Cwm Taf UHB COPD MANAGEMENT AND PRESCRIBING GUIDE NB – This is guidance only. Any inhaler on formulary can be prescribed if clinical need dictates – see appendices for other options. Obstructive spirometry is mandatory to diagnose COPD and should be offered to all current and ex-smokers who are symptomatic. A post-bronchodilator FEV1 / FVC ratio < 0.7 is required for diagnosis. (£ = 30 day costs unless otherwise stated) Inhaler technique Dry Powder Inhalers (DPIs) should be first choice but if poor inspiratory flow (<30 l/min,) or patient preference prescribe Metered Dose Inhalers (MDIs) with spacer. DPI - Dry Powder Inhaler MDI – Metered Dose Inhaler SABA Options DPI Salbutamol 100mcg Easyhaler PRN (200 doses £3.31) MDI Salbutamol 100mcg MDI + spacer PRN (200 doses £1.50) Salbutamol 100mcg Easi-Breathe PRN (200 doses £6.30) At every opportunity Smoking cessation (MORE EFFECTIVE THAN ANY INHALER) Flu Vaccination Pulmonary Rehabilitation Inhaler Technique Depression/CVS + Osteoporosis risk End of life care planning STEP 1 SABA As required LAMA Options DPI Seebri Breezhaler 50mcg 1 puff OD (£27.50) MDI Spiriva Respimat 2.5mcg 2 puffs od (£23.50) STEP 2 LAMA Increasing symptoms Breathlessness Exercise limitation Exacerbations LABA/LAMA Options DPI Ultibro Breezhaler 50/110 1 puff OD (£32.50) MDI Spioloto Respimat 2.5/2.5 2 Puffs OD (£32.50) STEP 3 LABA/LAMA IF >2 exacerbations /yr + FEV1 < 60 % or Peripheral eosinophil count > 0.3 LABA/LAMA/ICS Options DPI Seebri Breezhaler 1 puff od + Relvar 92/22 1 puff od (£49.50) Or Trelegy Ellipta 1 puff od (£44.50) MDI Spiriva Respimat 2 Puffs od + Fostair 100/6 2 puffs bd (£52.32) or Trimbow 2 puffs bd (£44.50) Consider Risks (Pneumonia rate ↑ with ICS in COPD) vs Benefits (some improvement in SOB ; exacerbation rate may ↓) STEP 4 LAMA/LABA/ICS Review at 6-12 months and step down if no benefit from ICS Mucolytic - Only prescribe to those with chronic bronchitis phenotype Stop if no symptomatic improvement after 4 weeks Prescribe only over winter if that is period of exacerbations Reduce from TDS starting dose to BD maintenance after 2 weeks -Carbocisteine 750mg BD (£213 p.a.) Referral to secondary care - Diagnostic uncertainty - Oxygen saturations <93% - Acute deteriorations New CXR changes or haemoptysis (urgent referral) Device Seebri Breezhaler (Glycopyrronium) Spiriva Respimat (Tiotropium) Ultibro Breezhaler (Indacaterol/ Glycopyrronium) Spioloto Respimat (Olodaterol/ Tiotropium) Fostair MDI (Beclamethasone/Formoterol) Relvar Ellipta (Fluticasone/ Vilatenterol) Trimbow MDI (Budesonide/ Formeterol/ Glycopyrronium) Trelegy Ellipta (Fluticasone fuorate/ Vilanterol/ Umeclidinium) Class LAMA LABA/LAMA LABA/ICS LABA/LAMA/ICS Technique Hard and fast Soft and gentle via spacer Soft and gentle via spacer Soft and gentle via spacer Soft and gentle via spacer Hard and fast Alternative Inhalers LAMA Braltis Zolanda 12mcg od (£25.80); Eklira Genuair 322mcg 1 puff BD (£28.60); Incruse Ellipta 55mcg 1 puff OD (£27.50) LABA/LAMA Duaklir Genuair 340 / 12 1 puff BD (£32.50); Anoro Ellipta 55/22 1 puff OD (£32.50) LABA/ICS DuoResp Spiromax 320/9 1puff BD (£29.97); Symbicort Turbohaler 400/12 1 puff BD (£38.00)

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Chrystyn, H et al.Device errors in asthma and COPD: systematic literature review and meta-analysisPrimary Care Respiratory Medicine (2017) 27:22 42. Rogliani, P et al .Optimizing drug delivery in COPD: The role of inhaler devicesRespiratory Medicine 124 (2017) 6-14 43. Vestbo J et al. Effectiveness of Fluticasone Furoate–Vilanterol for COPD in Clinical PracticeN Engl J Med 2016;375:1253-60. Preparation date: June 2015, updated May 2016 and August 2017. Prices from MIMS and Drug Tariff online (accessed 5th Aug 2017)