory-related deaths when hyperinflation, Formoterol or salmeterol LABA used with no ICS in people with 5 Formoterol Easyhaler ® £11.87 Asthma : resulting in increased should be prescribed as asthma. A combination inhaler containing Oxis ® Turbohaler ® £24.80 6–12 micrograms respiratory capacity an add-on therapy to an both LABA and ICS is recommended. ® during exercise and at inhaled corticosteroid. Foradil Dry powder £28.06 twice a day In people with confirmed diagnosis of Atimos Modulite ®□ MDI □ (Oxis ® licensed up to 72 rest £18.04 • Reduction of COPD COPD (and no overlap with asthma) a micrograms daily if LABA can be used with no concurrent ICS exacerbations Maintenance treatment needed) for people with persistent breathlessness. Onset of action: of COPD for people with COPD : • formoterol within persistent breathlessness. 12 micrograms twice a day 3 minutes Side effects include: • salmeterol fine tremor (particularly in hands), headache, muscle cramps and tachycardia. Indacaterol COPD : approximately 20 Maintenance treatment ® minutes High doses associated with hypokalaemia. Onbrez Breezhaler ® £32.19 150 micrograms once a of COPD for people with • indacaterol within In studies with indacaterol, upper day, increased to maximum persistant breathlessness 5 minutes respiratory tract infections, 300 micrograms once a day (not licensed for asthma). • olodaterol within nasopharynigitis, sinusitis and rhinorrhoea 5 minutes were commonly observed. Olodaterol Duration of action: Striverdi ® Respimat ® £26.35 COPD : • salmeterol and Drug interactions: 5 micrograms once a day formoterol 12 hours All LABAs shoud be used cautiously with • indacaterol and drugs that increase the risk of prolongation olodaterol have a of the QTc interval (e.g. ketoconazole, longer duration of tricyclic antidepressants, quinidine, action of 24 hours, disopyramide, proacinamide, hence once daily dosing erythromycin).

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LONG ACTING BRONCHODILATORS continued Long Acting Muscarinic Antagonist (LAMA)

Tiotropium bromide ® ® Mechanism of action: Maintenance treatment Side effects include: Spiriva Respimat £23.00 5 micrograms once a day ® • Bronchodilation of COPD in those Dry mouth (relatively common), which may in Spiriva Handihaler ® £34.87 18 micrograms once a day through antagonism at people with persistent the long term be associated with dental caries. (refill pack £33.50) muscarinic receptors on Nasopharyngitis, headache, and diarrhoea ® , ® symptoms. Braltus Zonda £25.80 airway smooth muscle commonly reported with both glycopyrronium • Reduction of dynamic bromide and aclidinium bromide. May help to reduce Aclidinium bromide 322 micrograms twice a hyperinflation, resulting Precautions for use: ®t ® exacerbations of COPD. Eklira Genuair £28.60 day (equivalent to in increased respiratory Use with caution in people with prostatic capacity during exercise hyperplasia, bladder outflow obstruction, those 400 micrograms of Tiotropium Respimat is susceptible to angle-closure glaucoma, previous aclidinium bromide) and at rest • Antimuscarinics in also licensed for people history of cardiovascular disease and renal theory should help with asthma, who are impairment (see notes below). Glycopyrronium reduce mucus secretion adherent to combined Caution in cardiovascular disease: 44 micrograms once a day • May reduce COPD ICS (≥800 micrograms) Studies have suggested an increased risk of bromide (equivalent to cardiovascular morbidity and mortality associated ®t exacerbations and LABA with ≥1 severe Seebri Breezhaler ® £27.50 with the use of antimuscarinics. 4 Other studies 55 micrograms of exacerbations in the glycopyronnium bromide) Onset of action: have shown that tiotropium handihaler and • tiotropium bromide, previous year. The respimat are not associated with the increased aclidinium bromide and BTS/SIGN guideline risk. 6,7 All LAMAs should be used with caution umeclidinium bromide states that ‘LAMA appear for people with unstable ischaemic heart disease, within 30 minutes to be as effective as left ventricular failure, history of myocardial infarction or arrythmias. Δ Patients should be • glycopyrronium has a salmeterol in the short reminded not to exceed the recommended dose. faster onset within 5 term and may be superior minutes Caution in renal impairment: to doubling the dose of Tiotropium bromide should only be used if the Duration of action: ICS in fixed airways expected benefit outweighs the risk in people • tiotropium bromide, obstruction’. with moderate to severe renal impairment glycopyrronium Addition to ICS/LABA (creatinine clearance ≤50 ml/min). bromide and may benefit patients who Glycopyrronium bromide has similar concerns umeclidinium bromide but if creatinine clearance is <30 ml/min. remain symptomatic Aclidinium bromide can be prescribed in renal Umeclidinium at least 24 hours despite ICS/LABA. ® 55 micrograms once a day impairment as it is qrapidly and extensively Incruse ® Ellipta £27.50 • aclidinium has a shorter (equivalent to hydrolysed to pharmacological inactive duration of metabolites.Umeclidinium can be prescribed in 65 micrograms of approximately 12 hours, renal impairment. umeclidinium bromide) hence the twice daily Once umeclidinium foil packaging is opened it dosing has an in-use shelf life of 6 weeks.

