Based on Version 4 Dudley Asthma Treatment Guidelines May 2017

ASTHMA TREATMENT GUIDELINES

SPACERDEVICESSpacer devices are recommended for use with

Metered Dose Inhalers (MDI’s) in all age groups.

CLEANING– Wash the spacer once a month using detergent,

such as washing-up liquid.

– Don’t scrub the inside of the spacer as this affects the way it works.

– Leave it to air-dry as this helps to prevent the medicine sticking to the sides of the chamber and reduces the static.

– Wipe the mouthpiece clean of detergent before using it again. Don’t worry if the spacer looks cloudy - that doesn’t mean its dirty.

– The spacer should be replaced at least every year, especially if used daily, but some may need to be replaced sooner.

– Ensure the inhaler is compatible with the spacer device

Aerochamber Child Device with mask (Yellow)

1 - 5 years

Volumatic

3+ years

Aerochamber Plus (Blue)

5+ years

Aerochamber Plus with mask (Blue)

5+ years

Volumatic with Face Mask

0+ years

©2017 Produced by Dudley Respiratory Group Chairman Dr Mark Hopkin. www.dudleyrespiratorygroup.org

ASTHMA TREATMENT GUIDELINES

forall ages

Version 2.4.2 June 2017 Based on Version 4 of Dudley Asthma Treatment Guidelines May 2017

• This has been produced, based on Dudley Asthma Guidelines V4 May 2017, BTS/SIGN 2016

• The purpose is to assist Health Care Professionals, who are managing patients with a Diagnosis of Asthma, to select an appropriate inhaler device.

• There are many devices available, withdifferent steroid potencies, which has caused much confusion.

• The total daily steroid load equivalent to Beclometasone is highlighted in each box.

Definition of Asthma

Central to all definitions is the presence of

symptoms (more than one of wheeze,

breathlessness, chest tightness, cough) and of

variable airflow obstruction.

More recent descriptions of asthma in both

children and adults have included airway

hyper-responsiveness and airway inflammation

as components of the disease. (BTS/SIGN 2016)

BEST PRACTICE

- Review patients regularly Considering Step Up & Down accordingly- A Spacer device is recommended when using a MDI (see back sheet)- Check Inhaler technique and compliance at each appointment and before starting any additional therapy- Use an in-check device to measure inspiratory effort- Consider total steroid load when reviewing patient- All patients should have a written Personal Asthma Action Plan (PAAP)- Reconsider the diagnosis in patients who continue to have symptoms- Follow up patients who have an asthma attack within 2 working days – see Acute Guidelines

Asthma is not controlled at any step if using Short Acting B2 Agonists (SABAs)3 times a week or more: having symptoms 3 times a week or more: waking at least once a week.

A WELL CONTROLLED ASTHMATIC SHOULD NOT REQUIRE MORE THAN ONE TO TWO SABAINHALERS PER YEAR

The aim of asthma management is control of the disease. Complete control of asthma is defined as:

• No daytime symptoms • No asthma attacks• No night time awakening due to asthma • Normal lung function• No need for rescue medication • Minimal side effects from medication• No limitations on activity including exercise

INHALED CORTICOSTEROIDS ARE THE CORNERSTONE OF TREATMENT IN ASTHMASpacer devices should be replaced every 6-12 months.

Aerochamber Infant Device with mask (Orange)

0-18 months

In adults and adolescents over the age of 12 combined maintenance and relievertherapy can be considered for patients who have a history of asthma attacks, onmedium dose ICS or ICS/LABA (800-1000mcgs BDP/day) - BTS/SIGN 2016.

Version 2.4.2 June 2017 www.dudleyrespiratorygroup.org

Spiriva Respimat 2.5 mcgs

• Two inhalations once a day

This is indicated as an add on brochodilator treatment in adult patients with asthma who are currently treated with a maintenance combination inhaler (ICS+LABA) at 800mcgs/day BDP equivalent and who experience one or more severe exacerbations in the previous year.

