Berkshire East Asthma Pathway: Step-up/ Step-down Issue date May 2014
SABA as required:
Up to once a day
Add low dose inhaled steroids:
200 doses of 100mcg
or equivalent
Salbutamol MDI
SABA more
than twice
a week/
night-time
symptoms at
least once
weekly/
exacerbation
within last
2 years
£1.50
Salbutamol Easyhaler
£3.31
Salbutamol Easi-Breathe (Salamol®)
£6.30
Salbutamol Accuhaler
£10.00
Terbutaline Turbohaler
£13.84
Adults: Increase inhaled steroid
dose to 800mcg/day
(Beclometasone & Budesonide),
400mcg/day (Fluticasone)
Adults:
No response
to LABA:
Stop LABA
Continue
SABA prn
Beclometasone MDI 800mcg/day = £9.06
Beclometasone Easyhaler = £8.36
Beclometasone Easi-Breathe (Qvar®) = £9.49
Beclometasone Autohaler = £9.64
Continue
SABA prn
Beclometasone MDI (100micrograms/ dose) | 100 – 400 mcg bd
Beclometasone Easyhaler 200 - 400mcg bd
(Adults only)
(Adults only)
Beclometasone Easi-Breathe (Qvar®) | 50 – 200mcg bd
(Adults only)
Beclometasone Autohaler (Qvar®) | 50 – 200mcg bd
Budesonide Easyhaler 100 – 400 mcg bd
Budesonide Turbohaler | 100 – 400 mcg bd
£2.54 - £10.16
£5.96 – £16.67
Spacer device: Volumatic® | (change every 6 - 12 months)
Aerochamber Plus® | (change every 12 months)
£3.81 - £13.40
£4.75 - £7.92
Children (5 – 12 years): Increase
inhaled steroid dose to
400mcg/day (Beclometasone &
Budesonide), 200mcg/day
(Fluticasone)
Beclometasone 100mcg/ Formoterol 6mcg (Fostair®)
1 – 2 doses bd (Fostair® licensed > 18 years of age)
Children (5 – 12 years):
Beclometasone MDI 400mcg/day = £4.53
Benefit from
LABA but
control still
inadequate:
Continue
SABA prn
Fluticasone 400mcg/day MDI = £10.16
Fluticasone 400mcg/day Accuhaler = £16.67
Flutcasone 200mcg/day MDI =£5.08
Flutiasone 200mcg/day Accuhaler = £8.34
Beclometasone 400mcg/day MDI = £4.53
Budesonide Easyhaler = £9.92
Budesonide 800mcg/day Turbohaler = £15.52
Budesonide 400mcg/day Turbohaler = £7.76
Fluticasone 400mcg/day MDI = £10.16
Fluticasone 400mcg/day Accuhaler = £16.67
Fluticasone 200mcg/day MDI = £5.08
Fluticasone 200mcg/day Accuhaler = £8.34
£13.68 - £27.36
Budesonide 200 mcg/ Formoterol 6mcg Turbohaler (Symbicort®)
1 dose bd
Fluticasone 50mcg/ Salmeterol 25mcg MDI
2 puffs bd
Fluticasone 100mcg/ Salmeterol 50mcg Accuhaler (Seretide®)
1 dose bd
£17.73
£16.80
£16.80
Continue LABA
Children (5 – 12 years): Increase
inhaled steroid dose to
400mcg/day (Beclometasone &
Budesonide), 200mcg/day
(Fluticasone)
Children (5 – 12 years):
Continue SABA prn
Continue low dose
inhaled corticosteroids
Add inhaled long-acting β2 agonist (LABA):
Budesonide 400mcg/day Turbohaler = £7.76
Adults:
Beclometasone MDI 800mcg/day = £9.06
Beclometasone Easyhaler = £8.36
Beclometasone Easi-Breathe (Qvar®) = £9.49
Beclometasone Autohaler = £9.64
INADEQUATE
CONTROL
on low dose
inhaled
corticosteroids
£2.48 - £9.92
£3.32 - £15.52
Fluticasone MDI (+ Spacer – costs below) | 50 – 200 mcg bd
Fluticasone Accuhaler | 50 – 200 micrograms bd
Budesonide Easyhaler = £9.92
Budesonide 800mcg/day Turbohaler = £15.52
Adults: Increase inhaled steroid
dose to 800mcg/day
(Beclometasone & Budesonide),
400mcg/day (Fluticasone)
(Child > 6yrs)
£2.08 - £9.06
£4.18 - £8.36
£2.17 - £9.49
£2.20 - £9.64
Leukotriene Receptor Antagonists:
Montelukast
Control still
inadaquate &
LABA stopped:
Trial of other
add-on therapy
for 6 weeks
Child 6 months – 6 years
4mg od £2.35 (sachet)/£3.88 (dispersible tablets)
Child 6 – 15 years of age
5mg od
£2.66
Adults and over 15 years
10mg od
£2.66
Theophyllines:
Uniphyllin Continus® Child
9mg/ kg bd
Adult
200 – 400mg bd
Slo-Phyllin®
£2.96 - £5.65
Child 2 – 6 years of age
60 – 120mg bd
£2.76 - £5.52
Child 6 – 12 years of age
125 – 250mg bd
£3.84 - £4.34
Adult
250 – 500mg bd
£4.34 - £8.68
High-dose inhaled corticosteroids:
Adults:
Children (5 – 12 years):
