Patients on long term continuous treatment or having frequent doses should have an Emergency Steroid Card.
NHS Somerset for links to resources for the Emergency Steroid Card
Using inhaled or topical corticosteroids during breastfeeding (SPS July 2023)
NHS Somerset formulary Topical Corticosteroids
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| 3.2 Corticosteroids (See advice on safer use of inhaled corticosteroids link) | |||
| Inhaled corticosteroids (ICS) | BTS / SIGN Guideline (141) on the management of asthma states: many children with recurrent episodes of viral-induced wheezing in infancy do not develop chronic atopic asthma and do not require regular inhaled steroids. NICE TAG138 states: for patients with chronic asthma in whom an ICS is appropriate, the least costly product that is suitable for the individual, within its license, is recommended |
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| Beclometasone | NB. Prescribe beclometasone MDIs by brand name to avoid confusion over the product intended. Clenil Modulite® and Qvar® are not equipotent nor are Soprobec® and Kelhale® 400mcg Soprobec® = 400mcg BDP 400mcg Clenil Modulite® = 400mcg BDP 200mcg Kelhale® = 400mcg BDP 200mcg Qvar® = 400-500mcg BDP 200mcg Fostair® = ~500mcg BDP 400mcg budesonide (Pulmicort®/Symbicort®/Easyhaler®) = 400mcg BDP 200mcg fluticasone (Flixotide®/Seretide®/Flutiform®) = 400mcg BDP 160mcg ciclesonide = 240-320mcg BDP 200mcg mometasone furoate = 200mcg BDP BTS guide to ICS potencies pages 67-69 |
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| Choose a dry powder inhaler wherever possible | |||
| Beclometasone diproprionate In no particular order# | Dry powder as Beclometasone Easyhaler®  | 200mcg: £14.93 (200 dose) | Not suitable for children, though SPC does not specify age range this covers. Budesonide Easyhaler can be used from 6 years and has a once daily license if required. See below |
| pMDIs | CFC-free MDIs as Soprobec®  as Clenil Modulite® | 50 mcg:£2.78(200 dose) 100 mcg=£5.57 (200 dose) 200 mcg=£12.13 (200 dose) 250 mcg=£12.22 (200 dose) 50mcg: £3.70 (200 dose) 100mcg: £7.42 (200 dose) 200mcg: £16.17 (200 dose) 250mcg: £16.29 (200 dose) | Children up to age 15 should use these products with a Volumatic® and patients 16 years and above should use a Volumatic if their dose is 1000mcg or more Both Soprobec and Clenil say suitable for children but do not specify an actual age. Consensus from professionals suggest 4 years and above. |
| as Kelhale® | 50mcg: £5.20 (200 dose) 100mcg: £5.20 (200 dose) | Kelhale is cost effective alternative to QVAR, and is considered equipotent. Benefit- has a dose counter Kelhale is licensed only for adults 18 years and above |
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| as Qvar® | 50mcg: £7.87 (200 dose) 100mcg: £17.21 (200 dose) | Qvar® is not licensed in patients under 5yrs. |
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| Breath-actuated CFC-free MDI as Qvar Easi-breathe® | 50mcg: £7.74 (200 dose) 100mcg: £16.95 (200 dose) | ||
| Budesonide | Dry Powder inhaler as Easyhaler® | 100mcg:£8.86 (200 dose) 200mcg £17.71 (200 dose) 400mcg: £17.71 (100 dose) | Licensed from age 6 years. In patients already controlled on inhaled corticosteroids (eg budesonide or beclometasone dipropionate) administered twice daily, once daily dosing up to 800 micrograms may be used. Adults with mild to moderate asthma (including the elderly and adolescents 12 to 17 years): In patients who have not previously received inhaled corticosteroids the usual maintenance dose is 200-400 micrograms once daily. In patients already controlled on inhaled corticosteroids (eg budesonide or beclometasone dipropionate) administered twice daily, once daily dosing up to 800 micrograms may be used. Children 6 to 11 years with mild to moderate asthma: In steroid naive patients or patients controlled on inhaled corticosteroids (eg budesonide or beclometasone dipropionate) administered twice daily the usual maintenance dose is 200-400 micrograms once daily. |