LAMA - Long Acting MuscarinicAntagonist 18+ years

12+ yearsHow to Use Symbicort SMART

18+ yearsHow to use Fostair MART

The use of separate reliever inhaler( SABA) is NOT required

ADDITIONALINFORMATIONSUPPLEMENT

• Symbicort SMART means patients use Symbicort as both their preventer and their reliever

• The SMART dosing regimen applies to both the Symbicort 100/6 and 200/6

• Adult and adolescent patients (≥12 years)• Recommended maintenance dose is two inhalations per day• Patients should take one additional inhalation as needed in response to symptoms

• A total daily dose of more than 8 inhalations is not normally needed:• No more than 6 inhalations on any single occasion• Patients using >8 inhalations daily should be strongly recommended to seek medical advice

• Fostair MART means patients use Fostair as both their preventer and their reliever

• The MART dosing regimen applies to the Fostair 100/6 Metered Dose Inhaler (MDI)

• Adult patients (>18+ years)• Recommended maintenance dose is one inhalation twice a daypatients should take one additional inhalation as needed in response to symptoms

• A maximum of 8 inhalations per day (Maintenance & Reliever)

• Patients requiring frequent use of rescue inhalations daily should be strongly recommended to seek medical advice. Their asthma should be reassessed and their maintenance therapy reconsidered

New 2017

INITIAL ADD ON PREVENTER

ASTHMA TREATMENT G

UID

ELI

NES

REGULAR PREVENTER

Sym

bic

ort

10

0/6

Turb

oh

aler

1 puff twice a day

Sym

bic

ort

10

0/6

Turb

oh

aler

2 puffs twice a day

Flu

tifo

rm 5

0/5

MD

I

2 puffs twice a day

ADDITIONAL ADD ON THERAPIES

Cle

nil

50

MD

I

2 puffs twice a day

(Spacer recommended)

Pu

lmic

ort

10

0Tu

rbo

hal

er

1 puff twice a day

Cle

nil

10

0 M

DI

2 puffs twice a day

(Spacer Recommended)

Pu

lmic

ort

20

0Tu

rbo

hal

er

1 puff twice a day

Key

for

asth

ma

guid

elin

es

< 5

years

5-11

years

12-1

7 years

18+

years

MOVE UP TO IMPROVE CONTROL AS NEEDED

REFER

Sym

bic

ort

10

0/6

& 2

00

/6

Turb

oh

aler

Fo

stai

r 1

00

/6M

DI

2 puffs daily plus 1 puff as

required (max 12/day)

1 puff twice a day plus 1 puff

as required (max 8/day)

Flu

tifo

rm 2

50

/10

MD

I

2 puffs twice a day

Fost

air

20

0/6

MD

I

2 puffs twice a day

Fost

air

20

0/6

Nex

thal

er

2 puffs twice a day

SHORT ACTING B2AGONIST (SABA)

Salb

uta

mo

l 10

0 M

DI

2 puffs as required

Sala

mo

l 10

0 E

asi-

Bre

ath

e M

DI

2 puffs as required

Bri

cany

l 50

0 T

urb

oh

aler

1 puff as required

STOP

SABA

REFER

REFER

Co

nsi

der

RE

FE

R

HIGH DOSE THERAPIES

Spir

iva

Res

pim

at 2

.5m

cgs

2 puffs once a day

Long Acting

Muscarinic

Antagonist - LAMA

MOVE DOWN AND MAINTAIN LOWEST CONTROLLING THERAPY

Version 2.4.2 June 2017 ©2016 Produced by Dudley Respiratory Group Chairman Dr Mark Hopkin. Adapted from BTS/SIGN 2016 - 153

