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 nor are Soprobec® and Kelhale®
400mcg Soprobec® = 400mcg BDP
400mcg Clenil Modulite® = 400mcg BDP
200mcg Kelhale® = 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 furoate = 200mcg BDP
BTS guide to ICS potencies pages 67-69
Beclometasone diproprionate
In no particular order
CFC-free MDIs
as Soprobec®




as Clenil Modulite®
50 mcg:£2.78(200 dose)
100 mcg=£5.57 (200 dose)
200 mcg=£12.13 (200 dose)
250 mcg=£12.22 (200 dose)


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®

Both Soprobec and Clenil say suitable for children but do not specify an actual age. Consensus from professionals suggest 4 years and above.
as Kelhale®50mcg: £5.20 (200 dose)
100mcg: £5.20 (200 dose)
Kelhale is cost effective alternative to QVAR, and is considered equipotent.
Benefit- has a dose counter
Kelhale is licensed only for adults 18 years and above
as Qvar®50mcg: £7.87 (200 dose)
100mcg: £17.21 (200 dose)
Qvar® is not licensed in patients under 5yrs.
Dry powder
as Beclometasone Easyhaler®
200mcg: £14.93 (200 dose) Not suitable for children, though SPC does not specify age range this covers. Budesonide Easyhaler can be used from 6 years and has a once daily license if required. See below
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.
Adults with mild to moderate asthma (including the elderly and adolescents 12 to 17 years): In patients who have not previously received inhaled corticosteroids the usual maintenance dose is 200-400 micrograms once daily. 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.

Children 6 to 11 years with mild to moderate asthma: In steroid naive patients or patients controlled on inhaled corticosteroids (eg budesonide or beclometasone dipropionate) administered twice daily the usual maintenance dose is 200-400 micrograms once daily.
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 order, but see bottom of page for cost comparison tablesAirFluSal®
Fluticasone/ salmeterol
MDI
125mcg/25mcg £16.42
250mcg/25mcg: non-formulary £20.52
Asthma only. 18 years and over
Sereflo®
Fluticasone/ salmeterol
MDI
125mcg/25mcg £14.99
250mcg/25mcg: non-formulary £19.99
Asthma only. 18yrs and over
Combisal®
Fluticasone/ salmeterol
MDI
50/25mcg: £13.50
125/25mcg: £17.59
250/25mcg is non formulary £27.99
Asthma only.
Children 4 yrs plus use 50/25mcg only
Seretide Evohaler® Fluticasone/salmeterol
CFC-free MDI
50/25: £17.46 (120 doses)
125/25: £23.45(120 doses)
250/25 is non formulary £29.32
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: £22.45 (120 doses)
250mcg: £28.32 (120 doses) NON FORMULARY
Asthma only. 18 years and over
Flutiform®

Fluticasone/formoterol
CFC-free MDI

Flutiform K-haler®

Fluticasone/formoterol
CFC-free Breath actuated MDI
50mcg/5mcg £14.40
125mcg/5mcg £28.00
250mcg/10mcg:
non-formulary
£45.46

50mcg/5mcg £14.40.
125mcg/5mcg £28.00.
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.)

12 years and above
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)
Asthma only

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

200mcg/6mcg: £29.32
(120 dose inhaler)
Asthma only
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
Luforbec®

Beclomethasone/formeterol
CFC-free MDI
100mcg/6mcg: £20.52
(120 dose inhaler)
Cost effective alternative to Fostair with same licensed indications and equivalent extrafine formulation.
Atectura Breezhaler®
Indacaterol/mometasone
dry
powder inhaler
125 mcg/62.5 mcg £17.49 (30 dose)
125 mcg/127.5 mcg £21.50 (30 dose)
125 mcg/260 mcg £27.97.(30 dose)
Maintenance treatment of asthma inadequately controlled by short-acting β2-agonists and inhaled corticosteroids.
Adults: 1 daily by inhalation, titrated to the lowest effective mometasone dose. Max 125 microgram/260 microgram once daily.
Children: Under 12 years, not recommended; ≥12 years, as adult.
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
Cost effective alternative to Seretide Accuhaler,and AirFluSal DPIs
Stalpex®
Fluticasone/ salmeterol
Dry powder
500mcg/50mcg £16.37 60 doseCost effective alternative to Seretide Accuhaler and AirFluSal DPIs. Only single strength available
Relvar®
Ellipta®

(Fluticasone
furoate/vilanterol)
Dry powder inhaler
92mcg/22mcg: £22.00
(30 dose)
184mcg/22mcg: £29.50
(30 dose)
Regular treatment of ASTHMA where long acting β2-agonist and inhaled corticosteroid is appropriate.
Symptomatic treatment of COPD with a post-bronchodilator FEV1 <70% predicted and a history of exacerbations despite regular bronchodilator therapy.

