Asthma

Prescribing Notes:

• Symbicort 200/6 Turbohaler can be used as reliever therapy for adults and adolescents (12 years and older) with mild asthma.
• SMC accepted Symbicort 200/6 Turbohaler for restricted use in patients who would otherwise receive low dose inhaled corticosteroid (ICS) maintenance therapy plus short-acting beta-2 adrenoceptor agonist (SABA) as needed. 

Prescribing Notes:

• Dry powder inhalers (DPIs) have lower estimated carbon footprints than pressurised metered-dose inhalers (pMDIs). Where clinically appropriate, prescribers should discuss with patients the potential environmental impact of inhaler choices and the carbon footprint associated with device choices. Inhaler device choice should consider patient factors, training, inhaler technique and environmental impact, please see the NICE Patient decision aid: Inhalers for asthma for further information.
• There is virtually no difference in efficacy between salbutamol and terbutaline; currently salbutamol is less expensive and available in a wider range of devices. The preferred dry powder device is the Easyhaler Salbutamol.
• Inhalation is preferred to oral administration because it provides more rapid relief and causes fewer side effects.
• Inhalation of a short-acting beta2-agonist bronchodilator using a pressurised metered-dose inhaler (pMDI) with a spacer is more effective in emergency use.
• Patients with asthma using a short-acting beta2-agonist bronchodilator, three times or more per week, should have their asthma control re-assessed.
• Salbutamol can be used as prophylaxis in exercise induced bronchospasm at a dose of 200micrograms.
• Caution in patients who may be overusing short-acting beta2-agonist inhalers – patients prescribed more than 12 SABAs in a 12-month period should be reviewed to assess asthma symptoms and control.

Prescribing Notes:

• Beclometasone is first choice because it is as effective but less expensive than alternative steroid inhalers at standard equivalent doses.
• Soprobec should be prescribed by brand name to avoid inadvertent switching to a different metered dose inhaler (MDI) device with a different potency.
• Soprobec has a slightly different colour range to Clenil Modulite, another beclometasone dipropionate MDI. Patients should be reassured it is equivalent to their previous device.
• A spacer device should also be used with beclometasone MDI.
• Patients receiving more than 800micrograms daily of beclometasone or equivalent may have some systemic effects, should be given a steroid card and monitored for adrenal suppression.
• Patients on high doses of inhaled steroids (more than 800micrograms daily of beclometasone dipropionate or equivalent) who receive more than three to four courses of oral steroids per year should be considered for bone protection. See osteoporosis recommendations in the Endocrine chapter of the formulary.
• Prescribers should be aware that higher doses of inhaled steroids may be needed in patients who are smokers.
• Asthma guidelines suggest patients may do better with moderate doses of steroid (400micrograms beclometasone dipropionate) plus a long-acting beta2-adrenoceptor stimulant rather than increasing the steroid dose.

Prescribing Notes:

• Fostair (beclometasone dipropionate and formoterol fumarate) and Luforbec (beclometasone dipropionate and formoterol fumarate)  are formulated with extrafine particles and are therefore more potent than traditional inhalers containing beclometasone dipropionate.
• Luforbec has a slightly different colour range to Fostair MDI, another Beclometasone + Formoterol MDI. Patients should be reassured it is equivalent to their previous device.
• A spacer device should also be used with Beclometasone + Fomoterol MDI.
• The fluticasone salt in Relvar Ellipta is not the same as that contained in single drug fluticasone inhalers. They are not interchangeable.
• Combination products can be a cost effective alternative to the individual products and are more convenient to use. In asthma they minimise the risk of inadvertent monotherapy with long-acting beta2-agonist bronchodilators. Choice will depend on the selected inhaled steroid and inhaler technique.
• Patients receiving more than 800micrograms daily of beclometasone or equivalent may have some systemic effects, should be given a steroid card and monitored for adrenal suppression.
• Patients on high doses of inhaled steroids (more than 800micrograms daily of beclometasone dipropionate or equivalent) who receive more than three to four courses of oral steroids per year should be considered for bone protection. See osteoporosis recommendations in the Endocrine chapter of the formulary.
• Fobumix Easyhaler, Luforbec MDI and Fostair NEXThaler can be used as part of maintenance and reliever therapy (MART) in asthmatic patients. Patients should be counselled on when to step up inhalations and when to seek further medical advice as part of their asthma management plan.

