Respiratory system - BNF chapter 3

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

1. Airways disease, obstructive

See NHS D&G Quit Your Way for smoking cessation

1.1 Asthma - acute and chronic

National pathways and resources

Inhaler Devices

  • The choice of device should be based on patient factors eg manual dexterity, inhaler technique. Where possible the most cost effective and sustainable device should be prescribed..
  • Combination inhalers are preferred over individual components to aid compliance.
  • Always check inhaler technique and compliance before switching therapy.
  • Patients with a metered dose inhaler (MDI) should have a spacer available for use for all occasions, but particularly for acute exacerbations.
  • Consider using lower carbon footprint (CF) inhalers where clinically appropriate. You may wish to use the NICE decision aid , which considers the carbon footprint of inhalers as well as other issues affecting inhaler selection.

Bronchodilators

SABA – Short Acting Beta2 Agonists

Do not prescribe alone or as first-line in asthma. Ensure a preventer (ICS or ICS/LABA as MART) is also prescribed. For new patients, consider low dose ICS/formoterol (AIR) or MART.

Prescribing Notes:
MDIs are most cost-effective, but DPIs have lower carbon footprint.
DPIs include dose counters which help monitor overuse.
MDIs should be used with a spacer for improved lung deposition.
DPIs and MDIs (with spacer) have equal deposition compared to nebulised salbutamol.

LABA – Long Acting Beta2 Agonists

Use as add-on if asthma is not well controlled with ICS. Always prescribe as combination LABA/ICS. Do not prescribe LABA alone in asthma.

Antimuscarinic Bronchodilators

Asthma

Spiriva Respimat® (tiotropium) ✓ First Choice: accepted for use in Scotland as add-on maintenance bronchodilator treatment in adult patients with asthma who are currently treated with the maintenance combination of inhaled corticosteroids (≥800 micrograms budesonide/day or equivalent) and long-acting beta2 agonists and who experienced one or more severe exacerbations in the previous year.

Moderate to High Risk COPD

Combination LABA/LAMA:

Prescribing Notes:
Combination bronchodilators may prevent unnecessary escalation to ICS in COPD and may also reduce oral steroid and antibiotic use.

The Respimat device (soft mist) is suitable for those unable to use a DPI.
Ensure the patient/carer can load and use the Respimat device; use with a spacer is off-license but may be helpful.
Respimat® inhalers (Spiriva and Spiolto)are reusable. Each base can be used with up to 6 cartridges.
Further info: www.medical.respimat.com/uk

Corticosteroids (Inhaled)

Asthma (Adults)

Note: Prescribe by brand – products are not bioequivalent. See Table 1.

Combination Corticosteroids (See Table 1)

MART therapy options highlighted in Table 1:

Anti-inflammatory Reliever Therapy (AIR) for Mild Asthma

  • Symbicort® 200/6 (DPI) – from age 12 ✓ First Choice

Asthma in Paediatric Patients

Combination ICS/LABA/LAMA (Triple Therapy)

  • Trimbow® 88/5/9 (DPI) ✓ First Choiceand 87/5/9 or 172/5/9 (pMDI) – high strength licensed for asthma only
  • Trelegy® 100/62.5/25 Ellipta (DPI) ✓ First Choice

Table 1, showing total daily dose categories in asthma (Check licenses for different age groups, maintain at lowest possible ICS dose) BTS/SIGN guideline September 2016.

ICS

Note: all MDIs should be delivered via a spacer to increase deposition and minimise adverse effects
 

Low dose

Medium dose

High dose

Beclometasone dipropionate as Soprobec or Clenil MDI

400mcg

800mcg

1000 – 2000mcg

Beclometasone dipropionate as Kelhale MDI or QVAR MDI/Easi-breathe (BA)

200mcg

400mcg

800mcg

Easyhaler beclometasone (DPI)

400mcg

800mcg

1600mcg

Easyhaler budesonide (DPI)

400mcg

800mcg

1600mcg

Combination inhalers

Fobumix Easyhaler ® (DPI)

 

80/4.5  one or two puffs twice a day

160/4.5  one puff twice a day

 

160/4.5 two puffs twice a day

320/9 one puff twice a day

 

320/9    two puffs twice a day

160/9  two puffs twice a day plus four puffs (MART)

 

Luforbec ® or Bibecfo ® MDI

 

100/6   one puff twice a day

100/6 two puffs twice a day

 

200/6 one puff twice a day

100/6    two puffs twice a day plus four puffs if needed (MART)

 

Or 200/6 two puffs twice a day

Fostair ® Nexthaler (DPI) or MDI, only if cannot tolerate alternatives

 

100/6 one puff twice a day

 

100/6 two puffs twice a day

 

200/6 one puff twice a day

 

100/6     two puffs twice a day plus four puffs if needed (MART)

 

 

200/6 two puffs twice a day

 

Symbicort (DPI)

200/6 One puff when required (AIR)

200/6 one puff twice a day plus four puffs if needed (MART)

200/6 two puffs twice a day plus four puffs if needed (MART)
Prescribing notes:
Formoterol containing - medium dose ICS combination inhalers can be used for Maintenance and Reliever Therapy in asthma (see SPC for detailed advice). Some are also licensed for Anti- inflammatory reliever (AIR) therapy in asthma (See GINA and individual SPC for full details).

