1. 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)

2. References
1. Prof C. Jensen et al. Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting β2 agonist: observational matched cohort study (PATHOS). British medical journal. 2013;346:f3306 available online [ ]
2. National Institute for Health and Clinical Excellence (2014). Chronic obstructive pulmonary disease: beclometasone/formoterol (Fostair). National Institute for Health and Clincal Excellence, 2014.
3. National Institute for Health and Clinical Excellence (2013). ESNM21.Chronic obstructive pulmonary disease: fluticasone furorate and vilanterol. National Institute for Health and Clincal Excellence, 2013
4. Calverley PMA, Kuna P, Monsó E, et al. (2010) Beclomethasone/formoterol in the management of COPD: a randomised controlled trial. Respiratory Medicine 104:1858−68
5. Nannini LJ, Lasserson TJ, Poole P. (2012). Combined corticosteroid and long-acting beta2-agonist in one inhaler versus long-acting beta2-agonists for chronic obstructive pulmonary disease (Review). The Cochrane Collaboration. 2012
6. Nannini LJ, Poole P, Milan SJ, Kesterton A. (2013). Combined corticosteroid and long-acting beta2-agonist in oneinhaler versus inhaled corticosteroids alone for chronic obstructive pulmonary disease (Review) The Cochrane Collaboration. 2013
7. Bateman E.D, Ferguson G.T, Barnes N, et al.(2013).Dual bronchodilation with QVA149 versus single bronchodilator therapy: the SHINE study. European Respiratory Journal. 2013;42(6):
8. Beeh K.M, Korn S, Beier J, et al. (2014). Effect of QVA149 on lung volumes and exercise tolerance in COPD patients: the BRIGHT study. Respiratory Medicine Apr;108(4):
9. Dahl R, Jadayel D, Alagappan V.K.T, et al. (2013). Efficacy and safety of QVA149 compared to the concurrent administration of its monocomponents indacaterol and glycopyrronium: the BEACON study [Corrigendum]. International Journal of Chronic Obstructive Pulmonary Disease. 2013;8:501–508.
10. Scottish Medicines Consortium. (2015). Aclidinium/formoterol fumarate dihydrate 340/12 micrograms inhalation powder (Duaklir Genuair) SMC No. (1034/15)
11. Zhong, C. Wang, X. Zhou. (2015). LATEBREAKING ABSTRACT: Efficacy and safety of once daily QVA149 compared with twice daily salmeterol/fluticasone combination (SFC) in patients with COPD: the LANTERN study. European Respiratory Society. 2015
12. National Institute for Health and Clinical Excellence (2014).Chronic obstructive pulmonary disease: umeclidinium/vilanterol combination inhaler (Anoro Ellipta). National Institute for Health and Clinical Excellence, 2014
13. National Institute for Health and Clinical Excellence (2014).Chronic obstructive pulmonary disease: Chronic obstructive pulmonary disease: indacaterol/glycopyrronium (Ultibro Breezhaler). National Institute for Health and Clinical Excellence, 2014
14. Wedzicha J.A, Decramer M, Ficker H.J,. (2013). Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study. The Lancet. 2013
20. Vogelmeier, C.F, Bateman, E.D., Pallante, J. (2012). Efficacy and safety daily QVA149 compared with twice daily salmeterol-fluticasone in patients with chronic obstructive pulmonary disease (ILLUMINATE): a randomised, double-blind, parallel group study. The Lancet Respiratory Medicine.2012;1:151-60
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23. Donohue, J.F., Fogarty, C., Lo¨tvall, J. et al.(2010) Once-Daily Bronchodilators for Chronic Obstructive Pulmonary Disease Indacaterol Versus Tiotropium. The American Journal Respiratory and Critical Care Medicine. 2010; 182:
24. Dahl, R. Chung, K.F. Buhl, F. et al (2010). Efficacy of a new once-daily long-acting inhaled b2-agonist indacaterol versus twice-daily formoterol in COPD. Thorax 2010;65:
25. Kornmann, O. Dahl R, Centann, R. et al (2011). Once-daily indacaterol versus twice-daily salmeterol for COPD: a placebo-controlled comparison. European Respiratory Jouranal 2011; 37: 273–279
26. Spencer S, Karner C, Cates C.J, et al. Inhaled corticosteroids versus long-acting beta2-agonists for chronic obstructive pulmonary disease (Review). The Cochrane Collaboration. 2011
27. National Institute for Health and Clinical Excellence (2015). Chronic obstructive pulmonary disease: Olodaterol. National Institute for Health and Clinical Excellence, 2015
28. Rossi, A. Kristufek, P. Levine, B.E. et al (2002). Comparison of the Efficacy, Tolerability, and Safety of Formoterol Dry Powder and Oral, Slow-Release Theophylline inthe Treatment of COPD. Chest 2002; 121:
29. Wadbo, M. Lo C.G., Larsson, K. et al. (2002).Effects of formoterol and ipratropium bromide in COPD: a 3-month placebo-controlled study. European Respiratory Journal 2002; 20: 1138–1146
30. Beier, J., Kirsten, A-M, Mróz, R. (2012). Effi cacy and Safety of Aclidinium Bromide Compared with Placebo and Tiotropium in Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease: Results from a 6-week, Randomized, Controlled Phase IIIb Study. COPD, 10:511–522
31. Ni, H., Soe, Z., Moe S. (2014). Aclidinium bromide for stable chronic obstructive pulmonary disease (Review). The Cochrane Collaboration. 2015
32. Kerwin, E. He´ber, J. Gallagher, N. et al. (2012). Efficacy and safety of NVA237 versus placebo and tiotropium in patients with COPD: the GLOW2 study. European Respiratory Journal. 2012; 40: 1106–1114
33. D’Urzo, A. Ferguson, G.T. Van Noord, J.A et al. (2011). Efficacy and safety of once-daily NVA237 in patients with moderate-to-severe COPD: the GLOW1 trial. Respiratory Research. 2012; 12:156
34. Beeh., M.K., Singh. D,. Scala, L.D, Drollmann, A. (2012). Once-daily NVA237 improves exercise tolerance from the first dose in patients with COPD: the GLOW3 trial. International journal of COPD. 2012; 4:
35. National Institute for Health and Clinical Excellence (2015). Chronic obstructive pulmonary disease: umeclidinium (incruse)l. National institute for Health and Clinical Excellence, 2015
36. National Institute for Health and Clinical Excellence (2013). Chronic obstructive pulmonary disease: glycopyrronium (seebri). National Institute for Health and Clinical Excellence, 2013
37. National Institute for Health and Clinical Excellence (2013). Chronic obstructive pulmonary disease: aclidinium (Eklira). National Institute for Health and Clinical Excellence, 2013
38. Jones, P.W., Singh, D., Bateman, E.D. et al (2012). Efficacy and safety of twice-daily aclidinium bromide in COPD patients: the ATTAIN study. European Respiratory Journal. 2012; 40: 830–836
39. Kerwin, E.M., D’Urzo, A.D., Gelb, A.F., et al. (2012). Efficacy and Safety of a 12-week Treatment with Twice-daily Aclidinium Bromide in COPD Patients (ACCORD COPD I). Journal of COPD. 2012; 9:1-12
40. Karner, C., Chong, J., & Poole, P. (2012) Tiotropium versus placebo for chronic obstructive pulmonary disease (Review). The Cochrane Collaboration. 2012
41. 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:
Preparation date: June 2015, updated May 2016 and August Prices from MIMS and Drug Tariff online (accessed 5th Aug 2017)