Prescribing Notes:

• Fostair (beclometasone dipropionate and formoterol fumarate) and Luforbec (beclometasone dipropionate and formoterol fumarate)  are formulated with extrafine particles and are therefore more potent than traditional inhalers containing beclometasone dipropionate.
• Luforbec has a slightly different colour range to Fostair MDI, another Beclometasone + Formoterol MDI. Patients should be reassured it is equivalent to their previous device. 
• The fluticasone salt in Relvar Ellipta is not the same as that contained in single drug fluticasone inhalers. They are not interchangeable.
• Combination products can be a cost effective alternative to the individual products and are more convenient to use. In asthma they minimise the risk of inadvertent monotherapy with long-acting beta2-agonist bronchodilators. Choice will depend on the selected inhaled steroid and inhaler technique.
• Patients receiving more than 800micrograms daily of beclometasone or equivalent may have some systemic effects, should be given a steroid card and monitored for adrenal suppression.
• Patients on high doses of inhaled steroids (more than 800micrograms daily of beclometasone dipropionate or equivalent) who receive more than three to four courses of oral steroids per year should be considered for bone protection. See osteoporosis recommendations in the Endocrine chapter of the formulary.
• Montelukast should be taken at bedtime; those patients that experience sleep disturbance will still get a clinical benefit by switching the dose to the morning.
• Montelukast has been associated with a risk of neuropsychiatric reactions and prescribers should be alert for reactions: please see MHRA Drug Safety Update.  Review after 4 weeks for ongoing benefit.
• Theophylline is a bronchodilator used for reversible airways obstruction, which may have an additive effect when used with small doses of beta2-adrenoceptor stimulants; this combination may increase the risk of side-effects including hypokalaemia.
• Theophylline has a narrow margin between therapeutic and toxic effects; therapy should be monitored.
  Theophylline and aminophylline interact with many drugs; see BNF for details.
• Smoking cessation may increase theophylline levels, this is independent of any nicotine replacement therapies that may be prescribed.

Prescribing Notes:

• First choice short-acting beta2-agonist bronchodilator choices may be used with or without oxygen – adjust flow to maintain an oxygen saturation of 94-98%.
• Acute attacks of asthma should be treated with short courses of 30-40mg prednisolone daily, reducing once the attack has been controlled. Usually doses of up to 40mg daily taken for less than 3 weeks do not need to be tapered. It may be appropriate for some patients to have a “rescue” course of prednisolone at home, if this is agreed as part of the self-management strategy of their asthma.
• See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
• For patients with swallowing difficulties prednisolone oral solution or soluble tablets may be considered. Prednisolone tablets may be dispersed in water as an alternative to soluble tablets or oral solution preparations. This is an off-label use but more cost-effective option. Refer to local board policies on the use of unlicensed (and off-label) medicines for further guidance. 
• 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.
• Intravenous hydrocortisone is used in the management of acute severe asthma.
• Hydrocortisone sodium succinate is recommended in preference to hydrocortisone sodium phosphate which has been associated with perineal irritation.

• Aminophylline has a narrow margin between therapeutic and toxic effects; therapy should be monitored.
• Intravenous aminophylline is not a recommended drug in primary care having been superseded by nebulised beta2-agonists.
• Theophylline and aminophylline interact with many drugs; see BNF for details.
• Smoking cessation may increase aminophylline levels, this is independent of any nicotine replacement therapies that may be prescribed.