Luforbec, Bibecfo and Fostair are twice as potent as beclometasone All 200/6 strength MDIs are licensed only for asthma

Luforbec contains different excipients to Bibeco (and Fostair) and so a change to Bibefco (or Fostair) may resolve issues that some patients have with Luforbec (e.g. cough).

Treat asthma with lowest possible ICS dose to control symptoms, maintenance usually at lower dose combinations.

Ensure ICS is appropriate in COPD (licensed in combinations) as many moderate COPD patients will benefit from LABA/LAMA combination alone. Inhaled corticosteroids in combination inhalers for COPD should only be prescribed for patients with an FEV1 of 50% predicted or less, who have two or more exacerbations needing treatment with antibiotics or oral corticosteroids a year. Eosinophils are a useful marker of people with COPD who will respond (>0.3 x 109 per L)

Therapy should be reviewed every 3 months with a view to stepping down or up as per national guidance

Those with both Asthma and COPD will require ICS treatment. There may be specialist initiation of ICS/LABA combination plus LAMA Inhalers should be prescribed by brand

Note: there are some less expensive ‘branded generic’ alternatives where people cannot manage the formulary inhaler options

Other corticosteroids

Prescribing notes:
Dose/ duration: COPD = 30mg for 7-14 day course Asthma = 40/50mg for 5-day course

Prednisolone oral solution and soluble tablets are restricted to use in patients who are unable to swallow tablets. These preparations are considerably more expensive than the standard tablets.

Time for onset for IV and oral hydrocortisone is no different, so there is little therapeutic gain if a patient has already started on an oral steroid prior to attendance.

Normally short courses of steroids can be stopped abruptly but in certain cases they should be tapered – see BNF for more information.

With regard to gastrointestinal effects, there is no advantage by using enteric coated prednisolone tablets; plain tablets should be used.

Osteoprotection: Patients on or commencing high dose corticosteroid long-term (≥7.5mg per day of prednisolone or its equivalent for 3 months or more) should be offered bone protection with bisphosphonate.

Three or more short courses of oral steroids for exacerbations may require introduction of osteoprotection therapy.

Patients taking lower doses of oral corticosteroids long-term should be considered for risk fracture assessment.

Drug delivery devices

Aerochamber ® Plus Flow-Vu Anti-static spacer device (compatible with all formulary inhalers)

Easychamber ® spacer device (compatible with all formulary inhalers)

Medi Peak Flow Meter® (Medicare plus international) standard (60-800 litres/minute) and low range 30-400 litres/minute

Theophylline preparations ✓ Specialist Initiation Only

  • Oral: Uniphyllin continus®
  • Aminophylline Injection (hospital use only)
Prescribing notes:
Smoking cessation may increase theophylline levels
Theophylline should be prescribed by brand due to varying bioavailability
Routine therapeutic monitoring is not required unless checking compliance or for toxicity

Drugs for respiratory diseases

Monoclonal antibodies – all specialist initiation and as per SMC advice

  • Benralizumab (Fasenra®) injection ✓ Specialist Use Only
  • Dupilumab (Dupixent) injection ✓ Specialist Use Only
  • Mepolizumab (Nucala®) ✓ Specialist Use Only
  • Omalizumab (Xolair®) ✓ Specialist Use Only
  • Tezepelumab ✓ Specialist Use Only

Leukotriene receptor agonist

  • Montelukast tablets (note not licensed in COPD)

 

2. Allergic conditions

Antihistamines

Note Allergic Emergencies – under review see BNF 8.1a

3. Conditions affecting sputum viscosity

Mucolytics

  • NACSYS ® effervescent tablets (contains 600mg acetylcysteine per tablet) ✓ First Choice
Prescribing notes:
Prescribe by brand to ensure most cost effective preparation.
Mucolytics should be reviewed after 4 weeks to assess if there has been any clinical benefit.
Patients prescribed carbocisteine capsules should be reviewed for continued benefit, if not then it should be stopped. If appropriate to continue consider switching to NACSYS/reducing to maintenance dose/using “when required”.

4. Cough and congestion

There is little evidence to support the use of cough suppressants. See cough guidance on DG Refhelp

5. Idiopathic pulmonary fibrosis

Antifibrotics– specialist initation as per SMC

  • Nintedanib (Ofev®) ✓ Specialist Use Only
  • Pirfenidone (Esbriet®)✓ Specialist Use Only

Editorial Information

Last reviewed: 25/04/2025

Next review date: 30/04/2027

Author(s): Formulary subgroup of ADTC.

Version: 1.0

Approved By: ADTC