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COMBINATION LONG-ACTING MUSCARINIC ANTAGONIST AND LONG-ACTING BETA-2 AGONIST (LAMA/LABA)

Umeclidinium (LAMA) Ensure patient has a correct diagnosis of COPD. / Vilanterol (LABA) LAMA/LABA combinations are not licensed for ®t ® Anoro Ellipta £32.50 55/22 micrograms once a Mechanism of action: Maintenance treatment asthma. Data from a large clinical trial showed an day at the same time • Bronchodilation of COPD for people with increased risk of series respiratory-related deaths of the day each day through both when LABA used with no ICS in people with persistant breathlessness. asthma. 5 activation of beta-2 receptors and Side effects include: antagonism at Urinary tract infection, sinusitis, nasopharyngitis, muscarinic receptors pharyngitis, upper respiratory tract infection, headache, cough, dry mouth and constipation. on airway smooth An increased incidence of cardiovascular and muscle cerebrovascular events may occur with long-term • Reduction of dynamic use (robust >1 year safety data is not yet hyperinflation, available). resulting in increased Precautions for use: respiratory capacity Contra-indicated if patient has a severe during exercise and hypersensitivity to milk proteins. Do not use in at rest combination with an additional medicine containing LABA because of risk of overdose. Glycopyrronium Use with caution in people with prostatic (LAMA) / Indacaterol hyperplasia, bladder outflow obstruction, those susceptible to angle-closure glaucoma, and (LABA) previous history of cardiovascular disease. ®t Ultibro Breezhaler ® £32.50 85/43 micrograms once a day Drug interactions: All LABAs shoud be used cautiously with drugs that increase the risk of prolongation of the QTc interval (e.g. ketoconazole,clarithromycin, Aclidinium (LAMA) / erythromycin itraconazole, tricyclic Formoterol (LABA) antidepressants, quinidine, disopyramide, ®t DuaKlir Genuair ® £32.50 340/12 micrograms proacinamide). twice a day Co-administration of LAMA/LABA combinations with other LAMA, LABA or products containing Olodaterol (LABA) / either of these agents has not been studied and is Tiotropium (LAMA) not recommended. Spiolto Respimat ® £32.50 2.5/2.5 micrograms Once Anoro’s foil packaging is open the in-use shelf life is 6 weeks. once a day