Prescribing Notes:

• Omalizumab (Xolair) is approved for specialist use only in patients with severe, persistent confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy (a full trial of and, if tolerated, documented compliance with inhaled high-dose corticosteroids, long-acting beta2 agonists, leukotriene receptor antagonists, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate) in people aged 6 years and older who need continuous or frequent treatment with oral corticosteroids (defined as 4 or more courses in the previous year).
• Mepolizumab (Nucala) is approved for specialist use only in adult patients with severe refractory eosinophilic asthma. It is restricted to patients requiring 4 or more courses of prednisolone for exacerbation in the previous 12 months or are on chronic daily oral steroids despite maintenance with high dose inhaled steroids plus one other controller therapy.
• SMC advice restricts mepolizumab use for adult patients as an add-on treatment for severe refractory eosinophilic asthma who have eosinophils of at least 150 cells per microlitre (0.15 x 109/L) at initiation of treatment and have had at least four asthma exacerbations in the preceding year or are receiving maintenance treatment with oral corticosteroids.
• Benralizumab (Fasenra) is specialist use only for add-on maintenance treatment in adult patients with severe eosinophilc asthma inadequately controlled by high dose inhaled corticosteroids plus long-acting β-agonists, blood eosinophils ≥150 cells/microlitre, and either ≥4 prior asthma exacerbations needing systemic corticosteroids in the previous 12 months or treatment with continuous oral corticosteroids over the previous 6 months.
• SMC advice restricts Tezepelumab (Tezpire) as an add on maintenance treatment in adults and adolescents 12 years and older with severe asthma who are inadequately controlled despite high dose inhaled corticosteroids plus another medicinal product for maintenance treatment and either: i) experience at least three exacerbations in the previous year and not receiving maintenance treatment with oral corticosteroids or ii) have a blood eosinophils ≥150 cells/microlitre and are receiving maintenance treatment with oral corticosteroid
• Dupilumab (Dupixent) is available for specialist use only in adults and adolescents 12 years and older as add-on maintenance treatment for severe asthma with type 2 inflammation characterised by raised blood eosinophils and/or raised fraction of exhaled nitric oxide (FeNO), who are inadequately controlled with high dose inhaled corticosteroids (ICS) plus another medicinal product for maintenance treatment. Use is restricted to the treatment of patients with blood eosinophils ≥150 cells/microlitre and FeNO ≥25 parts per billion, and ≥4 exacerbations in the preceding year, who have previously received biologic treatment with anti-IgE or anti-IL-5 therapies.
• Refer to local board prescribing guidelines for further advice.  

Prescribing Notes:

• Prescribing of azithromycin should be on the advice of a respiratory specialist, following sensitivities and investigations in secondary care.

Prescribing Notes:

• Best practice is to prescribe all inhalers by brand name (except salbutamol) and device type.
• Changing the type of inhaler device may impact the effectiveness of therapy and the incidence of adverse effects. There are new versions of existing combination inhalers coming on to the market. Take care to ensure the intended product is prescribed and dispensed.
• Assessment of a patient’s inhaler technique is required before an inhaler is prescribed as this will determine the choice of product. Information on assessing inhaler technique and counselling on the correct method can be found at the PrescQIPP website or the My Lungs My Life website. The individual forms can be printed out for patient use.
• Older patients may have difficulty using any inhaler device due to reduced hand strength, poor inspiratory effort, or confusion. Individual assessment is required.
• All inhalers have different ‘in use’ expiry, this can lead to unintended wastage. Ensure patients are given adequate advice on effective use of the device. For example, an inhaler with an in use expiry of 6 weeks: one inhaler lasts 1 month with regular use. If 2 inhalers are prescribed and dispensed and both opened at the same time, they will both expire 6 weeks later, but if opened one at a time they would have lasted 8 weeks.
• Inhaler-induced cough by MDI may be alleviated by use of a spacer or change of device.
• It is essential to specify inhaler device, strength and dose.
• Not all spacers are compatible with all inhalers; users should seek advice from their local pharmacist regarding the appropriate spacer to be used.

