Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
3.2 Corticosteroids (See advice on safer use of inhaled corticosteroids link)
Inhaled
corticosteroids (ICS)
BTS / SIGN Guideline (141) on the management of asthma states: many children with recurrent episodes of viral-induced wheezing in infancy do not develop chronic atopic asthma and do not require regular inhaled steroids.
NICE TAG138 states: for patients with chronic asthma in whom an ICS is appropriate, the least costly product that is suitable for the individual, within its license, is recommended
BeclometasoneNB. Prescribe beclometasone MDIs by brand name to avoid confusion over the product intended. Clenil Modulite® and Qvar® are not equipotent
400mcg Clenil Modulite® = 400mcg BDP
200mcg Qvar® = 400-500mcg BDP
200mcg Fostair® = 500mcg BDP
400mcg budesonide (Pulmicort®/Symbicort®/Easyhaler®) = 400mcg BDP
200mcg fluticasone (Flixotide®/Seretide®/Flutiform®) = 400mcg BDP
160mcg ciclesonide = 240-320mcg BDP
200mcg mometasone = 400mcg BDP
BTS guide to ICS potencies
In no particular orderCFC-free MDIs
as Clenil Modulite®
50mcg: £3.70 (200 dose)
100mcg: £7.42 (200 dose)
200mcg: £16.17 (200 dose)
250mcg: £16.29 (200 dose)
Children up to age 15 should use these products with a Volumatic®
as Qvar®50mcg: £7.87 (200 dose)
100mcg: £17.21 (200 dose)
Qvar® is not licensed in patients under 12yrs.
Dry powder
as Beclometasone Easyhaler®
200mcg: £14.93 (200 dose)
Breath-actuated
CFC-free MDI as
Qvar Easi-breathe®
50mcg: £7.74 (200 dose)
100mcg: £16.95 (200 dose)
Budesonide as Easyhaler®100mcg:£8.86 (200 dose)
200mcg £17.71 (200 dose)
400mcg: £17.71 (100 dose)
Licensed from age 6 years. In patients already controlled on inhaled corticosteroids (eg budesonide or beclometasone dipropionate) administered twice daily, once daily dosing up to 800 micrograms may be used.
Combination
long-acting
beta-agonist steroid
inhalers
NICE TAG 138 states that for patients with chronic asthma in whom an ICS and LABA is appropriate, the following apply:
- Use of a combination device within license is recommended as an option to ensure that long-acting β2 agonists are not taken without an inhaled steroid.
- The decision to use combinations or separates should be made on an individual basis.
- If a combination is chosen the least costly device that is suitable for the individual, within its license, is recommended
In no particular orderAirFluSal®
Fluticasone/ salmeterol
MDI
125mcg/25mcg £18.50
250mcg/10mcg: non-formulary £29.95
Asthma only. 18 years and over
Sereflo®
Fluticasone/ salmeterol
MDI
125mcg/25mcg £18.50
250mcg/10mcg: non-formulary £29.95
Asthma only. 18yrs and over
Combisal®
Fluticasone/ salmeterol
MDI
50/25mcg: £13.50
125/25mcg: £19.95
250/25mcg is non formulary
Asthma only.
Children 4 yrs plus use 50/25mcg only
Seretide Evohaler® Fluticasone/salmeterol
CFC-free MDI
50mcg: £18.00 (120 doses)
125mcg: £35.00
(120 doses)
Note that the 50mcg Evohaler® is licensed for adults and children over 4 years and the 125mcg inhaler for adults and children over 12 years
Sirdupla®
Fluticasone/Salmeterol CFC-free MDI
125mcg: £26.25 (120 doses)
250mcg: £44.61 (120 doses) NON FORMULARY
Asthma only. 18 years and over
Flutiform®

