NHS City and Hackney Prescribing Guidelines – Adults (≥12 years of age) CHARM ASTHMA TREATMENT GUIDELINE Written by: Hetal Dhruve (Specialist Respiratory Pharmacist, City and Hackney CCG) Checked by: Dr Meena Krishnamurthy, GP Respiratory Lead, City and Hackney Dr Angshu Bhowmik, Consultant – Respiratory Medicine, HUHFT Prof Raj Rajakulasingam - Respiratory Consultant, HUHFT Debbie Roots, Cardiorespiratory Nurse Consultant – HUHFT. Approved by: JPG City and Hackney and Homerton University Hospital Foundation Trust Date of approval: 12/02/18 Date of Review: 12/02/19 Version: 4.2
Transcript
NHS City and Hackney Prescribing Guidelines – Adults (≥12 years of age)
CHARM ASTHMA TREATMENT GUIDELINE
Written by: Hetal Dhruve (Specialist Respiratory Pharmacist, City and Hackney CCG) Checked by: Dr Meena Krishnamurthy, GP Respiratory Lead, City and Hackney
Approved by: JPG City and Hackney and Homerton University Hospital Foundation Trust Date of approval: 12/02/18 Date of Review: 12/02/19 Version: 4.2
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age)
Diagnosis
Diagnostic Algorithm
For patients with suspected Asthma, consider trial of low dose ICS and
assess response BTS Asthma Guidelines 2016
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age)
Treatment algorithm for patients with confirmed diagnosis of Asthma
All prescribing options to allow prescribing of most appropriate device. Also see “inhaler standards and competency” document and www.rightbreathe.com to aid assessment of inhaler technique.
A spacer should be offered to all patients using a MDI.
Consider stepping up therapy if on review patient is using a reliever more than 3 times a week, has nocturnal symptoms and/or exacerbates frequently.
Assess adherence to maintenance inhaler(s) and inhaler technique before stepping up.
Reductions in ICS dose should be considered every 3 months in stable mild to moderate patients, reducing the dose by 25% - 50% each time. It is best practice to produce a written asthma action plan with each change of medication.
Treat co-morbidities such as allergic rhinitis (see allergic rhinitis guidelines) and acid reflux, which may exacerbate symptoms
Short acting beta-agonist as required; consider moving up if the patient is adherent to preventer medication & requiring use of SABA more than 3 times per week pMDI: Ventolin® 100 Evohaler 1-2p PRN/Salamol® 100 MDI 1-2p PRN,
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age)
ASTHMA CONTROL TEST (ACT)
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
All of the time - 1
Most of the time - 2
Some of the time - 3
A little of the time - 4
None of the time – 5 During the past 4 weeks, how often have you had shortness of breath?
More than once a day - 1
Once a day - 2
3 to 6 times a week - 3
Once or twice a week - 4
Not at all – 5 During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
4 or more nights a week - 1
2 to 3 nights a week - 2
Once a week - 3
Once or twice - 4
Not at all - 5
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
3 or more times per day - 1
1 or 2 times per day - 2
2 or 3 times per week - 3
Once a week or less - 4
Not at all - 5 How would you rate your asthma control during the past 4 weeks?
Not Controlled at All - 1
Poorly Controlled - 2
Somewhat Controlled - 3
Well Controlled - 4
Completely Controlled - 5
Score: 20+ - well controlled asthma
19 or less – asthma could be better controlled
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age) Maintenance And Reliever Therapy (MART)
In selected patients, using MART with ICS and LABA has been shown to be an effective treatment regime, reducing the risk of a sthma attacks requiring oral corticosteroids in patients not well controlled on ICS alone.
This is treatment regime is only licensed in adults over the age of 18 for the following inhalers: Fostair 100/6 MDI only
The recommended maintenance dose is 1 inhalation twice a day. Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. The maximum dose is 8 inhalations per day. Patients requiring frequent use of rescue inhalations daily should be strongly advised to seek medical advice. Their asthma should be reassessed and their maintenance therapy should be reconsidered.
Spiromax 160/4.5 or Symbicort 200/6
The recommended maintenance dose is 2 inhalations per day, with some patients requiring a maintenance dose of 2 inhalations twice a day. Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion. The maximum dose is 12 inhalations per day.
If patients are requiring more than 8 inhalations per day, they should be strongly advised to seek medical advice, with reassessment of their maintenance therapy.
