Compound preparations with corticosteroid and long acting beta2 agonist (ICS/LABA) in asthma (Formulary)

TAM (Treatments and Medicines) NHS Highland
NHS Highland
  • In asthma always use combination inhalers when an inhaled corticosteroid and long-acting beta2 agonist (LABA) are indicated; there is no difference in efficacy in giving inhaled steroid and LABA in combination or in separate devices but there are risks associated with patients receiving a LABA on its own.
  • Use Symbicort® Turbohaler® first-line. Alternative, easy to use, cost-effective options are Fostair® NEXThaler and Relvar® Ellipta®. If an MDI is preferred, consider Flutiform® or Fostair®.
  • Doubling the dose in an exacerbation is of unproven value and is no longer recommended.
  • Maintain patients at the lowest possible dose of steroid; stepping down therapy once asthma is controlled is recommended; reduction in the steroid dose should be slow as patients deteriorate at different rates; consider a dose reduction every 3 months, decreasing the dose by approximately 25 to 50% each time.
  • In adult patients at step 3 of SIGN 158 whose symptoms are poorly controlled, the use of budesonide/formoterol in a single inhaler as rescue medication instead of a short-acting beta2 agonist, in addition to its regular use as a controller treatment, has been shown to be an effective treatment option. Fostair® is also licensed for maintenance and reliever therapy. This management technique has not been investigated with other combination inhalers. Careful patient education is required before instituting this management.
  • Please consider if a steroid emergency card needs to be given to the patient alongside the traditional steroid treatment card.  This is to support the timely recognition and treatment of potential adrenal crisis and is suitable for some patients on oral, inhaled, topical or rectal steroids.  For more information, including which patients should receive the card, see HIS for details.  Steroid emergency cards have been distributed to, hospitals, GP surgeries and community pharmacies. Primary care can order replacement cards from 01463 706886.
  • See Peri-operative guidelines for patients with or at risk of adrenal insufficiency.

Supplementary notes

 Steroid potency of combination inhalers in asthma: equivalent beclometasone dose per day 

Equivalent beclometasone dose per day (micrograms) Combination inhaler (in micrograms)*
Greater than 1000 micrograms


 Relvar Ellipta 184/22 (1 inhalation daily)
Seretide Accuhaler 500/50 (2 inhalations daily)
Flutiform inhaler 250/10 (4 inhalations daily)
Symbicort Turbohaler 400/12 (4 inhalations daily)
1000 micrograms or less Fostair NEXThaler 100/6 (4 inhalations daily)
Fostair inhaler 100/6 (4 inhalations daily)
Relvar Ellipta 92/22 (1 inhalation daily)
Seretide Accuhaler 250/50 (2 inhalations daily)
800 micrograms or less Fostair NEXThaler 100/6 (2 inhalations daily)
Fostair inhaler 100/6 (2 inhalations daily)
Symbicort Turbohaler 200/6 (4 inhalations daily)
Symbicort Turbohaler 400/12 (2 inhalations daily)
400 micrograms or less Symbicort Turbohaler 100/6 (1 inhalation daily)
Symbicort Turbohaler 200/6 (1 inhalation daily)
Symbicort Turbohaler 100/6 (2 inhalations daily)
Seretide Accuhaler 100/50 (2 inhalations daily)
Flutiform inhaler 50/5 (4 inhalations daily)
Symbicort Turbohaler 200/6 (2 inhalations daily)
Symbicort Turbohaler 400/12 (1inhalation daily)
Symbicort Turbohaler 100/6 (4 inhalations daily)

*Consider giving a ‘steroid card’ to patients using greater than maximum licensed doses of inhaled corticosteroids.

BUDESONIDE WITH FORMOTEROL (Symbicort® Turbohaler®) - (First line)

Therapy notes

Formulation and dosage details

Formulation:

PREFERRED: Dry Powder Inhaler (DPI) (Inhalation powder)These are more environmentally friendly than MDIs and should be considered first line providing that the patient shows good inhaler technique with the chosen device.

  • Dry powder for inhalation 100/6, 200/6, 400/12 (micrograms)

Dosage:

Asthma, by inhalation of powder:

  • 100/6 and 200/6 inhaler, 1 to 2 puffs twice daily, reduced in well-controlled asthma to once daily;
  • 400/12 inhaler, 1 puff twice daily reduced to 1 puff once daily if control maintained.

As per SMC1244/17 as Symbicort SMART: the regular treatment of asthma where use of a combination (inhaled corticosteroid and a long-acting β2 adrenoceptor agonist is appropriate: patients not adequately controlled with inhaled corticosteroids and “as needed” short-acting β2 adrenoceptor agonists, or patients already adequately controlled on both inhaled corticosteroids and long-acting β2 adrenoceptor agonists.

BECLOMETASONE WITH FORMOTEROL - (Second line)

Therapy notes

  • Fostair® NEXThaler is second choice in asthma

Formulation and dosage details

Formulation:

PREFERRED: Dry Powder Inhaler (DPI) (Inhalation powder)These are more environmentally friendly than MDIs and should be considered first line providing that the patient shows good inhaler technique with the chosen device.

  • Dry powder inhaler (Fostair® NEXThaler) 100/6 (in micrograms)

Dosage:

Asthma, by inhalation of powder, (Fostair® NEXThaler), 1 to 2 puffs twice daily, maximum 4 puffs daily.

Formulation and dosage details

Formulation:

ALTERNATIVE: Metered dose inhalers (MDI) (Pressurised inhalation)To be considered in the small proportion of patients who are unable to use a DPI.

  • Aerosol inhalation (Fostair®) 100/6 (in micrograms)

Dosage:

Asthma, by aerosol inhalation (Fostair®) , 1 to 2 puffs twice daily, maximum 4 puffs daily.

FLUTICASONE WITH VILANTEROL (Relvar Ellipta®▼) - (Third line)

Therapy notes

Formulation and dosage details

Formulation:

PREFERRED: Dry Powder Inhaler (DPI) (Inhalation powder)These are more environmentally friendly than MDIs and should be considered first line providing that the patient shows good inhaler technique with the chosen device.

  • Dry powder inhaler 92/22, 184/22 (in micrograms)

Dosage:

Asthma, by inhalation of powder, 92/22, 184/22 inhaler, 1 puff once daily.

FLUTICASONE WITH FORMOTEROL

Therapy notes

Formulation and dosage details

Formulation:

ALTERNATIVE: Metered dose inhalers (MDI) (Pressurised inhalation)To be considered in the small proportion of patients who are unable to use a DPI.

  • Inhaler (Flutiform®) 50/5micrograms/dose, 125/5micrograms/dose and 250/10micrograms/dose

Dosage:

Asthma, by aerosol inhalation, 2 puffs twice daily. Titrate to the lowest dose at which effective control of symptoms is maintained.

The 50/5 inhaler is licensed for use in adults and adolescents aged 12 years and above, the 250/10 inhaler is licensed for adults only.

Reserved for those patients who remain uncontrolled on Fostair and who are unable to use a DPI.

FLUTICASONE WITH SALMETEROL (Seretide® Accuhaler®)

Therapy notes

Formulation and dosage details

Formulation:

PREFERRED: Dry Powder Inhaler (DPI) (Inhalation powder)These are more environmentally friendly than MDIs and should be considered first line providing that the patient shows good inhaler technique with the chosen device.

  • Dry powder for inhalation (Seretide® Accuhaler®) disk containing blisters of 100/50, 250/50, 500/50 (in micrograms)/blister

Dosage:

Asthma, by inhalation of powder, 100/50, 250/50, 500/50, 1 blister twice daily.

Editorial Information

Document Id: F354