National (and International) Guidance
BTS Adult Asthma (Note Page 12)
GINA GOLD COPD (Note Pages 8 and 23)
OLD BTS Asthma for reference only (Note Page 13)
Note that in my opinion, to help prevent errors on prescriptions, prescription charts and records, all doses in micrograms should be written as micrograms, not mcg. Milligrams is ok as mg. This is general advice for all medicines and not related to respiratory products only. If it can go wrong, it will. We all need to be vigilant and help prevent errors where possible.
In my opinion, the general rule is that a MDI needs a slow, steady and deep inhalation of circa 25L/min and a DPI needs a forceful and strong inhalation of circa 60L/min. However, each device has a specific range where a therapeutic dose is delivered. Refer to individual SPCs for specific inhalation flow rates and resistance values for each device.
Ventolin Evohaler and Salamol MDI (both containing salbutamol 100mcg).
Clenil Modulite (a range of beclomethasone inhalers containing 50mcg to 250mcg at standard particle size).
Seretide Evohaler (containing fluticasone propionate with salmeterol) is also an MDI.
Fostair is available as an MDI and a DPI (see NEXThaler DPI below). Fostair is an ICS+LABA containing beclomethasone and formoterol.
Qvar Inhaler is a range of MDI inhalers containing extra fine particle beclomethasone (see notes below).
E.g. Salbutamol 100mcg (Salamol Easi-Breathe) and Beclomethasone 100mcg (Qvar 100 Easi-Breathe)
Qvar is extra fine particle. Dose needs to be approximately halved because extra fine particle size leads to approximately double potency due to improved lung periphery deposition and drug action (theory at least). Please see the relevant up-to-date SPC for dosage conversions. Qvar is available in MDI and Easi-Breathe (breath actuated aerosol). Fostair (see above, is also extra fine particle and requires similar dosing in relation to steroid potency as Qvar).
DuoResp Spiromax: https://www.youtube.com/watch?v=rH5fPcslZY0
This is a biosimilar of Symbicort i.e. an ICS+LABA (budesonide and formoterol). This was at old BTS Step 3 and 4.
DuoResp is labelled as 160/4.5 instead of 200/6 (the original Symbicort). This is because all new inhalers are labelled with their delivered dose rather than metered dose. The metered dose of DuoResp 160/4.5 is 200mcg budesonide and 6mcg formoterol, as the original Symbicort.
Bricanyl (terbutaline 500mcg), Pulmicort (budesonide 100mcg – 400mcg at standard particle size), Symbicort (budesonide and formoterol 100/6, 200/6 and 400/12 – all mcg).
These are usually all ONE inhalation ONCE daily. Potentially once daily dosing may be an advantage if patient reports that they often forget evening dose, irrespective or reminder strategies.
Relvar = ICS+LABA = fluticasone furoate and vilanterol
Incruse = LAMA = umeclidinium 55mcg
Anoro = LABA+LAMA = umeclidinium 55mcg and vilanterol 22mcg
This is available as a salbutamol 100mcg and 200mcg per inhalation.
Also available in beclomethasone and budesonide. Budesonide is licensed for children (certain strengths in certain age groups only – see SPC) and also has a once daily licensed option. Please see the relevant SPC.
This is the only aerosol propelled LAMA with MA in the UK (I think). This contains 2.5mcg of tiotropium per actuation. The usual dose is TWO doses to be inhaled ONCE daily. Brand name Spiriva Respimat. Please see the up-to-date SPC and BNF before using (as with all products).
This is a BI LAMA product containing dry powder tiotropium 18mcg in a capsule that is inserted into the Handihaler device. The capsule is pierced at both ends. Brand name Spiriva Handihaler.
This is the older GSK DPI and Ellipta seems to be the intended replacement. The Accuhaler (aka Diskus in Europe) is available as salbutamol 200mcg per dose (Ventolin Accuhaler) and as the ICS+LABA combination of fluticasone propionate with salmeterol (Seretide Accuhaler).
This is the Fostair (ICS+LABA) DPI. Excellent device in my opinion but only one product i.e. only ICS+LABA (two strengths), no LAMA or LABA+LAMA or SABA.
Some Example SPCs
Ventolin Evohaler: https://www.medicines.org.uk/emc/medicine/99
Ventolin Accuhaler: https://www.medicines.org.uk/emc/medicine/97
Salamol Easi-Breathe: https://www.medicines.org.uk/emc/medicine/31697
Clenil Modulite 100mcg: https://www.medicines.org.uk/emc/medicine/30652 (also available in 50, 200 and 250mcg)
Easyhaler Budesonide 100mcg: https://www.medicines.org.uk/emc/medicine/18772 (also available in 200 and 400mcg)
Easyhaler Beclomethasone 200mcg: https://www.medicines.org.uk/emc/medicine/18757
Relvar Ellipta 92/22: https://www.medicines.org.uk/emc/medicine/28496 – Asthma and COPD
Relvar Ellipta 184/22: https://www.medicines.org.uk/emc/medicine/28495 – Asthma only
DuoResp Spiromax 160/4.5: https://www.medicines.org.uk/emc/medicine/29186
DuoResp Spiromax 320/9: https://www.medicines.org.uk/emc/medicine/29187
Symbicort Turbohaler 100/6: https://www.medicines.org.uk/emc/medicine/4820
Symbicort Turbohaler 200/6: https://www.medicines.org.uk/emc/medicine/4821
Symbicort Turbohaler 400/12: https://www.medicines.org.uk/emc/medicine/11882
Symbicort also available as an MDI.
Spiriva Handihaler: https://www.medicines.org.uk/emc/medicine/10039
Spiriva Respimat: https://www.medicines.org.uk/emc/medicine/20134
Anoro Ellipta: https://www.medicines.org.uk/emc/medicine/28949
Incuse Ellipta: https://www.medicines.org.uk/emc/medicine/29394
Fostair 100/6 MDI: https://www.medicines.org.uk/emc/medicine/21006
Fostair 100/6 NEXThaler: https://www.medicines.org.uk/emc/medicine/29177
Fostair 200/6 MDI: https://www.medicines.org.uk/emc/medicine/31255
Fostair 200/6 NEXThaler: https://www.medicines.org.uk/emc/history/31250#version3
Some Examples of Regional Pathways
MA= Marketing Authorisation
LAMA = Long acting muscarinic agonist
LABA = Long acting beta agonist
SABA = Short acting beta agonist
SPC = Summary of Product Characteristics (sometimes written SmPC)
BNF = British National Formulary (see links on the right hand side of the page)
mcg = micrograms (I know, I go against my own rules here!)
mg = milligrams
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