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age) Calculating Beclomethasone dipropionate (BDP) Equivalent
These dosage equivalents are approximate and will depend on factors such as inhaler technique.
Generic Brand Dose Daily
BDP
Price/30 days
License
Low Dose
Beclomethasone Clenil® MDI 100mcg 2p BD 400 £4.45 Asthma-adults and children over 2 Beclometasone Easyhaler 200mcg 1p BD 400 £4.48 Asthma – adults over 18 Beclomethasone QVAR® autohaler 50mcg 2pBD 400 £4.72 Asthma-adults and children over 12 Budesonide Pulmicort®
Turbohaler 100mcg 2p BD 400 £7.10 Asthma-adults and children over 5
Fluticasone Flixotide® Evohaler 50mcg 2p BD 400 £5.44 Asthma-adults and children over 4 Fluticasone Flixotide®
Accuhaler 100mcg 1p BD 400 £10.72 Asthma-adults and children over 4
Medium Dose
Beclomethasone Clenil® MDI 200mcg 2p BD 800 £9.70 Asthma-adults and children over 12 Beclomethasone Clenil® MDI 250mcg 2p BD 1000 £9.77 Asthma-adults and children over 12 Beclometasone Easyhaler 200mcg 2p BD 800 £8.96 Asthma – adults over 18 Beclomethasone QVAR® autohaler 100mcg 2p BD 800 £10.33 Asthma-adults and children over 12 Budesonide Pulmicort®
Turbohaler 200mcg 2p BD 800 £14.21 Asthma-adults and children over 5
Fluticasone Flixotide® Evohaler 250mcg 1p BD 1000** £18.07 Asthma-adults and children over 16 Fluticasone Flixotide® Evohaler 125mcg 2p BD 1000 £21.26 Asthma-adults and children over 16 Fluticasone Flixotide®
Accuhaler 100mcg 2p BD 800 £21.44 Asthma-adults and children over 4
Fluticasone Flixotide® Accuhaler
250mcg 1p BD 1000 £25.51 Asthma-adults and children over 16
High Dose
Fluticasone Flixotide® Evohaler 250mcg 2p BD 2000 £36.14 Asthma-adults and children over 16 Fluticasone Flixotide®
Accuhaler 500mcg 1p BD 2000 £43.37 Asthma-adults and children over 16
Budesonide Pulmicort® Turbohaler
400mcg 2p BD 1600 £33.26 Asthma-adults and children over 12
Combination ICS (Inhaled Corticosteroid)/ LABA (Long Acting Beta Agonist) Inhalers
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age)
Generic Brand Dose Daily
BDP
Price /30 days
License
Low dose + LABA
Beclomethasone/formoterol Fostair® MDI
100/6mcg 1p BD 500 £14.66 Asthma-adults over 18
Beclomethasone/formoterol Fostair® Nexthaler
100/6mcg 1p BD 500 £14.66 Asthma-adults over 18
Fluticasone/salmeterol Seretide® MDI 50/25mcg 2p BD 400 £18.00 Asthma-adults and children over 5
Fluticasone/formoterol Flutiform® MDI 50/5mcg 2p BD 400 £14.40 Asthma-adults and children over 12
Fluticasone/salmeterol Sereflo® MDI 250/25 2p BD 2000 £29.95 NON FORMULARY
Fluticasone/salmeterol AirFluSal® MDI 250/25 2p BD 2000 £29.95 NON FORMULARY
Fluticasone/salmeterol Seretide® Accuhaler
500/50mcg 1p BD
2000 £40.92 Asthma-adults and children over 12
Fluticasone/salmeterol Aerivio® Spiromax
500/50 1p BD 2000 £29.97 NON FORMULARY
Fluticasone/salmeterol AirFluSal® Forspiro
500/50 1p BD 2000 £29.97 NON FORMULARY
Fluticasone/vilanterol Relvar® Ellipta 184/22mcg 1p OD
2000 £29.50 Asthma-adults over 18
Budesonide/formoterol Duoresp®
Spiromax 320/9mcg 2p BD 1600 £55.94 Asthma-adults over 18
Budesonide/formoterol Symbicort®
Turbohaler
400/12mcg 2p BD
1600 £56.00 Asthma-adults over 18
# First line option in green- all else in no particular order. Inhaler to be chosen based on device and inhaler technique.