Prescribing Notes:

• Further information is available in the ‘National Guidance and Best Practice for Domiciliary Oxygen Therapy’.
• The Department of Health has issued safety advice through the Central Alerting Service regarding electronic cigarettes and oxygen therapy. Patients and carers should be advised not to use an electronic cigarette whilst a patient is receiving oxygen therapy and batteries of electronic cigarettes should not be charged in the vicinity of a patient receiving oxygen therapy or the oxygen source.

Prescribing Notes:

• A poster has been developed to provide guidance on selecting the correct AeroChamber Plus Flow-Vu Anti-Static valved holding chamber.
• Local advice is that patients should inhale from the spacer device using a single breath with 5-10 second breath hold.
• Spacers should be cleaned no more than weekly, with water and washing-up liquid, or put in a dishwasher, and allowed to air dry. More frequent cleaning affects their performance due to build-up of static.
• AeroChamber Plus Flow-Vu and Volumatic should be replaced every 12 months following regular use.

Prescribing Notes:

• Measurement of peak flow is helpful for patients who are unable to detect deterioration in their asthma, and for those with moderate or severe asthma. Mini-Wright and Vitalograph peak flow meters are the most commonly prescribed.

Prescribing Notes:

• Symbicort 200/6 Turbohaler can be used as reliever therapy for adults and adolescents (12 years and older) with mild asthma.
• SMC accepted Symbicort 200/6 Turbohaler for restricted use in patients who would otherwise receive low dose inhaled corticosteroid (ICS) maintenance plus short-acting beta-2 adrenoreceptor agonist (SABA) as needed. 

Prescribing Notes:

• All MDI inhalers should be given with a spacer device.
• Dry powder inhalers (DPIs) have lower estimated carbon footprints than pressurised metered-dose inhalers (pMDIs). Where clinically appropriate, prescribers should discuss with patients and their parents the potential environmental impact of inhaler choices and the carbon footprint associated with device choices. Inhaler device choice should consider patient factors, training, inhaler technique and environmental impact, please see the NICE Patient decision aid: Inhalers for asthma for further information.
• It is important to provide advice on how to tell when an inhaler is finished – see Medicines for Children article ‘Make sure you're not running on empty’.
• There is virtually no difference in efficacy between salbutamol and terbutaline; currently salbutamol is less expensive and available in a wider range of devices. The preferred dry powder device is the Easyhaler Salbutamol. Advise patients or carers that once the foil packet is opened the inhaler should be discarded after six months.
• Inhalation is preferred to oral administration because it provides more rapid relief and causes fewer side effects. Oral salbutamol should not be used for management of wheeze.
• Inhalation of a short-acting beta2-agonist bronchodilator using a pressurised metered-dose inhaler (pMDI) with a spacer is more effective in emergency use.
• Patients with asthma using a short-acting beta2-agonist bronchodilator, three times or more per week, should have their asthma control re-assessed.
• Salbutamol can be used as prophylaxis in exercise induced bronchospasm. See the BNF for dosage range.
• Caution in patients who may be overusing short-acting beta2-agonist inhalers – patients prescribed more than 6 SABAs in a 12-month period (taking into account social circumstances e.g. needing multiple devices for school, carers locations, nursery etc). This should be reviewed to assess asthma symptoms and control.