Asthma: 1 inhalation daily, titrated to the lowest effective fluticasone dose.<12 years not recommended; ≥12 years, as adult.
COPD: 1 inhalation of 22 microgram/92 microgram daily.
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 12 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.
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: £32.74 (60 dose)
Regular treatment of asthma where long acting β2-agonist and inhaled corticosteroid is appropriate.
Symptomatic treatment of COPD in patients with a pre-bronchodilator FEV1 <60% predicted and a history of exacerbations and with significant symptoms despite regular bronchodilator therapy.
Adults:
Asthma, 1 inhalation twice daily, titrated to the lowest effective fluticasone dose.
COPD, 1 inhalation of Seretide 500 twice daily.
Children:
Asthma, under 4 years, not recommended; over 4 years, 1 inhalation of Seretide 100 twice daily.
Fixkoh Airmaster®
(Fluticasone/Salmeterol 50mcg)
Dry powder inhaler
100mcg: £14.47 (60 dose)
250mcg: £19.29 (60 dose)
500mcg: £24.12 (60 dose)
Fixkoh Airmaster is indicated in adults and adolescents 12 years of age and
older.

Asthma
Fixkoh Airmaster is indicated in the regular treatment of asthma where use of
a combination product (long- acting β2 agonist and inhaled corticosteroid) is
appropriate:
- patients not adequately controlled with inhaled corticosteroids and 'as
needed' inhaled short-acting β2 agonist
or
- patients already adequately controlled on both inhaled corticosteroid and
long-acting β2 agonist

Note: Fixkoh Airmaster 50 microgram /100 microgram strength is not
appropriate in adults and children with severe asthma.

Chronic Obstructive Pulmonary Disease (COPD)
Fixkoh Airmaster is indicated for the symptomatic treatment of patients with
COPD, with a FEV1 < 60 % predicted normal (pre-bronchodilator) and a
history of repeated exacerbations, who have significant symptoms despite
regular bronchodilator therapy.
Triple component inhalersTrelegy Ellipta®
Vilanterol/fluticasone furoate/umeclidinium
22 microgram/92 microgram/55 microgram per inhalation,
DPI device
£44.50 (30 dose)Maintenance treatment of moderate to severe COPD where an inhaled corticosteroid plus a LABA is inadequate
Adults:1 puff once daily.
Children: Under 18 years, not recommended.
Enerzair Breezhaler®
Indacaterol/mometasone/glycopyrronium 114 microgram/136 microgram/46 microgram per inhalation,
DPI device
£44.50 (30 dose)Maintenance treatment of ASTHMA inadequately controlled by a long-acting β2-agonist plus a high-dose inhaled corticosteroid, in patients with ≥1 severe exacerbations in the previous year.
One puff daily
18 years and above only
Trimbow Nexthaler®
Beclometasone 88 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff
DPI 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

Four puffs daily delivers around 400mcg BDP
Not licensed in asthma
Trimbow®
Beclometasone 87 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff
MDI device
£44.50 (120 dose)COPD-Maintenance treatment of moderate to severe COPD where an inhaled corticosteroid plus a long-acting β2-agonist is inadequate
Asthma-Maintenance treatment of asthma, in adults not adequately controlled with a maintenance combination of a long-acting beta2-agonist and medium dose of inhaled corticosteroid, and who experienced one or more asthma exacerbations in the previous year.
Please note: this is a 2p bd dosage and is not a microfine aerosol.

Four puffs daily delivers around 400mcg BDP
Trixeo Aerosphere®
Budesonide 160 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff
MDI device
£44.50 (120 dose)Introduced in January 2021. Trixeo Aerosphere is indicated as a maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or combination of a long-acting beta2-agonistand a long-acting muscarinic antagonist.
Dose is 2 puffs bd = medium ICS dose
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.
Medium volume: EasyChamber®
adult with mouthpiece (blue)
with infant mask (orange)
with child mask (yellow)
with adult mask (blue)


AeroChamber Plus®
standard adult (blue)
adult with mask (blue)
infant with mask (orange)
child with mask (yellow)

AeroChamber Plus Flow-Vu Anti-Static®
Standard
Youth (5+ years)
Small mask for infants (0-18 months)
Medium mask for children (1-5 years)
Adult small mask
Adult large mask
£3.98 (1)
£6.53 (1)
£6.55 (1)
£6.59 (1)


£5.06 (1)
£8.42 (1)
£8.42 (1)
£8.42 (1)


£5.22
£5.22

£8.72

£8.72
£8.72
£8.72
Easychamber® is the most cost effective spacer. Anti-static with universal inhaler base that fits majority of pMDIs. Detachable, latex-free mask. Comes with outer box for easy storage. One-way inhalation cross valve. FlowSignal whistle indicator sounds when breathing in too fast.



AeroChamber Plus® spacer devices should fit ALL MDI devices (inhaler mouthpiece fits into flexible gasket) but prescribers should check SPC.
MHRA advise that deposition and therefore effectiveness and adverse effects may differ from Volumatic®















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®£3.88 (1)
MDI Fluticasone and formoterol or salmeterol
  50/25 50/5 125/25 125/5 250/25 250/5
Sereflo Not made £14.99 £19.99
Combisal £13.50 £17.59 £27.99
Flutiform £14.40 £28.00 £45.56
Flutiform K-haler £14.40 £28.00 Not made
Seretide £18.00 £23.45 £29.32
Sirdupla Not made £22.45 £28.32
 Airflusal  Not made  £16.42  £20.52

BTS definitions of ICS potencies in asthma-July 2019