| Combination long-acting beta-agonist steroid inhalers | NICE TAG 138 states that for patients with chronic asthma in whom an ICS and LABA is appropriate, the following apply: - Use of a combination device within license is recommended as an option to ensure that long-acting β2 agonists are not taken without an inhaled steroid. - The decision to use combinations or separates should be made on an individual basis. - If a combination is chosen the least costly device that is suitable for the individual, within its license, is recommended | ||
| Budesonide/formoterol | Fobumix Easyhaler® Budesonide/formoterol dry powder inhaler | 80mcg/4.5mcg: £21.50 (120 doses) 160mcg/4.5mcg: £21.50 (120 doses) 320mcg/9mcg; £21.50 (60 doses) | Not under 18 years, suggest WockAIR (12 years+) |
| WockAIR Budesonide/formoterol Dry powder inhaler | 160mcg/4.5mcg £19.00 120 doses 320mcg/9mcg £19.00 60 doses | Cost effective dry powder formoterol/budesonide. All strengths licensed for asthma and COPD and has asthma MART licence at lower strength 160/4.5 only Asthma, under 12 years, not recommended. COPD, under 18 years, not recommended. |
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| Duoresp® Spiromax Budesonide/formoterol Dry powder inhaler | 160mcg/4.5mcg: £27.97 (120 doses) 320mcg/9mcg: £27.97 (60 doses) | New legislation demands that delivered dose is stated. 160/4.5 is comparative to Symbicort 200/6, and 320/9 is comparative to 400/12. Can be used as maintenance or maintenance and reliever therapy. License in asthma and COPD (COPD 320/9mcg twice a day dose). Licensed 12yrs and above. SPC for Duoresp suggests that stepdown from 160/4.5 may require separation into separate inhalers but does not preclude single daily dose regimen if considered clinically appropriate | |
| Symbicort® Turbohaler (Budesonide / Formoterol) Dry-powder inhaler | 100mcg/6mcg: £28.00 (120 doses) 200mcg/6mcg: £28.00 (120 doses) 400mcg/12mcg: £28.00 (60 doses) | Licensed in asthma and COPD. The 100/6 strength is now licensed in age >6 years. 200/6 licensed 12yrs and above. Symbicort® Maintenance and Reliever Therapy (SMART): Patients over 12 years who are poorly controlled may also use Symbicort® 200/6 as a rescue medication (maximum 12 puffs per day), with no salbutamol. Careful patient education is required and quantity of inhalers used monitored. Symbicort 200/6 is now licensed in mild asthma when needed in response to symptoms in patients 12 years and above. Patients should take one inhalation in response to symptoms. If symptoms persist after a few minutes a further inhalation may be taken. A maximum of 6 inhalations on a single occasion. |
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| Symbicort® MDI (Budesonide / Formoterol) MDI | 200mcg/6mcg: £28.00 (120 doses) | Symptomatic treatment of COPD with a post-bronchodilator FEV1 <70% predicted and a history of exacerbations despite regular bronchodilator therapy. NB CONTAINS HFA227 WHICH HAS A VERY HIGH CARBON FOOTPRINT Not licensed in asthma, so no MART licence |
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| Salmeterol/fluticasone inhalers Dry powder inhalers (preferred) | Campona Airmaster®Salmeterol/ Fluticasone Dry powder | 50mcg/100mcg (60 dose) £7.95 50mcg/250mcg (60 dose) £8.95 50mcg/500mcg (60 dose) £9.95 | |
| Fusacomb Easyhaler® Fluticasone/ salmeterol Dry powder | 250mcg/50mcg £21.50 60 dose 500mcg/50mcg £26.99 60 dose | Cost effective alternative to Seretide Accuhaler,and AirFluSal DPIs | |