Prescribing Notes:

• All MDI inhalers should be given with a spacer device.
• If using Soprobec 50mcg do not prescribe two puffs twice a day switch to a 100mcg inhaler One puff twice a day.
• Children receiving more than 800micrograms daily of beclometasone or equivalent) should be given a steroid card and monitored for adrenal suppression. For information on equivalent steroid doses refer to British Thoracic Society (BTS) and SIGN guidelines for management of asthma 2019 Table 13: Categorisation of inhaled corticosteroids by dose - children. A steroid card may be provided at lower inhaled corticosteroid doses if intranasal and/or topical corticosteroids are also administered.
• Patients who receive more than 2 courses of oral steroids per year should be considered for referral to the Asthma clinic.
• Patients receiving high doses of corticosteroids (more than 500micrograms of fluticasone daily or equivalent) should be referred to the Asthma clinic and assessed for adrenal suppression using a short Synacthen (tetracosactide) test.
• Beclometasone is first choice because it is as effective but less expensive than alternative steroid inhalers at standard equivalent doses.
• Soprobec should be prescribed by brand name to avoid inadvertent switching to a different metered dose inhaler (MDI) device with a different potency.
• It is important to provide advice on how to tell when an inhaler is finished – see Medicines for Children article ‘Make sure you're not running on empty’.
• All children should have their height and weight checked at their regular reviews.
• The aim of treatment should be to use the lowest possible steroid dose to control symptoms.
• Montelukast is indicated for add-on therapy in mild-moderate persistent asthma and to prevent exercise-induced bronchospasm.
• Montelukast should be taken at bedtime; those patients that experience sleep disturbance will still get a clinical benefit by switching the dose to the morning.
• Some children under 5 years may be given a trial of Montelukast monotherapy. These children tend to be non-atopic from non-atopic parents. It should be given for a trial period of 3 months and discontinued if not proving effective. If the child experiences adverse effects stop immediately and review to discuss alternatives.
• MHRA has produced the following advice – Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions.

Prescribing Notes:

• Montelukast is indicated for add-on therapy in mild-moderate persistent asthma and to prevent exercise-induced bronchospasm.
• Montelukast should be taken at bedtime; those patients that experience sleep disturbance will still get a clinical benefit by switching the dose to the morning.
• Montelukast is not effective in all patients. A 4-week trial would be recommended to check for efficacy.
• MHRA has produced the following advice – Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions.

Prescribing Notes:

• Combination products can be a cost-effective alternative to the individual products and are more convenient to use. In asthma they minimise the risk of inadvertent monotherapy with long-acting beta2-agonist bronchodilators. Choice will depend on the selected inhaled steroid, age and ability to use the device.
• It is recommended that patients should be 10 to 12yrs to be prescribed Symbicort due to difficulties with technique.
• Montelukast is indicated for add-on therapy in mild-moderate persistent asthma and to prevent exercise-induced bronchospasm.
• Montelukast should be taken at bedtime; those patients that experience sleep disturbance will still get a clinical benefit by switching the dose to the morning.
• MHRA has produced the following advice – Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions.

Prescribing Notes:

• All MDI inhalers should be given with a spacer device.
  
• Children receiving more than 800micrograms daily of beclometasone or equivalent) should be given a steroid card as they may suffer some systemic effects. For information on equivalent steroid doses refer to British Thoracic Society (BTS) and SIGN guidelines for management of asthma 2019 Table 13: Categorisation of inhaled corticosteroids by dose - children. A steroid card may be provided at lower inhaled corticosteroid doses if intranasal and/or topical corticosteroids are also administered.
  
• Patients who receive more than 2 courses of oral steroids per year should be considered for referral to their local Asthma clinic.
  
• Patients receiving high doses of corticosteroids (more than 500micrograms of fluticasone daily or equivalent) should be referred to the Asthma clinic and assessed for adrenal suppression using a short Synacthen (tetracosactide) test.
  
• All children should have their height and weight checked at their regular reviews.
  
• The aim of treatment should be to use the lowest possible steroid dose to control symptoms.
  

Prescribing Notes:

• All MDI inhalers should be given with a spacer device.
  
• It is recommended that patients should be 10 to 12yrs to be prescribed Symbicort due to difficulties with technique.
  