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MAST CELL STABILISERS

Nedocromil Tilade ® MDI o £85.58 (initial) 4mg four times a day, when Mechanism of action: Prophylaxis of asthma May be of benefit in asthma with an allergic £42.79 control achieved • not completely where regular basis, but in practice, it is difficult to predict (maintenance) reduce to twice a day understood preventative anti- who will benefit. Give for a trial of 4 to 6 • non-steroidal agent, inflammatory therapy is weeks and assess response. Stop inhaler if which has anti- indicated. no positive response. Sodium Cromoglycate inflammatory Intal ® MDI □ £39.28 10mg four times a day, properties Not currently Side effects include: (initial) increased if necessary to • inhibits the activation recommended in the Abdominal pain, vomiting, nausea, cough, 6–8 times daily; of many of the cell British Asthma Guideline bronchospasm, headache, dyspepsia and £19.64 maintenance 5mg four types involved in the for Adults. dysgeusia. (maintenance) times a day development and progression of asthma Must be used regularly. – inhibiting the release of inflammatory mediators from mast cells

Onset of action: • clinical improvement in symptoms and lung function usually occurs within 4 weeks of beginning treatment

Duration of action: • protection against antigen or exercise challenge (up to 2 hours)

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INHALED CORTICOSTEROIDS (ICS)

Budesonide Easyhaler ® £5.31 –£21.25 Adults and children Mechanism of action in Prophylactic Inhaled corticosteroid must be used Pulmicort ® Turbohaler ® £7.10 –£33.26 >12 years: asthma: management of mild, regularly for maximum benefit. For most Budelin ® Novolizer ® £8.92 –£35.66 200 micrograms twice a • Anti-inflammatory moderate and severe ICS this is twice a day, though ciclesonide day (low dose), effect on bronchial persistent asthma and mometasone are daily doses, and guidelines recommend that once daily may Beclometasone 400 micrograms mucosa (and hence (≥ Step 2 British Asthma be appropriate in some patients with milder ® reduce oedema and Guideline). Easyhaler £5.93 –£23.52 twice a day (medium dose), disease and good control of their asthma. Clenil Modulite ®□ MDI □ £4.43 –£19.55 and severe asthma (high secretion of mucus dose)up to 1600 into the airway) Please note, one inhaler Current and previous smoking reduces the micrograms/day • Reduces containing both ICS and effectiveness of inhaled corticosteroids and hyperresponsiveness LABA is preferred rather higher doses may be necessary. Children ≤ 12 years (check of the bronchial tract than individual inhalers, BNF for licensing and to exogenic challenges an approach that aims to For people with asthma the maintenance dosing) improve medicine dose of ICS should be individualised and Onset of action: adherence and reduce titrated to the lowest dose at which improvement in lung the potential risks effective control of asthma is maintained. Beclometasone function has been shown associated with people Side effects include: Extrafine to occur within 2 days after only using a LABA with Qvar ®o MDI o £4.45 –£20.65 Only licensed for adults Common local side-effects include initiation of treatment, no ICS. oropharyngeal candidiasis (fungal), Qvar ®o Easi-Breathe ® £4.45 –£20.65 and children > 12 years: although maximum benefit hoarseness, cough and headache. ®o ® 100 micrograms twice a Qvar Autohaler £4.45 –£20.65 may not be achieved for No inhaler containing To reduce incidence of oral fungal day (low dose), up to 6 weeks (full only ICS is recommended infections patients should be advised to 200 micrograms twice a reduction in airway for managing COPD. rinse their mouth out with water after use. day (medium dose), and hyperresponsiveness Ciclesonide is metabolised to its biologically severe asthma (high dose) may take 12 months) active metabolite by enzymes in the lung up to 400 micrograms and therefore is not associated with oral twice a day Mechanism of action in fungal infections. COPD: Prolonged treatment with high dose No inhaler containing only inhaled corticosteroids (equivalence of ICS is currently licensed >800 micrograms beclometasone per a day) for COPD in the UK. ICS may result in clinically significant adrenal

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INHALED CORTICOSTEROIDS (ICS) continued