Fluticasone/formoterol
CFC-free MDI
50mcg/5mcg £14.40
125mcg/5mcg £28.00
250mcg/10mcg:
non-formulary
Licensed for asthma only.
Flutiform 50mcg and 125mcg are licensed for adults and children over 12 years.
The 250mcg strength is non-formulary: licensed for over 18 years only and limited indications for high dose fluticasone in asthma (estimated only 1% asthma patients should need such a high dose combination.)
Fostair®

Beclomethasone/formeterol)
CFC-free MDI






Fostair NEXThaler®
Beclomethasone/formoterol)
ultrafine dry
powder inhaler
100mcg/6mcg: £29.32
(120 dose inhaler)

200mcg/6mcg: £29.32
(120 dose inhaler)
Only recommended as a cost effective to Seretide, Sirdupla or Flutiform at the highest licensed dose of 2000mcg BDP equivalent per day

100mcg/6mcg: £29.32.
(120 dose inhaler)

200mcg/6mcg: £29.32
(120 dose inhaler)
Only recommended as a cost effective to Seretide, Sirdupla or Flutiform at the highest licensed dose of 2000mcg BDP equivalent per day
100/6 is licensed for asthma and COPD. 200/6 licensed in asthma only
WARNING: beclomethasone 100mcg in Fostair® is equivalent to 250mcg of standard beclomethasone because of extra fine particle size. Patient should receive specific training and information leaflet on this issue. The formoterol element is not enhanced by the microfine particle size.
Beclometasone-formoterol as maintenance and reliever therapy (MART):
Patients over 18 years, at Step 3, who are poorly controlled may also use Fostair® as a rescue medication (maximum 8 puffs per day - equivalent 2000mcg standard BDP), with no Salbutamol. Careful patient education is required and quantity of inhalers used monitored.

NEXThaler® has same BDP equivalent as Fostair MDI
OVER 18 YEARS ONLY MDI and DPI
Fobumix Easyhaler®
Budesonide/formoterol
dry
powder inhaler
80mcg/4.5mcg: £21.50 (120 doses)
160mcg/4.5mcg: £21.50 (120 doses)
320mcg/9mcg; £21.50 (60 doses)
Not under 18 years, suggest Symbicort
Fusacomb Easyhaler®
Fluticasone/ salmeterol
Dry powder
250mcg/50mcg £21.50 60 dose
500mcg/50mcg £26.99 60 dose
NOT AVAILABLE UNTIL 2019
Cost effective alternative to Seretide Accuhaler, Aerivio and AirFluSal DPIs
Relvar®
Ellipta®

(Fluticasone
furoate/vilanterol)
Dry powder inhaler
92mcg/22mcg: £22.00
(30 dose)
184mcg/22mcg: £29.50
(30 dose)
Long acting once daily dosage due to the long acting furoate salt and LABA. 92/22 dose equivalent to 500mcg daily fluticasone proprionate (1000mcg BDP)

Asthma: Both strengths licensed in adults and children >12years

NOTE: Licensed for new patients uncontrolled at step 2 i.e no license for switching well controlled patients from another ICS/LABA combination.

Individual components not available in separate inhalers so step-down could prove difficult

Only 92/22 strength is licensed for COPD if FEV1<70% predicted normal (post-bronchodilator) with an exacerbation history despite regular bronchodilator therapy.
Duoresp® Spiromax
Budesonide/formoterol
Dry powder inhaler
160mcg/4.5mcg: £27.97
(120 doses)
320mcg/9mcg: £27.97
(60 doses)
New legislation demands that delivered dose is stated. 160/4.5 is comparative to Symbicort 200/6 and 320/9 is comparative to 400/12. Can be used as maintenance or maintenance and reliever therapy. License in asthma and COPD (COPD 320/9mcg twice a day dose). Not licensed in 12-17 year olds unlike Symbicort. SPC for Duoresp suggests that stepdown from 160/4.5 may require separation into separate inhalers but does not preclude single daily dose regimen if considered clinically appropriate
Symbicort®
Turbohaler

(Budesonide /
Formoterol)
Dry-powder inhaler
100mcg/6mcg: £28.00
(120 doses)
200mcg/6mcg: £28.00
(120 doses)
400mcg/12mcg: £28.00
(60 doses)
Some dosing flexibility is possible with Symbicort®, it is still not as flexible as ICS and LABA prescribed separately. It is licensed in COPD. The 100/6 strength is now licensed in age >6 years. 200/6 licensed 12yrs and above.