• Children receiving more than 800micrograms daily of beclometasone or equivalent) should be given a steroid card as they may suffer some systemic effects. For information on equivalent steroid doses refer to British Thoracic Society (BTS) and SIGN guidelines for management of asthma 2019 Table 13: Categorisation of inhaled corticosteroids by dose - children. A steroid card may be provided at lower inhaled corticosteroid doses if intranasal and/or topical corticosteroids are also administered.
  
• Patients who receive more than 2 courses of oral steroids per year should be considered for referral to the Asthma clinic. NHS Lothian referrals can be made through the eTriage system and the asthma team can now use telephone, NearMe video call or face to face review to support these referrals (see RefHelp website).
  
• Patients receiving high doses of corticosteroids (more than 500micrograms of fluticasone daily or equivalent) should be referred to the Asthma clinic and assessed for adrenal suppression using a short Synacthen (tetracosactide) test.
  
• All children should have their height and weight checked at their regular reviews.
  
• The aim of treatment should be to use the lowest possible steroid dose to control symptoms.
  
• MHRA has produced the following advice – Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions.

Prescribing Notes:

• Theophylline should be initiated on hospital advice.
• For patients who are unable to swallow Uniphyllin Continus prolonged release tablets or for lower doses consider the use of theophylline oral syrup 50mg/5ml (immediate release) unlicensed special. The usual dose of immediate release theophylline is 5mg/kg 3-4 times a day.
• Theophylline is a bronchodilator used for reversible airways obstruction, which may have an additive effect when used with small doses of beta2-adrenoceptor stimulants; this combination may increase the risk of side-effects including hypokalaemia.
• Theophylline has a narrow margin between therapeutic and toxic effects; therapy should be monitored after 2 weeks initially and then ideally every 6 months in hospital.
• Plasma-theophylline concentration should be measured 5 days after starting oral treatment and at least 3 days after any dose adjustment.
• A blood sample should usually be taken 4-6 hours after an oral dose of a modified-release preparation (sampling times may vary-consult local guidelines), for immediate release products samples should be taken 1-2 hours after administration. In most individuals, a plasma-theophylline concentration of 10-20 mg/litre (55-110 micromole/litre) is required for satisfactory bronchodilation, although a lower plasma-theophylline concentration of 5-15 mg/litre may be effective.
• Adverse effects can occur within the range 10-20 mg/litre and both the frequency and severity increase at concentrations above 20 mg/litre.
• Different brands of modified-release theophylline have different bioavailability; modified-release preparations should be prescribed by brand name.
• Theophylline and aminophylline interact with many drugs; see BNF for details.

Prescribing Notes:

SABA

• In acute severe asthma, salbutamol may be administered by ‘emergency doses’ as 10 puffs MDI via a spacer device. Each actuation should be followed by 5 tidal breaths in and out using mouthpiece or by holding the face mask in place and watching the valve above the nose moving in and out 5 times. Wait 30 seconds between each actuation.
• Doses may be increased in hospital with monitoring as per acute wheeze management guideline. In acute severe asthma, continuous doses may be given in hospital with monitoring.
• On discharge from hospital, children will receive salbutamol 4 puffs 4 times a day for 4 days, this is not a course and parents will be advised to continue this at home for as long as they feel is needed. They may also complete at least a 3-day course of oral prednisolone.
• First choice short-acting beta2-agonist bronchodilator choices should be used with oxygen – adjust flow to maintain an oxygen saturation of 94-98%.

Steroids

• Prednisolone oral solution 5mg/5mL, single-dose unit presentation should not be prescribed for doses exceeding 30mg daily.
• See the Medicines for Children leaflet: Prednisolone for asthma.
• Local advice is that children who receive a single course of systemic corticosteroids for up to 5 days do not routinely require a reducing course.
• Weaning/reduction of steroid doses are required for those that;
  