Ciclesonide Alvesco ® MDI o £8.21 –£9.66 Only licensed for adults (in combination with suppression, growth retardation in children max £58.62 and children >12 years: LABA) may reduce COPD and adolescents (regularly monitor height), 80 to 160 microgram once exacerbations but do not decrease in bone mineral density, cataract, a day preferably in the improve symptoms glaucoma, increased susceptibility to infection, including pneumonia. For people evening (severe asthma prescribed high dose ICS give a “steroid maximum dose 32 card” (usually blue). micrograms twice a day) Precautions for use: Patients with active or quiescent pulmonary tuberculosis, and in patients with fungal or Fluticasone viral infections in the airways. Proprionate Flixotide TM □ Accuhaler TM £7.66 –£43.37 Adults and children Drug interactions: Flixotide TM □ MDI □ >12 years: All current ICS are metabolised by the liver. 100 micrograms twice a Concomitant administration of potent day (low dose), inhibitors of cytochrome enzymes 250 micrograms twice a (e.g. ketoconazole, itraconazole) should be avoided unless the benefit outweighs the day (medium dose), and increased risk of potential systemic side severe asthma (high dose) effects of corticosteroids. up to 500 micrograms twice a day All ICS appear to be equally clinically effective at equivalent doses. Care should Children ≤ 12 years be taken when switching people between (check BNF for licensing different ICS. The available ICS vary in and dosing) potency (e.g. fluticasone proprionate is double the potency of beclometasone) and efficiency of lung deposition (e.g. Mometasone furoate beclometasone extrafine delivers twice the Asmanex ® Twisthaler ® £21.78 –£43.56 Only licensed for adults amount to the lung) influencing their and children >12 years: comparative doses. See PCRS ICS Table on 400 micrograms once a day Equivalent Doses and relevant information. ® ® (low dose). Maximum dose Qvar and Clenil are not interchangeable and should be prescribed by brand name. 400 micrograms twice a day (medium dose)

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COMBINATION INHALED CORTICOSTEROID AND LONG-ACTING BETA-2 AGONIST (ICS/LABA)

Fluticasone priopionate/ salmeterol Patients should be made aware that Seretide ® ® £18.00 –£40.92 Asthma Mechanism of action: Prophylactic Accuhaler ICS/LABA inhalers must be used daily for (COPD £40.92) Usual starting dose in • Anti-inflammatory management of moderate effect on bronchial optimum benefit, even when Seretide ® MDI □ £18.00 –£59.48 adults at step 3 Seretide and severe persistent 100/50 micrograms twice mucosa (and hence asthma (≥ Step 3 British asymptomatic. Sirdupla MDI □ £26.25 –£44.61 a day, increased to reduce oedema and Asthma Guideline). 250/50 micrograms secretion of mucus Side effects: AirFluSal Forspiro £32.74 twice a day into the airway) Symptomatic treatment As these are combination inhalers Few patients will require • Reduces of people with COPD containing ICS and LABA the type and ® * Sereflo MDI £23.50-£39.95 the maximum dose hyperresponsiveness with a FEV 1 <50% severity of side effects associated with 500/50 microgram of the bronchial tract to predicted normal each of the compounds may be expected. Aerivio ® Spiromax £29.97 twice a day exogenic challenges (post-bronchodilator) There are no additional adverse effects Aerivio, AirFluSal, • Bronchodilation with an exacerbations following concurrent administration of the Sereflo and Sirdupla through activation of history despite regular two compounds. See notes above for each (over 18 years only) beta-2 receptors on therapy with long-acting drug class. airway smooth muscle bronchodilators. COPD • Reduction of lung Precautions for use: Aerivio Spiromax, hyperinflation, The precautions for use are related to both AirFluSal Forspiro and resulting in increased the ICS and the LABA component of the Seretide Accuhaler ® respiratory capacity inhaler. See notes above for each drug 500/50 micrograms during exercise and class. twice a day at rest • Reduction of COPD Drug Interactions: exacerbations The drug interactions are related to both the ICS component and the LABA Onset of action (inhalers component of the inhaler. See notes containing): above for each drug class. • formoterol within 3 minutes

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COMBINATION INHALED CORTICOSTEROID AND LONG-ACTING BETA-2 AGONIST (ICS/LABA) continued