@ Red items – non formularly.
** Most cost effective option for ingredient/device/dose
Prices correct at time of update on 13/02/17. References: MIMS online and SPC.
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age) Steroids All patients on high dose ICS (>1000BDP) should receive a steroid card. For patients receiving high dose ICS for a prolonged period and/or has frequently prescribed oral prednisolone, bone protection should be considered. Gradual withdrawal of Prednisolone - Should be considered for the following patients
- Received more than 40mg of prednisolone daily for more than 1 week
- Been given repeat doses in the evening,
- Recently received repeated courses (particularly if taken for longer than 3 weeks),
- Taken a short course within 1 year of stopping long-term therapy
Self Management All patients should be given a self management plan detailing the following:
- PEF 80-100% of annual best: As per usual prescription
- PEF 60-80% of annual best: increase the dose of ICS to double, and if symptoms do not resolve/PEF is not back to >75% of annual
best within 48 hours, to consult GP/practice Nurse
- PEF <60% of annual best – take 40mg prednisolone daily for 5 days.
**Continue use of salbutamol 1-2 puffs via spacer. Maximum dose of 10 puffs every 2 hours** Antibiotics in asthma Most patients with asthma do NOT require antibiotics. Please see PHE antibiotic guidelines if infection is suspected.
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age) Theophylline Theophylline is a xanthine used as a bronchodilator in asthma. Once initiated, patients should remain on the same brand as the rates of absorption from modified-release preparations can vary between the brands. Theophylline available brands: · Nuelin SA® tablets: 175-350mg every 12 hours.
· Nuelin SA 250® tablets: 250-500mg every 12 hours
· Slo-Phyllin® capsules: 250-500mg every 12 hours
· Uniphyllin Continus® tablets: 200mg – 400mg every 12 hours according to response. May be appropriate to give larger evening or morning dose to optimise therapeutic effect when symptoms are most severe. In patients whose night or daytime symptoms persist despite adherence to other therapy, who are not currently receiving theophylline, total daily requirement may be added as single evening or morning dose. Aminophylline available brands:
- Phyllocontin Continus® tablets: 225mg T BD then increase to 450mg BD if necessary, according to plasma concentration levels.
- Phyllocontin Forte ® tablets: 350mg BD then increase to TT D if necessary (this brand should be prescribed to smokers and other
patients with shorter theophylline half life).
Therapeutic levels: Target range 10-20mg/L. Levels should be taken 5 days after starting oral treatment and at least 3 days after any dose adjustment. A sample should be taken 4-6 hours after an oral dose. Thereafter, levels should be taken every 6-12 months if the patient remains stable. More frequent monitoring may be required if the result was out of range, there is a newly initiated medication that interacts with theophylline or if you are querying adherence. Common interactions with Theophylline which may warrant more frequent monitoring:
- levels are reduced in smoker and with high alcohol consumption
- increased levels in patients with heart failure, hepatic impairment, viral infections and in the elderly
For a full list of drug interactions see BNF or Stockleys Drug Interactions – Pharmaceutical Press.
NHS City and Hackney Asthma Prescribing Guidelines – Adults (≥12 years of age) Guidance to support the stepwise review of asthma patients There are a large number of patients receiving high dose inhaled corticosteroids but are not adhering to the prescribed treatment and/or have poor inhaler technique. For every patient reviewed, levels of adherence must be confirmed using the GP records. In general, patients collecting 10 out of 12(>80%) inhalers per annum (based on a 30 day refill), are considered to be adherent. Patients collecting less than this amount, may not be adherent and the usage of their medication should be questioned. Using this information, work out the approximate daily BDP in relation to their QoL (using the ACT), and use this as a guide to prescribe the appropriate daily dose. Check inhaler technique and trigger factors to aid decision-making. For patients who are fully adherent, complete asthma control need to be achieved for at least 12 weeks before attempting to step patient’s down1. If asthma is controlled with a combination ICS/LABA, the preferred approach is to reduce the ICS by approximately 25-50% whilst continuing the LABA at the same dose. If control is maintained after stepping down, further reductions in the ICS should be attempted until a low dose is reached, when the LABA may be stopped2.
** Adapted from Barking and Dagenham, Havering and Redbridge CCG.
1 British Thoracic Society. Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised 2 Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2012 update.