| Fixkoh Airmaster® (Fluticasone/Salmeterol 50mcg) Dry powder inhaler | 100mcg: £14.47 (60 dose) 250mcg: £19.29 (60 dose) 500mcg: £16.12 (60 dose) | Fixkoh Airmaster is indicated in adults and adolescents 12 years of age and older. Asthma Fixkoh Airmaster is indicated in the regular treatment of asthma where use of a combination product (long- acting β2 agonist and inhaled corticosteroid) is appropriate: - patients not adequately controlled with inhaled corticosteroids and 'as needed' inhaled short-acting β2 agonist or - patients already adequately controlled on both inhaled corticosteroid and long-acting β2 agonist Note: Fixkoh Airmaster 50 microgram /100 microgram strength is not appropriate in adults and children with severe asthma. Chronic Obstructive Pulmonary Disease (COPD) Fixkoh Airmaster is indicated for the symptomatic treatment of patients with COPD, with a FEV1 < 60 % predicted normal (pre-bronchodilator) and a history of repeated exacerbations, who have significant symptoms despite regular bronchodilator therapy. |
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| Seretide Accuhaler® (Fluticasone/Salmeterol 50mcg) Dry powder inhaler | 100mcg: £18.00 (60 dose) 250mcg: £35.00 (60 dose) 500mcg: £32.74 (60 dose) | Regular treatment of asthma where long acting β2-agonist and inhaled corticosteroid is appropriate. Symptomatic treatment of COPD in patients with a pre-bronchodilator FEV1 <60% predicted and a history of exacerbations and with significant symptoms despite regular bronchodilator therapy. Adults: Asthma, 1 inhalation twice daily, titrated to the lowest effective fluticasone dose. COPD, 1 inhalation of Seretide 500 twice daily. Children: Asthma, under 4 years, not recommended; over 4 years, 1 inhalation of Seretide 100 twice daily. |
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| Stalpex® Fluticasone/ salmeterol (50mcg) Dry powder | 500mcg £16.12 60 dose | Cost effective alternative to Seretide Accuhaler and AirFluSal DPIs. Only single strength available | |
| Seffalair Spiromax® (Fluticasone/Salmeterol 12.5mcg) Dry powder inhaler | 12.75/100, 60 dose £23.97 12.75/202, 60 dose £23.97 | Asthma only.12yrs and above. Note that salmeterol dose is significantly less that the 50mg in similar products | |
| AirFluSal Forspiro 50/500® (Fluticasone/Salmeterol 50mcg) Dry powder inhaler | 500mcg: £29.97(60 dose) | AirFluSal Forspiro is licensed for the symptomatic treatment of adults with COPD, with a FEV1 <60% predicted normal (prebronchodilator) and a history of repeated exacerbations and who have significant symptoms despite regular bronchodilator therapy. Also in asthma in patients requiring high dose steroid. It provides the same drugs and doses as Seretide Accuhaler 50/500 but unlike Seretide, it is not for use in under 18 year olds |
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| Sereflo Ciphaler Fluticasone/Salmeterol 50mcg Dry powder inhaler | 250mcg £33.95 | Asthma only. 12 years and over. | |
| Pressurised metered dose inhalers | Avenor® Fluticasone/ salmeterol MDI | 25/50, 120 puffs=£12.99. 25/125, 120 puffs=£10.33. 25/250, 120 puffs=£13.66. | Asthma only- best value salmeterol/fluticasone pMDI Under 4 years, not recommended; 4—11 years, 2 puffs of 25 microgram/50 microgram inhaler twice daily. |
| AirFluSal® Fluticasone/ salmeterol MDI | 125mcg/25mcg £16.42 250mcg/25mcg: non-formulary £20.52 | Asthma only. 18 years and over | |
| Sereflo® Fluticasone/ salmeterol MDI | 125mcg/25mcg £14.99 250mcg/25mcg: non-formulary £19.99 | Asthma only. 18yrs and over | |
| Combisal® Fluticasone/ salmeterol MDI | 50/25mcg: £13.50 125/25mcg: £17.59 250/25mcg is non formulary £27.99 | Asthma only. Children 4 yrs plus use 50/25mcg only |
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| Seretide Evohaler® Fluticasone/salmeterol CFC-free MDI | 50/25: £17.46 (120 doses) 125/25: £23.45(120 doses) 250/25 is non formulary £29.32 | Note that the 50mcg Evohaler® is licensed for adults and children over 4 years and the 125mcg inhaler for adults and children over 12 years | |
| Sirdupla® Fluticasone/Salmeterol 50mcg CFC-free MDI | 125mcg: £22.45 (120 doses) 250mcg: £28.32 (120 doses) NON FORMULARY | Asthma only. 18 years and over | |
