General Notes

• British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guideline: SIGN 245 - Asthma: diagnosis, monitoring and chronic asthma management.
• British Thoracic Society (BTS) and SIGN guidelines on the management of asthma: SIGN 158 - British Guideline on the Management of Asthma. Note, this guideline was amended in 2024 to take account of SIGN 245 which is linked above.
• NHSL Guideline - Pharmacological Management of Adult Asthma in Primary and Secondary Care. This includes a stepwise approach to formulary inhaler choices, guidance on asthma reviews and a step-down guide. Preferred formulary options for both the updated adult asthma treatment pathway (as per SIGN 245) and the traditional treatment pathway are included.

• NICE Guideline (NG115) for Chronic Obstructive Pulmonary Disease (COPD)
• NHSL Guideline for the Pharmacological Management of COPD
• Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024.

Smoking cessation for patients with asthma and/or COPD is extremely important. Patients can be referred to NHSL Stop Smoking Service for support and supply of medication (e.g. NRT, varenicline).

For further information see Chapter 4. Central Nervous System: Nicotine Dependence.

Additional important points for COPD patients include: ensuring pneumococcal and influenza vaccines are up to date, optimising BMI, promoting exercise, and enrolment onto a pulmonary rehabilitation programme if MRC score >3.

A patient-centred decision on inhaler device will help ensure optimised disease management. Device choice may be considered on the basis of patient acceptability, ease of use, environmental impact and cost.

It is essential to specify inhaler strength and dose. Branded products may need stated so that individuals receive the correct device they are trained to use.

The propellant used in metered dose inhalers (MDIs) are powerful greenhouse gases which have global warming potential. The Scottish Government aim to reduce emissions from inhaler propellants by 70% by 2028.¹ The formulary outlines the carbon footprint per puff of each inhaler, as either Low (<35 g CO2e) or High (≥35 g CO2e)².

References

1. Public Health Scotland Quality Prescribing Strategy: Improvement Guide 2024-2027 [accessed 13/06/2025]
2. PrescQIPP Bulletin 295: Inhaler carbon footprint [accessed 03/09/2025]