Beclometasone MDI | 400 – 1000mcg bd
£9.06 - £18.25
Beclometasone Easyhaler
£8.36 - £20.90
Beclometasone Easi-Breathe (Qvar®) | 400mcg bd
£9.49
Beclometasone Autohaler
£9.64
Beclometasone MDI | 200 – 400mcg bd
£4.53 - £9.06
Continue LABA
Budesonide Easyhaler | 400 – 800mcg bd
Budesonide Turbohaler | 400 – 800mcg bd
£9.92 - £19.84
£15.52 - £19.84
Budesonide Turbohaler | 200 – 400mcg bd
£7.76 - £15.52
Fluticasone MDI | 200 – 500mcg bd
Fluticasone Accuhaler | 200 – 500mcg bd
£10.16 - £33.73
£16.67 - £33.73
Fluticasone MDI | 100 – 200mcg bd
Fluticasone Accuhaler | 100 – 200mcg bd
£5.08 - £10.16
£8.34 - £16.67
(if benefit)
High-dose inhaled
corticosteroids
Continue
SABA prn
Control still
inadaquate &
LABA stopped:
Objective Measurements
Peak Flow Diurnal Variability ≥20% variability on 3 or more days per week indicates
poor control
FEV1 ≥ 15% increase after short-acting β2 agonist
FEV1 ≥ 15% increase after trial of steroids
FEV1 ≤ 15% decrease after 6 minutes of exercise
Encourage monitoring/ recording of Peak Flow readings twice daily in Personal Asthma
Management Plan available on Asthma UK
www.asthma.org.uk/yourasthma
(Advice for you/Just diagnosed/Manage your asthma better – Your Peak Flow Diary)
Diagnosis and Assessment in Children
Record basis on which diagnosis of asthma suspected.
Inhaler Device
Prescribe inhaler after patient has received training AND can demonstrate satisfactory
technique.
Prescribe a spacer with an MDI
Check technique at least annually, at every review and before any changes to medication
Only prescribe EasyHaler after trial of an MDI if:
• patient has first had an asthma management plan/ inhaler technique check check
to ‘qualify’ that they will ‘do better’ with this inhaler device rather than a spaced MDI
• Your asthma review as per Asthma Management Plan
Spacer should be cleaned monthly
Inhaled corticosteroids
Consider for:
• exacerbations in last 2 years
• using inhaled β2 agonists ≥ three times a week
• symptomatic ≥ three times a week
• waking one night a week
Give ICS twice daily, except Ciclesonide.
Consider ICS once a day at same total daily dose if good control and monitoring
Titrate dose to lowest effective dose for maintenance
Step down dose where appropriate by 25-50% each time; review patient every 3 months
as step-down
Ensure steroid card issued if:
• ≥ 3 weeks duration systemic steroids
• Long-term maintenance steroids
• Prolonged treatment with high doses ICS
• ≥ 3 courses of short burst steroids
Emphasise good oral care after ICS use
Higher doses may be needed in smokers/ ex-smokers
Add-On Therapy
Before any add-on therapy check:
• Compliance, inhaler technique
• Eliminate trigger factors [refer if occupational]
First choice adults and children (5-12 years) LABA
First choice children (under 5 years) leukotriene receptor antagonist
Combination ICS/ LABA Inhaler
Available with careful education for selected adults at Step 2 who are poorly controlled
Self-Management Plan
See Asthma UK
www.asthma.org.uk/advice-personal-action-plan
(Advice for you/Just diagnosed/Manage your asthma better – Personal Action Plan)
Rescue Packs
Detailed in Appendix II.
Contents include a course of oral steroids and Antibiotic choice according to
East Berkshire Formulary
Ensure review of patient during Rescue course to establish if duration of treatment
appropriate
(Prices from BNF 66 September 2013, MIMS October 2013, Drug Tariff Online October 2013)
British Thoracic Society: Scottish Intercollegiate Guidelines Network
British Guideline on the Management of Asthma A national clinical guideline (May 2008, Revised January 2012)
Slough Clinical Commissioning Group
Bracknell and Ascot Clinical Commissioning Group
Windsor Ascot and Maidenhead Clinical Commissioning Group
Designed by Central Southern CSU