Bronchodilators

Therapeutic Area	Formulary Choices	Cost per inhaler (unless otherwise stated)	Rationale for decision / comments
Short acting beta-2 agonist bronchodilators (SABAs)	A salbutamol inhaler contains 25 days supply at full dose (8 puffs/day). Asthmatic patients who are reliant on their SABA inhaler >3 times a week are poorly controlled and should be reviewed. Poor inhaler technique and compliance issues with preventer medication are often the cause. In Somerset 1 in 5 patients are prescribed 6+ SABA inhalers in a 12 month period. COPD patients will benefit from dual bronchodilation with long acting LABA/LAMA combination rather than SABA ad hoc.
First line:	Dry powder inhaler as Salbutamol Easyhaler® as Salbulin Novolizer®	100mcg/dose(200 dose): £3.31 200mcg/dose: £6.63 Complete unit 100mcg/dose £4.95 Refill 100mcg/dose £2.75	Ensure that patients have same types of device, avoiding mixtures of pMDIs and DPIs. If patient is on a LABA/ICS dry powder device, consider a DPI reliever also. Salbutamol Easyhaler has an integrated dose counter unlike salbutamol pMDIs
Second line:	as Salamol® CFC free MDI as Salamol Easibreathe® CFC free MDI as Airomir® CFC free MDI as Airomir Autohaler® CFC free MDI	100mcg/dose (200 dose): £1.46 100mcg/dose (200 dose): £6.30 100mcg/dose (200 dose) £1.97 100mcg/dose (200 dose) £6.02	Salamol or Airomir are preferred pMDI as it is low volume HFC which is environmentally more beneficial than large volume such as Ventolin or other generic brands. Low volume puffs may be beneficial for many patients as they may have a better user technique
Long acting Beta-2 agonist bronchodilators (LABAs)	In asthma LABAs should only be added if regular use of a standard dose ICS has failed to control asthma adequately and should be discontinued if there is no response to treatment. LABA should only be started in patients who are already on inhaled corticosteroids, and the inhaled corticosteroid should be continued. Consider stopping LABAs in well-controlled patients once inhaled corticosteroid dose has been reduced (See step-down guidance) In COPD, LABAs should be used in line with the local COPD guidance If no benefit after trial period, stop treatment
First line:	Formoterol Dry powder inhaler as Easyhaler®	12mcg: £23.75 (120 dose)	Formoterol is the first line LABA as Easyhaler. Maintenance dose is 12mcg once or twice daily.
	as Oxis Turbohaler®	6mcg: £24.80 (60 dose)	Turbohaler formulation is second line Formoterol option. It costs 2-4 times per dose more than an Easyhaler. 12mg and 6mg strengths cost the same so use 1x 12mcg bd rather than 2x6mcg bd. Licensed over age of 6 years.
	MDI as Atimos®	12mcg: £30.06 (100 dose)	MDI version licensed for over age of 12 years
Second line:	Salmeterol as Soltel® as Serevent Accuhaler®	25mcg: £19.95 (120 dose mdi inhaler) 50mcg: £29.26 (60 dose dry powder inhaler)	Salmeterol is the second line LABA to formoterol Licensed over the age of 12 years. Avoid in patients with nut allergy as contains lecithin. Accuhaler licensed from 4 years as is Serevent MDI inhaler. Formoterol is preferred.
	Indacaterol as Onbrez Breezhaler®	150mcg: £32.19 (30 dose inhaler) 300mcg: £32.19 (30 dose inhaler)	Indacaterol is indicated for maintenance bronchodilator treatment of airflow obstruction in adult patients with COPD. This is a cost neutral alternative to established treatments and may be appropriate for patients for whom once-daily administration is appropriate, especially those not requiring inhaled corticosteroids. It has been approved by the SMC
	Olodaterol as Striverdi Respimat®	2.5mcg:£26.35 (60 doses)	Adults over 18, 2 puffs twice a day
Short acting anticholinergic bronchodilators	Ipratropium as cfc-free MDI	20mcg: £5.56 (200 dose inhaler)	Do not co-prescribe Ipratropium with Tiotropium because of risk of increased anticholingeric adverse effects.