Symbicort® Maintenance and Reliever Therapy (SMART): Patients over 18 years, at Step 3, who are poorly controlled may also use Symbicort® 200/6 as a rescue medication (maximum 12 puffs per day), with no Salbutamol. Careful patient education is required and quantity of inhalers used monitored.
Symbicort®
MDI

(Budesonide /
Formoterol) MDI
200mcg/6mcg: £28.00
(120 doses)

Symptomatic treatment of COPD with a post-bronchodilator FEV1 <70% predicted and a history of exacerbations despite regular bronchodilator therapy.
Aerivio Spiromax®
(Fluticasone/Salmeterol 500/50mcg)
Dry powder inhaler
Salmeterol (as xinafoate) 50 microgram, fluticasone propionate 500 microgram

60 inhalations=£29.97.
Most cost effective salmeterol/fluticasone dry powder
AirFluSal Forspiro 50/500®
(Fluticasone/Salmeterol 50mcg)
Dry powder inhaler
500mcg: £29.97(60 dose) AirFluSal Forspiro is licensed for the symptomatic treatment of adults with COPD, with a FEV1 <60% predicted normal (prebronchodilator) and a history of repeated exacerbations and who have significant symptoms despite regular bronchodilator therapy. Also in asthma in patients requiring high dose steroid.

It provides the same drugs and doses as Seretide Accuhaler 50/500 but unlike Seretide, it is not for use in under 18 year olds
Seretide Accuhaler®
(Fluticasone/Salmeterol 50mcg)
Dry powder inhaler
100mcg: £18.00 (60 dose)
250mcg: £35.00 (60 dose)
500mcg: £40.92 (60 dose)
Seretide® 500mcg Accuhaler is included for moderate to severe COPD where there is proven response to ICS. If no benefit after a trial period, stop treatment.
Triple component inhalersTrelegy Ellipta®
Vilanterol (as trifenatate)/fluticasone furoate/umeclidinium (as bromide)
22 microgram/92 microgram/55 microgram per inhalation,
DPI device
£44.50 (30 dose)Once daily dose
Maintenance treatment of moderate to severe COPD where an inhaled corticosteroid plus a long-acting β2-agonist is inadequate

92mcg fluticasone furoate may be equivalent to 1000mcg of BDP
Trimbow®
Beclometasone 97 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff
MDI device
£44.50 (120 dose)Maintenance treatment of moderate to severe COPD where an inhaled corticosteroid plus a long-acting β2-agonist is inadequate
Please note: this is a 2p bd dosage and is not a microfine aerosol.

Four puffs daily delivers around 400mcg BDP
Spacer devicesPatient's ability to use different devices varies; assessment of response to a prescribed treatment should include evaluation of inhaler
technique as demonstrated by patient. First line recommended is MDI plus spacer on grounds of cost.
Medium volume: AeroChamber Plus®
standard adult (blue)
adult with mask (blue)
infant with mask (orange)
child with mask (yellow)
£4.86 (1)
£8.11 (1)
£8.11 (1)
£8.11 (1)
The AeroChamber Plus® is recommended as the spacer device of choice, in view of its portability and flexible inhaler orifice, which permits most MDIs to be used with it. MHRA advise that deposition and therefore effectiveness and adverse effects may differ from Volumatic®

AeroChamber Plus® spacer devices should fit ALL MDI devices (inhaler mouthpiece fits into flexible gasket) but prescribers should check SPC.

Volumatic® spacer device is only compatible with inhalers manufactured by GSK or if mouthpiece has same specifications as inhalers manufactured by GSK.
Large volume:Volumatic®£3.85 (1)