| Fluticasone/formoterol | Flutiform® Fluticasone/formoterol CFC-free MDI | 50mcg/5mcg £14.40 125mcg/5mcg £28.00 250mcg/10mcg: non-formulary £45.46 | Licensed for asthma only. Flutiform 50mcg and 125mcg are licensed for adults and children over 12 years. The 250mcg strength is non-formulary: licensed for over 18 years only and limited indications for high dose fluticasone in asthma (estimated only 1% asthma patients should need such a high dose combination.) NB. CONTAINS HFA227 WHICH HAS VERY HIGH CARBON FOOTPRINT |
| Beclometasone/formoterol | Bibecfo® Beclomethasone/formeterol MDI | 100mcg/6mcg: £13.98 (120 dose inhaler) 200mcg/6mcg: £13.98 (120 dose inhaler) | |
| Luforbec® Beclomethasone/formeterol CFC-free MDI | 100mcg/6mcg: £13.98 (120 dose inhaler) 200mcg/6mcg: (120 dose inhaler) £13.98 | Cost effective alternative to Fostair with same licensed indications and equivalent extrafine formulation. | |
| Fostair® Beclomethasone/formeterol CFC-free MDI Fostair NEXThaler® Beclomethasone/formoterol ultrafine dry powder inhaler | 100mcg/6mcg: £29.32 (120 dose inhaler) 200mcg/6mcg: £29.32 (120 dose inhaler) Asthma only 100mcg/6mcg: £29.32. (120 dose inhaler) 200mcg/6mcg: £29.32 (120 dose inhaler) Asthma only | 100/6 is licensed for asthma and COPD. 200/6 licensed in asthma only WARNING: beclomethasone 100mcg in Fostair® is equivalent to 250mcg of standard beclomethasone because of extra fine particle size. Patient should receive specific training and information leaflet on this issue. The formoterol element is not enhanced by the microfine particle size. Beclometasone-formoterol as maintenance and reliever therapy (MART): Patients over 18 years, at Step 3, who are poorly controlled may also use Fostair® as a rescue medication (maximum 8 puffs per day - equivalent 2000mcg standard BDP), with no Salbutamol. Careful patient education is required and quantity of inhalers used monitored. NEXThaler® has same BDP equivalent as Fostair MDI OVER 18 YEARS ONLY MDI and DPI |
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| Indacaterol/mometasone | Atectura Breezhaler® Indacaterol/mometasone dry powder inhaler | 125 mcg/62.5 mcg £17.49 (30 dose) 125 mcg/127.5 mcg £21.50 (30 dose) 125 mcg/260 mcg £27.97.(30 dose) | Maintenance treatment of asthma inadequately controlled by short-acting β2-agonists and inhaled corticosteroids. Adults: 1 daily by inhalation, titrated to the lowest effective mometasone dose. Max 125 microgram/260 microgram once daily. Children: Under 12 years, not recommended; ≥12 years, as adult. |
| Vilanterol/fluticasone furoate | Relvar® Ellipta® ▼ (Fluticasone furoate/vilanterol) Dry powder inhaler | 92mcg/22mcg: £22.00 (30 dose) 184mcg/22mcg: £29.50 (30 dose) | Regular treatment of ASTHMA where long acting β2-agonist and inhaled corticosteroid is appropriate. Symptomatic treatment of COPD with a post-bronchodilator FEV1 <70% predicted and a history of exacerbations despite regular bronchodilator therapy. Asthma: 1 inhalation daily, titrated to the lowest effective fluticasone dose.<12 years not recommended; ≥12 years, as adult. COPD: 1 inhalation of 22 microgram/92 microgram daily. |
| Triple component inhalers | Trelegy Ellipta® Vilanterol/fluticasone furoate/umeclidinium 22 microgram/92 microgram/55 microgram per inhalation, DPI device | £44.50 (30 dose) | Maintenance treatment of moderate to severe COPD where an inhaled corticosteroid plus a LABA is inadequate Adults:1 puff once daily. Children: Under 18 years, not recommended. |
| Enerzair Breezhaler® Indacaterol/mometasone/glycopyrronium 114 microgram/136 microgram/46 microgram per inhalation, DPI device | £44.50 (30 dose) | Maintenance treatment of ASTHMA inadequately controlled by a long-acting β2-agonist plus a high-dose inhaled corticosteroid, in patients with ≥1 severe exacerbations in the previous year. One puff daily 18 years and above only |