  • are likely to relapse on withdrawal
  • have received a course of oral corticosteroids within the last 4 weeks
  • are on long-term (>1month) oral corticosteroids or stopped within the last 12 months
  • have proven adrenocortical insufficiency
  • are administered repeated evening doses
  • require a prolonged course (>7 days) or who have multiple recent courses
• See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
• 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.
• Prednisolone tablets may be dispersed in water as an alternative to soluble or liquid preparations. This is a more cost-effective option.
• Normally short courses of steroids can be stopped abruptly but in certain cases they should be tapered - see BNF for more information.
• Regarding gastrointestinal effects, there is no advantage by using enteric coated prednisolone tablets; plain tablets should be used.
• Intravenous hydrocortisone is used in the management of acute severe asthma.
• Hydrocortisone sodium succinate is recommended in preference to hydrocortisone sodium phosphate which has been associated with perineal irritation.

Equivalent doses

Theophylline

• Theophylline levels should be measured 6 hours after initiating intravenous aminophylline.
• Aminophylline has a narrow margin between therapeutic and toxic effects; therapy should be monitored.
• Intravenous aminophylline is not a recommended drug in primary care having been superseded by nebulised beta2-agonists.
• Theophylline and aminophylline interact with many drugs; see BNF for details.

Prescribing Notes:

• Omalizumab (Xolair) is approved for specialist use only in patients with severe, persistent confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy (a full trial of and, if tolerated, documented compliance with inhaled high-dose corticosteroids, long-acting beta2 agonists, leukotriene receptor antagonists, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate) in people aged 6 years and older who need continuous or frequent treatment with oral corticosteroids (defined as 4 or more courses in the previous year).
• Mepolizumab (Nucala) is approved as an add on treatment for severe refractory eosinophilic asthma in adolescents and children aged 6 years and older. It is restricted to patients who have eosinophils of at least 150 cells per microlitre (0.15 x 109/L) at initiation of treatment and have had at least four asthma exacerbations in the preceding year or are receiving maintenance treatment with oral corticosteroids.
• SMC advice restricts Tezepelumab (Tezpire) as an add on maintenance treatment in adults and adolescents 12 years and older with severe asthma who are inadequately controlled despite high dose inhaled corticosteroids plus another medicinal product for maintenance treatment and either:(i) experience at least three exacerbations in the previous year and not receiving maintenance treatment with oral corticosteroids or (ii) have a blood eosinophils ≥150 cells/microlitre and are receiving maintenance treatment with oral corticosteroid 
• Dupilumab (Dupixent) is available for specialist use only in adults and adolescents 12 years and older as add-on maintenance treatment for severe asthma with type 2 inflammation characterised by raised blood eosinophils and/or raised fraction of exhaled nitric oxide (FeNO), who are inadequately controlled with high dose inhaled corticosteroids (ICS) plus another medicinal product for maintenance treatment. Use is restricted to the treatment of patients with blood eosinophils ≥150 cells/microlitre and FeNO ≥25 parts per billion, and ≥4 exacerbations in the preceding year, who have previously received biologic treatment with anti-IgE or anti-IL-5 therapies.
• Dupilumab may be used in 6 yrs and above but there needs to have been treatment failure with a trial of mepolizumab or omalizumab.
• Refer to local board prescribing guidelines for further advice. 

Prescribing Notes:

• Best practice is to prescribe all inhalers by brand name (except salbutamol) and device type.
• All DPI inhalers should be prescribed by brand to ensure continuity of treatment.
• It is good practice for Healthcare professionals to use all interactions to assess inhaler technique and revise training as necessary.
• Changing the type of inhaler device may impact the effectiveness of therapy and the incidence of adverse effects. There are new versions of existing combination inhalers coming on to the market. Take care to ensure the intended product is prescribed and dispensed.
• Assessment of a patient’s inhaler technique is required before an inhaler is prescribed as this will determine the choice of product. Information on assessing inhaler technique and counselling on the correct method can be found at the PrescQIPP website or the Asthma + Lung UK. The individual forms can be printed out for patient use.
• All inhalers have different ‘in use’ expiry, this can lead to unintended wastage. Ensure patients are given adequate advice on effective use of the device. For example, an inhaler with an in use expiry of 6 weeks: one inhaler lasts 1 month with regular use. If 2 inhalers are prescribed and dispensed and both opened at the same time, they will both expire 6 weeks later, but if opened one at a time they would have lasted 8 weeks.
• Inhaler-induced cough by MDI may be alleviated by use of a spacer or change of device.
• It is essential to specify inhaler device, strength and dose.
• Not all spacers are compatible with all inhalers; users should seek advice from their local pharmacist regarding the appropriate spacer to be used.
• AeroChamber Plus Flow-Vu is compatible with all inhalers. Volumatic is not. The Volumatic device should be reserved for children who cannot use AeroChamber Plus Flow-Vu.
• The choice of inhaler device should take into consideration; the ability of the child, their age, their developmental skills and convenience of use. All children require a MDI reliever and spacer for acute treatment of wheeze. All children and carers should be properly trained on the use of the inhaler device.
• In general terms a child of 10 to 12 yrs or above, with the appropriate training, is competent to use a dry powder inhaler.
• Training should include checking the child has the correct device for their individual needs and explanation of how to use the device.

Prescribing Notes:

• Further information is available in the ‘National Guidance and Best Practice for Domiciliary Oxygen Therapy’.
• The Department of Health has issued safety advice through the Central Alerting Service regarding electronic cigarettes and oxygen therapy. Patients and carers should be advised not to use an electronic cigarette whilst a patient is receiving oxygen therapy and batteries of electronic cigarettes should not be charged in the vicinity of a patient receiving oxygen therapy or the oxygen source.

Prescribing Notes:

• A poster has been developed to provide guidance on selecting the correct AeroChamber Plus Flow-Vu Anti-Static valved holding chamber.
• Local advice is that patients should inhale from the spacer device using 5 tidal breaths.
• Aerochamber plus Flow-Vu is antistatic coated. Spacers should be cleaned weekly as per manufacturers guidelines.
• AeroChamber Plus Flow-Vu should be replaced every 12 months following regular use. Volumatic should be changed every 6 months with regular use.
• Spacer devices should be used for all children.
• Local advice is that patients should inhale from the spacer device using 5 breaths per actuation according to age and ability. Only one actuation should be delivered at one time. Wait 30 seconds between each actuation.
• When using a face mask the parent/ carer should hold the spacer gently over their child’s nose and mouth. The child should take 5 breaths in and out per actuation. The parent/carer should observe the valve above the nose move in and out with each breath.
• AeroChamber Plus Flow-Vu is compatible with all metered dose inhalers. Volumatic is not.
• A suitable AeroChamber Plus Flow-Vu spacer appropriate for age should be selected.
• There are 3 different Aerochamber Plus Flow-Vu spacer devices available for children; orange (small with mask) for age 0-12 months, yellow (medium with mask) for age 1-5 years, green (youth with mouthpiece) for ages >5 years. For young adults there are 3 different Aerochamber Plus Flow-Vu spacer devices available: purple (small with mask), blue (large with mask), blue with mouthpiece. It is recommended that young adults use a spacer with mouthpiece unless they have a neuro or learning disability.
  
  

Prescribing Notes:

• Measurement of peak flow is helpful for patients who are unable to detect deterioration in their asthma, and for those with moderate or severe asthma. Mini-Wright and Vitalograph peak flow meters are the most commonly prescribed. Children up to age 7 or 8 years should receive a low range peak flow meter.

Prescribing Notes:

• Nebulisers are not currently prescribable in general practice; patients should be referred for respiratory assessment and if suitable they will be leased a machine. A spacer should be tried before considering a nebuliser.
• See MHRA warning on home use of nebulisers in paediatric asthma.
• All nebulisers should be serviced regularly. However, difficulties are often encountered in the servicing of privately owned nebulisers. Patients should be discouraged from buying a nebuliser.