Therapeutic AreaFormulary ChoicesCost per inhaler
(unless otherwise stated)
Rationale for decision / comments
3.1 Bronchodilators
Short acting
beta-2 agonist
bronchodilators
(SABAs)
A salbutamol inhaler contains 25 days supply at full dose (8 puffs/day).

Patients reliant on this dosage are poorly controlled and should be urgently reviewed. We would recommend that any patient using more than 2 reliever inhalers in a year have their technique and compliance checked.
First line: Salbutamol
CFC free MDI
100mcg/dose: £1.50
(200 dose inhaler)
First line: MDI (plus spacer if necessary) on grounds of cost
If patient cannot manage an MDI plus spacer, consider a breath-activated MDI
or a dry powder device.
Second line: Salbutamol
Breath actuated CFC free MDI
as Airomir
Autohaler®
100mcg/dose: £6.02
(200 dose)
as
Salamol
Easi-breathe®
100mcg/dose: £6.30
(200 dose)
Dry powder inhaler
as Salbutamol
Easyhaler
®
100mcg/dose: £3.31
(200 dose)

Long acting
Beta-2 agonist
bronchodilators
(LABAs)
In asthma LABAs should only be added if regular use of a standard dose ICS has failed to control asthma adequately and should be discontinued if there is no response to treatment. LABA should only be started in patients who are already on inhaled corticosteroids, and the inhaled corticosteroid should be continued. Consider stopping LABAs in well-controlled patients once inhaled corticosteroid dose has been reduced (See step-down guidance)
In COPD, LABAs should be used in line with the local COPD guidance If no benefit after trial period, stop treatment
First line: Formoterol
Dry powder inhaler
as Easyhaler®
12mcg: £23.75 (120 dose)Formoterol is the first line LABA as Easyhaler. Maintenance dose is 12mcg once or twice daily.
as Oxis
Turbohaler®

6mcg: £24.80 (60 dose)Turbohaler formulation is second line Formoterol option. It costs 2-4 times per dose more than an Easyhaler. 12mg and 6mg strengths cost the same so use 1x 12mcg bd rather than 2x6mcg bd. Licensed over age of 6 years.
MDI
as Atimos®
12mcg: £30.06 (100 dose) MDI version licensed for over age of 12 years
Second line:Salmeterol

as Soltel®

as Serevent Accuhaler®


25mcg: £19.95 (120 dose mdi
inhaler)


50mcg: £29.26
(60 dose dry powder inhaler)
Salmeterol is the second line LABA to formoterol
Licensed over the age of 12 years. Avoid in patients with nut allergy as contains lecithin.


Accuhaler licensed from 4 years as is Serevent MDI inhaler. Formoterol is preferred.
Indacaterol

as Breezhaler®
150mcg: £32.19 (30 dose
inhaler)
300mcg: £32.19 (30 dose
inhaler)
Indacaterol is indicated for maintenance bronchodilator treatment of airflow obstruction in adult patients with COPD.
This is a cost neutral alternative to established treatments and may be appropriate for patients for whom once-daily administration is appropriate, especially those not requiring inhaled corticosteroids. It has been approved by the SMC
Olodaterol

as Striverdi
Respimat®
2.5mcg:£26.35 (60 doses)Adults over 18, 2 puffs twice a day
Short acting
anticholinergic
bronchodilators
Ipratropium
as cfc-free MDI
20mcg: £5.56 (200 dose
inhaler)
Do not co-prescribe Ipratropium with Tiotropium because of risk of increased
anticholingeric adverse effects.
Long acting
anticholinergic
bronchodilators
Aclidinium bromide
Dry powder inhaler
as Eklira
Genuair®
400mcg: £28.60
(60 dose pack)
Aclidinium is licensed for the maintenance treatment of COPD. The dose is
400mcg bd. The device may be suitable for some patients who are unable to use
a Handihaler®.
NB. Each 400 mcg metered inhalation of aclidinium bromide delivers 322 mcg of
aclidinium
Glycopyrronium
bromide