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| Trimbow Nexthaler® Beclometasone 88 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff DPI device | £44.50 (120 dose) | Maintenance treatment in adult patients with moderate to severe COPD who are not adequately controlled by a combination of an inhaled corticosteroid and a LABA or a combination of LABA and LAMA Please note: this is a 2p bd dosage Not licensed in asthma |
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| Trimbow® Beclometasone 87 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff MDI device | £44.50 (120 dose) | COPD- Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long acting beta2 agonist (LABA) or a combination of a LABA and long acting muscarinic antagonist (LAMA). Asthma-Maintenance treatment of asthma, in adults not adequately controlled with a maintenance combination of a long-acting beta2-agonist and medium dose of inhaled corticosteroid, and who experienced one or more asthma exacerbations in the previous year. This is a fixed 2p bd dosage |
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| Trimbow® Beclometasone 172 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff MDI device | £44.50 (120 dose) | Maintenance treatment of asthma, in adults not adequately controlled with a maintenance combination of a long-acting beta2-agonist and high dose of inhaled corticosteroid, and who experienced one or more asthma exacerbations in the previous year. Please note: this is a 2p bd dosage |
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| Trixeo Aerosphere® Budesonide 160 mcg, Formoterol 5 mcg, glycopyrronium 9mcg per puff MDI device | £44.50 (120 dose) | Introduced in January 2021. Trixeo Aerosphere is indicated as a maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or combination of a long-acting beta2-agonistand a long-acting muscarinic antagonist. Dose is 2 puffs bd = medium ICS dose |
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| Spacer devices | Patient's ability to use different devices varies; assessment of response to a prescribed treatment should include evaluation of inhaler technique as demonstrated by patient. MHRA states- spacers should not be considered as interchangeable: patients who use a spacer with their inhaler should use a spacer named in the summary of product characteristics SPC (where specified by name) |
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| Medium volume: | EasyChamber® adult with mouthpiece (blue) with infant mask (orange) with child mask (yellow) with adult mask (blue) AeroChamber Plus® standard adult (blue) adult with mask (blue) infant with mask (orange) child with mask (yellow) AeroChamber Plus Flow-Vu Anti-Static® Standard Youth (5+ years) Small mask for infants (0-18 months) Medium mask for children (1-5 years) Adult small mask Adult large mask | £3.98 (1) £6.53 (1) £6.55 (1) £6.59 (1) £5.21(1) £8.69 (1) £8.69 (1) £8.69 (1) £5.22 £5.22 £8.72 £8.72 £8.72 £8.72 | Easychamber® is the most cost effective spacer. Anti-static with universal inhaler base that fits majority of pMDIs. Detachable, latex-free mask. Comes with outer box for easy storage. One-way inhalation cross valve. FlowSignal whistle indicator sounds when breathing in too fast. AeroChamber Plus® spacer devices should fit ALL MDI devices (inhaler mouthpiece fits into flexible gasket) |
| Large volume: | Volumatic® | £3.88 (1) | Volumatic® spacer device is only compatible with inhalers manufactured by GSK or if mouthpiece has same specifications as inhalers manufactured by GSK. Patients 16 years and above must use a Volumatic spacer device if their total daily dose exceeds 1000mcg beclometasone diproprionate equivalent |
| MDI Fluticasone and formoterol or salmeterol | ||||||
| 50/25 | 50/5 | 125/25 | 125/5 | 250/25 | 250/5 | |
| Sereflo | Not made | £14.99 | £19.99 | |||
| Combisal | £13.50 | £17.59 | £27.99 | |||
| Flutiform | £14.40 | £28.00 | £45.56 | |||
| Avenor | ||||||
| Seretide | £18.00 | £23.45 | £29.32 | |||
| Sirdupla | Not made | £22.45 | £28.32 | |||
| Airflusal | Not made | £16.42 | £20.52 | |||
BTS definitions of ICS potencies in asthma-July 2019