Budesonide / formoterol Symbicort ® Turbohaler £19.00 –£76.00 Asthma • salmeterol DuoResp Spiromax is dispensed foiled (COPD £38.00) Usual starting dose in approximately wrapped. After opening the foil wrap the MDI □ adults at step 3 20 minutes shelf life is 6 months. • vilanterol Symbicort Turbohaler DuoResp ® Spiromax £14.99 –£59.94 approximately 200/6 micrograms twice Aerivio Spiromax is dispensed foiled (COPD £29.97) 15 minutes a day, increasing to wrapped. After opening the foil wrap the 400/12 micrograms twice shelf life is 3 months. The ICS component of the a day (few patients inhaler will take longer to require maximum dose Symbicort (100/6 and 200/6) and DuoResp work (see notes above 800/24 micrograms (160/4.5) are licensed for Maintenance and ICS) ╦ twice a day) † reliever therapy. }

DuoResp (over 18 years Duration of action: To avoid inadvertent switching between only) 160/4.5 to • approximately 12 hours different devices it is advised to prescribe maximum inhalers by brand name. 640/18 micrograms See above for the different twice a day potency of ICS and the equivalent dosage COPD schedules. Symbicort Turbohaler 400/12 micrograms twice a day Symbicort MDI 200/ 6 micrograms 2 puffs twice a day DuoResp 320/9 micrograms twice a day

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NOT LICENSED IN THE UK ® Easyhaler Fobumix Unknown (expected to be licensed for the management of asthma)

Fluticasone Furoate / Vilanterol Relvar ® Ellipta £22.00 –£29.50 Asthma As above. As above. See notes above. (COPD £22.00) 92/22 micrograms once a day, increased to The exact bioequivalence of fluticasone ® 184/22 micrograms fuorate to belcometasone (CFC or Clenil ) once a day is not known. The SPC suggests that ® It is anticipated that few 92/22 microgram Relvar is equivalent to patients will require the 250/50 Seretide twice a day (equivalent to higher dose Step 4 BTS/SIGN asthma guideline). Not licensed in children Further studies are being undertaken. under 12 years Once the foil packaging is open the in-use COPD shelf life is 6 weeks. 92/22 micrograms once a day at the same time of the day. If a dose is missed the next dose should be taken at the usual time the next day (the higher dose is not licensed and should not be prescribed)

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Beclometasone extra-fine/formoterol Fostair ® MDI □ £14.66 –£29.32 Asthma As above. As above. See notes above. (COPD £29.32) Usual starting dose 100/6 one puff twice a day, Fostair ® is characterised by an extrafine increased to two puffs particle size distribution which results in twice a day (few patients more potent effect than formulations of require 400/12 twice a day) beclometasone with a non-extrafine size Licensed in adults distribution. 100 micrograms of 18 years and older belometasone extrafine in Fostair ® are (licensed for MART equivalent to 250 micrograms of therapy ╦) belometasone in non-extrafine formulations. COPD 100/6 two puffs Prior to dispensing Fostair MDI is stored in twice a day the refrigerator (2-8 oC). Keep at room Adults 18 years and older: temperature for one hour before using. One or two inhalations After dispensing Fostair MDI can be kept twice daily at room temperature (below 25 oC) for The maximum daily dose is 5 months. 4 inhalations daily Fostair NEXThaler is dispensed foiled Fostair ® NEXThaler ® £14.66 –£29.32 Asthma As above. Prophylactic wrapped. After opening the foil wrap the Usual starting dose 100/6 management of moderate shelf life is 6 months one puff twice a day, and severe persistent increased to two puffs asthma (≥ Step 3 British twice a day Asthma Guideline). It is Licensed in adults not licensed for people 18 years and older with COPD. COPD 100/6 two puffs twice a day

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Fluticasone proprionate/ formoterol Flutiform ® MDI □ £14.40 –£14.56 Usual adult/adolescent Prophylactic See notes above. (>12yrs) starting dose management of moderate 50/5 microgram two puffs and severe persistent Once the foil packaging is open the in-use twice a day, increasing to asthma (≥ Step 3 British shelf life is 3 months. 125/5 micrograms two Asthma Guideline). puffs twice a day It is not licensed for The 50/5 microgram strength inhaler is Maximum dose 250/ people with COPD. grey/white but has a blue band around the 10 micrograms two puffs top of the canister. This could potentially twice a day only for adults cause patients to mistakenly use it on an as who remain symptomatic needed basis rather than regularly twice a day.