Long acting anticholinergic bronchodilators	Aclidinium bromide Dry powder inhaler as Eklira Genuair® ▼	400mcg: £32.60 (60 dose pack)	Aclidinium is licensed for the maintenance treatment of COPD. The dose is 400mcg bd. The device may be suitable for some patients who are unable to use a Handihaler®. NB. Each 400 mcg metered inhalation of aclidinium bromide delivers 322 mcg of aclidinium
	Glycopyrronium bromide as Seebri Breezhaler® ▼	50mcg: £27.50 (30 capsules plus device) 50mcg: £5.50 (6 dose capsules plus device)	Glycopyrronium is licensed for the maintenance treatment of COPD. The dose is 50mcg od. Each 50 microgram capsule delivers a dose of 44 micrograms of glycopyrronium
	Tiotropium Dry powder inhaler as Braltus Zonda®	10mcg: £25.80 (30 dose)	Braltus Zonda® delivers 10mcg tiotropium to the lungs and is dose equivalent to the 18mcg tiotropium Handyhaler. Tiotropium is licensed for use in COPD and asthma. Use in COPD should be in line with the local COPD guidance, which is consistent with the NICE guidance, see here for more information. May be used in asthma as an alternative to increasing ICS dose. Ask for specialist guidance. If no benefit after trial period, stop treatment. Tiotropium should not be combined with ipratropium due to increased risk of anticholinergic side-effects
	Tiotropium Dry powder inhaler as Acopair®	£19.99 (30 inhalation capsules + device)
	Tiotropium Dry powder inhaler as Tiogiva®	£19.99 (30 inhalation capsules + inhaler) £19.20 (30 inhalation capsules) £38.40 (60 inhalation capsules)
	Tiotropium Soft-mist inhaler as Spiriva Respimat® ▼	2.5mcg: £23.00 (60 dose pack)	Tiotropium Spiriva Respimat® (soft-mist inhaler) was included in the formulary for patient choice The soft-mist inhalers Spiriva Respimat (tiotropium), Striverdi Respimat (olodaterol) and Spiolto Respimat (olodaterol/tiotropium) can now be reused with up to six refill cartridges rather than disposed of as soon as a single cartridge is finished. Patients prescribed Respimat inhalers will now receive one inhaler plus one cartridge for their initial prescription, followed by packs containing one refill cartridge. At six months, the patient will once again receive one inhaler plus one cartridge.
	Umeclidinium Dry powder inhaler as Incruse Ellipta®▼	55mcg:£27.50 (30 doses)	The recommended dose in adults (also the maximum dose) is one inhalation of Incruse Ellipta once daily at the same time of the day each day.
Combination long acting muscarinic antagonists (LAMA) and long acting β agonists (LABA)	Anoro Ellipta®▼ (Umeclidinium/vilanterol 55/22) Dry powder inhaler	£32.50 (30 doses - one month)	Once daily dose. Maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD)
	Duaklir Genuair®▼ (aclidinium/formoterol 340/12) dry powder inhaler	£32.50 (60 doses - one month)	Twice daily dose. COPD only.
	Ultibro Breezhaler® ▼ (glycopyrronium/indacaterol 110/50 mcg) dry powder inhaler	£32.50 (30 doses – one month)	Once daily dose. Indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with (COPD).Capsule has to be placed into device, needs certain dexterity.
	Spiolto Respimat® ▼ (tiotropium 2.5mcg/olodaterol 2.5mcg soft mist inhaler inhaler	£32.50 (60 doses – one month)	Two puffs once daily. The soft-mist inhalers Spiriva Respimat (tiotropium), Striverdi Respimat (olodaterol) and Spiolto Respimat (olodaterol/tiotropium) can now be reused with up to six refill cartridges rather than disposed of as soon as a single cartridge is finished. Patients prescribed Respimat inhalers will now receive one inhaler plus one cartridge for their initial prescription, followed by packs containing one refill cartridge. At six months, the patient will once again receive one inhaler plus one cartridge.
	Bevespi Aerosphere® ▼ (glycopyrronium 7.2mcg/formoterol 5mcg pMDI	£32.50 (120 doses)	Maintenance treatment of COPD. Adults: 2 puffs twice daily. Children: Under 18 years, not recommended.
Theophylline	Reduce the dose of theophyline if macrolide or quinolones antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation.
Prescribe by brand. The rate of absorption from modified-release preparations can vary between brands. If a brand name is not specified on the prescription, pharmacists should contact the prescriber to establish which brand is to be dispensed.	Theophylline MR as Nuelin SA®	175mg tablets: £6.38 (60) 250mg tablets: £8.92 (60)	Offer theophylline only after trials of short- and long-acting bronchodilators, or to people who cannot use inhaled therapy. Theophylline can be used in combination with beta2 agonists and muscurinic antagonists. Please note, the risk of hypokalaemia is increased when theophylline is given in combination with a beta2 agonist. Take care when prescribing theophylline to older people. Consider altered pharmacokinetics, comorbidities, and interactions with other medicines; • Plasma theophylline level is increased in heart failure, hepatic impairment, viral infections, in the elderly, and by drugs that inhibit its metabolism. •Plasma theophylline level is decreased in smokers, by alcohol consumption, and by drugs that induce its metabolism.
	as Uniphyllin Continus®	200mg tablets: £2.96 (56) 300mg tablets: £4.77 (56) 400mg tablets: £5.65 (56)
Aminophylline is no longer available.
Macrolides	Azithromycin	250mg tablet: £1.06 (4)	Anti-inflammatory effect to reduce the number of exacerbations in people with chronic obstructive pulmonary disease (COPD). 250mg daily three times a week (Off-label) as per NICE guidance.