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) Eq

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aily

Do

se

*200

0mcgs/day

ICS + LABA

MART

SMART

BDP

ICS

Budesonide

ICS

Fluticasone

Propionate IC

SBDP

Extra fine: IC

SFormoterol

LABA

Salmeterol

LABA

Tiotropium

LAM

A

Cle

nil

�

Pu

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ort

�

Sym

bic

ort

��

Flu

tifo

rm�

�

Fost

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P - Beclomethasone Dipropionate

ICS -Inhaled Corticosteroid

LAB

A -Long Acting Beta 2Agonist

MD

I- Metered Dose Inhaler

DP

I- Dry Powder Inhaler

Montelukast 4mg Chewtab

or4mg Granules (do not mix with fluid

can be mixed with food)

Once a day at night

Montelukast 5mg Chewtab

once a day at night

Montelukast 10mg Tablet

once a day at night

6 m

on

ths

to

5 y

ears

6-1

4 y

ears

15

+ y

ears

11

LAM

A10

1110

73

2

61

*400mcgs/dayICS

Cle

nil

10

0 M

DI

2 puffs twice a day

(Spacer Recommended)

Pu

lmic

ort

20

0Tu

rbo

hal

er

1 puff twice a day

4

Cle

nil

20

0 M

DI

2 puffs twice a day

Pu

lmic

ort

40

0 T

urb

oh

aler

1 puff twice a day

8

incr

ease

ICS

to4

00

mcg

s/d

ay

bef

ore

ad

din

g in

LA

BA

6+

Sym

bic

ort

20

0/6

Turb

oh

aler

2 puffs twice a day

Flu

tifo

rm 1

25

/5M

DI

2 puffs twice a day

Fost

air

10

0/6

MD

I

2 puffs twice a day

Fost

air

10

0/6

Nex

hal

er

2 puffs twice a day

99

Sym

bic

ort

10

0/6

Turb

oh

aler

***

2 puffs twice a day

Sere

tid

e 5

0M

DI

2 puffs twice a day

(Spacer Recommended)

5

6+

ALWAYS

• P

resc

rib

e by

bra

nd

• C

hec

k in

hal

er t

ech

niq

ue

• C

hec

k C

om

plia

nce

• Is

it A

sth

ma?

• U

se a

sp

acer

wit

h M

DI

5 y

rs6

-11

yrs

wh

o c

ann

ot

use

Tu

rbo

hal

er(D

PI)

OR

Cle

nil

10

0 M

DI

2 puffs twice a day

(Spacer Recommended)

OR

Asthma is not

controlled at any

step if:

•using SABA 3

times a week

or more.

• having symptoms

3 times a week

or more.

• waking at least

once a week.

LTR

A**

LTR

A**

LTR

A**

*20

0mcgs/day

ICS+LABA

In a

combination

inhaler

2

*40

0mcgs/day

3 ICS

GOOD RESPONSE - continue

IF BENEFIT from LABA but

control still inadequate...

increase ICS in a

Combination Inhaler (ICS+LABA)

consider trial of

LTR

A**

48

*40

0mcgs/day

ICS

10LA

MA

*80

0mcgs/day

ICS 9

*80

0 *

10

00

mcgs/day

ICS+LABA

REFER

*20

0mcgs/day

ICS1

*40

0mcgs/day

ICS6

*40

0mcgs/day

ICS+LABA

In a

combination

inhaler

7

NO RESPONSE

from LABA

STOP and INCREASE ICS

*40

0mcgs/day

ICS+LABA

5

*2000mcgsICS + LABA

Based on Version 4 of Dudley Asthma Treatment Guidelines May 2017

See

sep

arat

en

ote

s

*800mcgs

ICS + LABA

*200mcgs

ICS + LABA

Very Low dose ICS

Lowdose ICS

Mediumdose ICS

Highdose ICS

POTENCY KEY

*200mcgs/dayICS

*400mcgs/dayICS

*400mcgsICS + LABA

Maintenance & Reliever Therapy

*800mcgsICS

*400mcgsICS + LABA

*1000mcgsICS + LABA

either

or

< 12 years

12+ years

New 2017