K Inhaler Devices RED = Dry powder inhalers (Accuhaler TM , Breezhaler ®, Clickhaler ®, Easyhaler ®, Ellipta ®, Forspiro, Genuair ®, Handihaler ®, NEXThaler ®, Novolizer ®, Pulvinal ®, Spiromax ®, Turbohaler ®, Twisthaler ®) ® ® ® E BLUE = Aerosol inhalers (Autohaler , Easi-breathe , Metered dose inhaler (MDI), Respimat ) Y Spacer compatibility*: o MDI with mouthpiece shape round (not compatible with Volumatic TM spacer device) □ MDI with mouthpiece shape compatible with all spacer devices * compatibility based on ability to fit spacer – not the evidence base to support optimal drug delivery t This medicine is subject to additional monitoring. Please report any suspected adverse reactions to the Yellow Card scheme, including any possible side effects not listed in the Summary of Product Characteristics (SPC). Δ Please remember to report suspected adverse reactions on a Yellow Card at www.yellowcard.gov.uk † The delivered dose is equivalent to a metered dose of 200 or 400 micrograms budesonide and 6 or 12 micrograms of formoterol fumarate dihydrate ╦ MART stands for Maintenance and Reliever Therapy. Combination of ICS and LABA in a single inhaler prescribed as a twice a day maintenance treatment but can be used when required for symptoms relief. Maximum doses apply – see BNF $ Cost based on 100 actuations of 200 micrograms

References 1. The British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) British guideline on the management of asthma (Sept 2016); available at www.brit-thoracic.org.uk 2. NICE. Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in primary and secondary care. 2004 (updated 2010). Available from www.nice.org.uk 3. Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD), Confidential Enquiry. London: RCP, 2014 4. Singh S, Loke YK, Furberg CD. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA 2008; 300 (12):1439-1450. 5. Nelson HS, Weiss ST, Bleecker ER, et al (SMART Study Group). The Salmeterol Multicenter Asthma Research Trial (SMART): a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest 2006; 129 :15–26 6. Tashkin DP, Celli B, Senn S, et al . A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med 2008; 359 (15):1543–54 7. Wise RA, Anzueto A, Cotton D, et al . Tiotropium Respimat Inhaler and the Risk of Death in COPD. N Engl J Med 2013; 369 :1491-1501 Respiratory inhaler table A4 _Layout 1 20/09/2017 17:01 Page 15

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Details correct at date of publication. Publication reference number. Date of Preparation : December 2014 Revised : August 2017 Author : Dr Anna Murphy, Consultant Respiratory Pharmacist, University Hospitals of Leicester NHS Trust Conflict of interest : None declared Editor : Dr Hilary Pinnock, University of Edinburgh Registered Address : PCRS-UK, Miria House, 1683b High Street, Knowle B93 0LL Telephone : +44 (0)1675 477600 Facsimile : +44 (0)121 336 1914 Websites : http://www.pcrs-uk.org, http://www.thepcrj.com Email : [email protected] ©Primary Care Respiratory Society UK. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without the prior permission of the PCRS-UK. The PCRS-UK is a registered charity (Charity Number: 1098117) and a company, registered in England and limited by guarantee (Company number 4298947). Registered Offices: 2 Wellington Place, Leeds, LS1 4AP Notice : No responsibility is assumed by the publisher for any injury or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operations of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in medical sciences, in particular, independent verification of drug dosages should be made.