Algorithm for Inhaled therapies in the management of COPD

1. Algorithm for Inhaled therapies in the management of COPD (adapted from NICE Clinical Guideline 101 – Chronic Obstructive Pulmonary Disease (update) June 2010); all prices from Drug Tariff online 11th May 2011 (30 day costs unless otherwise stated). Use SABA (Salbutamol or Terbutaline) or SAMA (Ipratropium) 2 puffs QDS PRN Per device: Salbutamol inhaler £1.50, Salbutamol Easyhaler £3.31, Salbutamol Easibreathe inhaler £6.30, Salbutamol Accuhaler £4.92, Terbutaline turbohaler £6.92, Ipratropium inhaler £5.05 Breathlessness or Exercise limitation FEV1> 50% FEV1 < 50% Exacerbations or persistent breathlessness 1st line or Formoterol 12mcg BD Salmeterol 50mcg BD as another option Reserve Indacaterol▼ for patients who require a once daily preparation Formoterol easyhaler £11.88 Formoterol mdi inhaler £18.04 Formoterol dry powder (Foradil) £23.38, Formoterol turbohaler (Oxis) £24.80 Salmeterol Accuhaler and Evohaler £29.26; Indacaterol breezhaler £29.26 Offer Tiotropium handihaler 18mcg OD (£34.87 with inhaler device, £31.89 refill pack) in place of Ipratropium Use inhaled Seretide 500 Accuhaler 1puff BD or Symbicort 400/12 Turbohaler 1 puff BD. Consider using either Salmeterol or Formoterol, plus Tiotropium if inhaled steroid declined or not tolerated. Seretide 500 accuhaler £40.92 Symbicort 400/12 turbohaler £38.00 Offer Tiotropium handihaler 18mcg OD (£34.87 with inhaler device, £31.89 refill pack) in place of Ipratropium Persistent Exacerbations or breathlessness Use Seretide 500 Accuhaler 1 puff BD or Symbicort 400/12 Turbohaler 1 puff BD. Consider using either Salmeterol or Formoterol, plus Tiotropium if inhaled steroid declined or not tolerated. Use Seretide or Symbicort plus Tiotropium Although not included within the NICE guidance, in patients with severe disease who remain breathless, at the discretion of the Respiratory Specialist, Seretide or Symbicort may be replaced by Indacaterol plus an inhaled corticosteroid plus Tiotropium. Offer Therapy Consider therapy Guideline adapted May 2011: Dr H Mahdi, Respiratory Consultant and COPD Lead; Gillian Smith, Senior Pharmacist, Medicines Information, BHNFT