Swapping from legacy asthma treatment age 12+

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

Current NICE/SIGN/BTS guidance recommends all new asthma treatment to be with a combined inhaled corticosteroid and long-acting beta-agonist (ICS/LABA) regime for patients age 12 and over. For any new patients see the treatment algorithms on DGRefHelp.

Patients who are well controlled on their existing asthma treatment do not need to be swapped, although the option should be discussed with them at routine asthma review.

Patients who are poorly controlled on a 'legacy' asthma treatment should be moved to maintenance and reliever treatment (MART) treatment and then titrated up or down using the current management algorithms

To find the appropriate step of the current treatment to swap to, find their current treatment in the list below and swap to the suggested MART treatment.

If they are on Montelukast and that has been beneficial they should continue it.

Step 1 - Regular low dose inhaled steroid

Formulary Choices:

Dry Powder Inhalers
Easyhaler Beclometasone 200mcg 1 Puff BD (£4.48) or
Easyhaler Budesonide 200mcg 1 puff BD (£5.31)

Metered Dose Inhalers
Soprobec 100mcg 2 puffs BD (£3.34)
Kelhale 50 2 puffs BD (£3.12)
Qvar 50 Easi-Breathe 2 puffs BD(£4.64)

Equivalents - Non-Formulary:

Dry Powder Inhalers
Pulmicort Turbohaler 100mcg 2 puffs BD (£7.10)
Fluticasone Accuhaler 100mcg 1 puff BD (£8.93)
Asmanex Twisthaler 200mcg 1 puff BD (£23.54)

Metered Dose Inhalers
Clenil 100mcg 2 Puffs BD (£4.45) equivalent to Soprobec
Qvar 50mcg 2 puffs BD MDI (£4.72) equivalent to Kelhale

If uncontrolled and/or exacerbating:

Swap to Low Dose MART

Step 2 – Add regular long acting beta agonist (LABA)

Formulary Choices:

 Dry powder inhalers
Fostair Nexthaler 100/6  - 1 puff BD (£14.66)
DuoResp Spiromax 160/4.5 - 1 puff BD (£13.98)
Fobumix Easyhaler 160/4.5 - 1 puff BD (£10.75)

Metered dose inhalers
Luforbec (100/6) - 1 puff BD (£10.26)
Bibefco 100/6 - 1 puff BD (£10.26) does not contain maleic acid as excipient

Equivalents - Non Formulary:

Dry powder inhalers
Symbicort 200/6 - 1 puff BD (£14.00)
Seretide 100 Accuhaler - 1 puff BD (£18.00)
Relvar Ellipta 92/22 - 1 puff daily (£22.00)

Metered dose inhalers
 Fostair 100/6 - 1 puff BD (£14.66)
Flutiform 50/5 2 puffs BD (£18.00)
Seretide Evohaler 50 - 2 puffs BD (£17.46)
Combisal 25/50 - 2 puffs BD (£13.50)

Note:
Qvar, Fostair, Flixotide, Flutiform, Seretide and Asmanex are ‘double strength’ compared to standard Beclometasone (Prices from step 2 per 30 days supply)

If uncontrolled and/or exacerbating:

Swap to Low Dose MART

Step 3 – Increase to moderate dose inhaled steroid

Formulary Choices:

 Dry powder inhalers
Fostair Nexthaler 100/6  - 2 puffs BD (£29.32)
DuoResp Spiromax 160/4.5 - 2 puffs BD (£27.97)
Fobumix Easyhaler 160/4.5 - 2 puffs BD (£21.50)

Metered dose inhalers
Luforbec 100/6 - 2 puffs BD (£20.52)
Bibefco 100/6 - 2 puffs BD (£20.52) does not contain maleic acid as excipient

Equivalents - Non Formulary:

Dry powder inhalers
Symbicort 200/6 - 2 puffs BD (£28.00)
Symbicort 400/12 - 1 puff BD (£28.00)
Seretide 100 Accuhaler - 2 puffs BD (£36.00)
Seretide 250 Accuhaler 1 puff BD (£35.00)
Fusacomb Easyhaler 250 1 puff BD (£21.50)
Relvar Ellipta 92/22 - 2 puffs daily (£44.00)
Relvar Ellipta 184/22 1 puff daily (£29.50)

Metered dose inhalers
 Fostair 100/6 - 2 puffs BD (£29.32)
Flutiform 125/5 2 puffs BD (£28.00)
Seretide Evohaler 125 - 2 puffs BD (£23.45) or Seretide clones:
     Combisal 25/125,  Aloflute 25/125, Sereflo 25/125, Sirdupla 25/125

Note:
Qvar, Fostair, Flixotide, Flutiform, Seretide and Asmanex are ‘double strength’ compared to standard Beclometasone (Prices from step 2 per 30 days supply)

If uncontrolled and/or exacerbating:

Swap to Moderate Dose MART

Step 3b – Trial of Montelukast 10mg OD

If uncontrolled and/or exacerbating:

Swap to Moderate Dose MART

Continue Montelukast if beneficial

Step 4 – Review diagnosis - referral/discussion with specialist before increase to high dose inhaled steroid

Formulary Choices:

Dry powder inhalers
Fostair Nexthaler 200/6 - 2 puffs BD (£29.32)
DuoResp SpiroMax 320/9 - 2 puffs BD (£55.94)
Fobumix Easyhaler 320/9 - 2 puffs BD (£43.00)

Metered dose inhalers
Fostair 200/6 - 2 puffs BD (£29.32)
Luforbec 200/6 2 puffs BD (£13.98)
Bibefco 200/6 - 2 puffs BD (£13.98) does not contain maleic acid as excipient

Equivalents - Non Formulary:

Dry powder inhalers
Beclometasone 800mcg BD plus LABA
Symbicort 400/12 2 puffs BD (£56.00)
Seretide 500 Accuhaler 1 puff BD (£40.92) – also available as AirfluSal Forspiro (£29.97), Fusacomb Easyhaler 500 (£26.99) and Stalpex 500 DPI (£24.56)

Metered dose inhalers
Flutiform 250/5 2 puffs BD (£45.56)
Seretide Evohaler 250 2 puffs BD (£29.32) or clones:
    AirFluSal (£20.52), Aloflute (£28.32), Combisal (£27.99), Sereflo (£19.99), Sirdupla (£28.32)

Note:
Qvar, Fostair, Flixotide, Flutiform, Seretide and Asmanex are ‘double strength’ compared to standard Beclometasone (Prices from step 2 per 30 days supply)

Reliever as required - Consider step up if using 3 doses a week or more

No-one with a diagnosis of asthma should be taking Salbutamol alone

Formulary Choice:
Easyhaler Salbutamol 100mcg 2 puffs as required (£3.31)

If confirmed asthma:

Swap to AIR

If uncontrolled and/or exacerbating:

Swap to Low dose MART

Editorial Information

Last reviewed: 20/01/2025

Next review date: 20/01/2027

Author(s): Emily Kennedy, Fergus Donachie.

Version: 1