as Seebri
Breezhaler®
50mcg: £27.50 (30 capsules
plus device)
50mcg: £5.50 (6 dose capsules
plus device)
Glycopyrronium is licensed for the maintenance treatment of COPD. The dose is
50mcg od.
Each 50 microgram capsule delivers a dose of 44 micrograms of glycopyrronium
Tiotropium
Dry powder inhaler
as Braltus Zonda®
10mcg: £25.80 (30 dose)
Braltus Zonda® delivers 10mcg tiotropium to the lungs and is dose equivalent to the 18mcg tiotropium Handyhaler.
Tiotropium is licensed for use in COPD and asthma. Use in COPD should be in line with the local COPD guidance, which is consistent with the NICE guidance, see here for more information. May be used in asthma as an alternative to increasing ICS dose. Ask for specialist guidance.

If no benefit after trial period, stop treatment. Tiotropium should not be combined with ipratropium due to increased risk of anticholinergic side-effects
Soft-mist inhaler
as Tiotropium Spiriva Respimat®
2.5mcg: £23.00
(60 dose pack)
Tiotropium Spiriva Respimat® (soft-mist inhaler) was included in the formulary for patient choice
Umeclidinium
Dry powder inhaler
as Incruse Ellipta®
55mcg:£27.50 (30 doses)The recommended dose in adults (also the maximum dose) is one inhalation of
Incruse Ellipta once daily at the same time of the day each day.
Combination long
acting muscarinic
antagonists (LAMA)
and long acting β
agonists (LABA)
Anoro Ellipta®
(Umeclidinium/vilanterol 55/22)
Dry powder inhaler
£32.50 (30 doses - one month)Once daily dose. Maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD)
Duaklir Genuair®
(aclidinium/formoterol 340/12)
dry powder inhaler
£32.50 (60 doses - one month)Twice daily dose. COPD only.
Ultibro Breezhale®
(glycopyrronium/indacaterol 110/50 mcg) dry powder inhaler
£32.50 (30 doses – one month)Once daily dose. Indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with (COPD).Capsule has to be placed into device, needs certain dexterity.
Spiolto Respimat®
(tiotropium 2.5mcg/olodaterol 2.5mcg soft mist inhaler inhaler
£32.50 (60 doses – one month)Two puffs once daily.
TheophyllineReduce the dose of theophyline if macrolide or quinolones antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation.
Prescribe by brand.
The rate of absorption from modified-release preparations can vary between brands. If a brand name is not specified on the prescription, pharmacists should contact the prescriber to establish which brand is to be dispensed.
Theophylline MR
as Nuelin SA®
175mg tablets: £6.38 (60)
250mg tablets: £8.92 (60)
Offer theophylline only after trials of short- and long-acting bronchodilators, or to people who cannot use inhaled therapy.

Theophylline can be used in combination with beta2 agonists and muscurinic antagonists. Please note, the risk of hypokalaemia is increased when theophylline is given in combination with a beta2 agonist.

Take care when prescribing theophylline to older people. Consider altered pharmacokinetics, comorbidities, and interactions with other medicines;
• Plasma theophylline level is increased in heart failure, hepatic impairment, viral infections, in the elderly, and by drugs that inhibit its
metabolism.
•Plasma theophylline level is decreased in smokers, by alcohol consumption, and by drugs that induce its metabolism.
as Slo-Phyllin®
60mg capsules: £2.76 (56)
125mg capsules: £3.48 (56)
250mg capsules: £4.34 (56)
as Uniphyllin
Continus®

200mg tablets: £2.96 (56)
300mg tablets: £4.77 (56)
400mg tablets: £5.65 (56)
AminophyllineAminophylline MR
as Phyllocontin
Continus®


225mg tablets: £2.40 (56)
350mg tablets: £4.22 (56)