Asthma

Prescribing Notes:

• Best practice is to prescribe all inhalers by brand name (except salbutamol) and device type.
• Take care to ensure the correct product is prescribed and dispensed.
• Assessment of a patient's inhaler technique is required before an inhaler is prescribed as this will determine the choice of product. Information on assessing inhaler technique and counselling on the correct method can be found at the Asthma and lung UK inhaler technique videos. 
• Refer to Lothian Respiratory resources for Healthcare professionals for inhaler technique, inhaler training guide and inhaled therapies guidance poster.
• Regularly checking inhaler technique is recommended to ensure patients still have the ability and inspiratory effort needed for the device prescribed.
• All inhalers have different 'in use' expiry, this can lead to unintended wastage. Ensure patients are given adequate advice on effective use of the device. For example, an inhaler with an in use expiry of 6 weeks: one inhaler lasts 1 month with regular use. If 2 inhalers are prescribed and dispensed and both opened at the same time, they will both expire 6 weeks later, but if opened one at a time, they would have lasted 2 months.
• Inhaler-induced cough by MDI may be alleviated by use of a spacer or change of device.
• It is essential to specify inhaler device, strength, and dose.
• Not all spacers are compatible with all inhalers; users should seek advice from their local pharmacist regarding the appropriate spacer to be used. Please refer to RightBreathe.

Prescribing Notes:

• All new patients with a diagnosis of asthma and symptoms that occur three or less times a week should be started on AIR therapy.
• More regular doses can be taken for short periods of time such as seasonal allergies or a chest infection. This should be clear in the Action Plan.
• Symbicort can have higher maximum doses listed in the BNF when under medical review.
• AIR regimen: Your AIR Asthma Action Plan.

Prescribing Notes:

• All new patients with a diagnosis of asthma who are experiencing regular symptoms should be started on an appropriate dose of MART and NOT given a salbutamol inhaler.
• Some MART preparations have higher maximum doses listed in the BNF when under medical review.
• Check adherence and inhaler technique at every asthma-related healthcare review. Consider referral if asthma still uncontrolled.
• Remind patients to rinse their mouth after using an ICS to avoid oral thrush.
• Montelukast should be taken at bedtime; those patients that experience sleep disturbance will still get a clinical benefit by switching the dose to the morning.
• Montelukast has been associated with a risk of neuropsychiatric reactions and prescribers should be alert for reactions. Please see MHRA Drug Safety Update. 
• Following a trial of Montelukast or Tiotropium for 8 to 12 weeks unless there are side effects, if asthma control has improved but remains inadequate, continue treatment and add the other medication (Montelukast or Tiotropium). If control has not improved, stop the Montelukast or Tiotropium and start a trial of the alternative medicine.
• MART regimen: MART Asthma Action plan.
• Whilst Luforbec is no longer included as a formulary choice patients who are well managed on Luforbec can remain on this inhaler.

Prescribing Notes:

• Please see NICE CKS: Asthma for further information.
• Check adherence and inhaler technique at every asthma-related healthcare review. Consider referral if asthma symptoms still uncontrolled.
• A short-acting beta2-agonist bronchodilator when required for symptomatic relief and rescue therapy, should be prescribed at all steps of the traditional pathway. 
• Prescribers should be aware of the change in guidance that no longer recommends prescribing SABA without an inhaled corticosteroid. See MHRA alert. 
• Beclometasone is first choice because it is as effective, but less expensive than alternative steroid inhalers at standard equivalent doses. 
• A spacer device should also be used with all pMDI.
• Inhalation of a short-acting beta2-agonist bronchodilator using a pressurised metered-dose inhaler (pMDI) with a spacer is more effective in emergency use.
• Patients receiving more than 800micrograms daily of beclometasone or equivalent may have some systemic effects, should be given a steroid card, and monitored for adrenal suppression.
• Remind patients to rinse their mouth after using an ICS to avoid oral thrush.
• There is virtually no difference in efficacy between salbutamol and terbutaline; currently salbutamol is less expensive and available in a wider range of devices.
• Patients with asthma using a short-acting beta2-agonist bronchodilator, three times or more per week, should have their asthma control re-assessed.
• Caution in patients who may be overusing short-acting beta2-agonist inhalers – patients prescribed more than 3 SABAs in a 12-month period should be offered a review to assess asthma symptoms and control.
• Following a trial of Montelukast or Tiotropium or LABA/LAMA/ICS (Trimbow) for 8 to 12 weeks unless there are side effects, if asthma control has improved but remains inadequate, continue treatment and add the other medication (Montelukast or Tiotropium or LABA/LAMA/ICS (Trimbow). If control has not improved stop the Montelukast or Tiotropium or LABA/LAMA/ICS (Trimbow) and start a trial of the alternative medicine

Prescribing Notes:

• High strength ICS + LABA are not licensed for MART. 
• Combination products can be a cost-effective alternative to the individual products and are more convenient to use.  In asthma they minimise the risk of inadvertent monotherapy with long-acting beta2-agonist bronchodilators. Choice will depend on the selected inhaled steroid and inhaler technique. 
• Check adherence and inhaler technique at every asthma-related healthcare review. Consider referral if asthma symptoms still uncontrolled.
• Patients receiving more than 800micrograms daily of beclometasone or equivalent may have some systemic effects, should be given a steroid card and monitored for adrenal suppression.  
• Patients on high doses of inhaled steroids (more than 800micrograms daily of beclometasone dipropionate or equivalent) who receive more than three to four courses of oral steroids per year should be considered for bone protection. See osteoporosis recommendations in the Endocrine chapter of the formulary. 
• Remind patients to rinse their mouth after using an ICS to avoid oral thrush.
• Whilst Luforbec is no longer included as a formulary choice patients who are well managed on Luforbec can remain on this inhaler.

Prescribing Notes:

• First choice short-acting beta2-agonist bronchodilator choices may be used with or without oxygen – adjust flow to maintain an oxygen saturation of 94-98%.
• Acute attacks of asthma should be treated with short courses of 40mg prednisolone daily. Usually doses of up to 40mg daily taken for less than 3 weeks do not need to be tapered. It may be appropriate for some patients to have a “rescue” course of prednisolone at home, if this is agreed as part of the self-management strategy of their asthma.
• See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
• For patients with swallowing difficulties prednisolone oral solution or soluble tablets may be considered. Prednisolone tablets may be dispersed in water as an alternative to soluble tablets or oral solution preparations. This is an off-label use but more cost-effective option. Refer to local board policies on the use of unlicensed (and off-label) medicines for further guidance. 
• Normally short courses of steroids can be stopped abruptly but in certain cases they should be tapered - see BNF for more information.
• With regard to gastrointestinal effects, there is no advantage by using enteric coated prednisolone tablets; plain tablets should be used.
• Intravenous hydrocortisone is used in the management of acute severe asthma.
• Hydrocortisone sodium succinate is recommended in preference to hydrocortisone sodium phosphate which has been associated with perineal irritation.

• Aminophylline has a narrow margin between therapeutic and toxic effects; therapy should be monitored.
• Intravenous aminophylline is not a recommended drug in primary care having been superseded by nebulised beta2-agonists.
• Theophylline and aminophylline interact with many drugs; see BNF for details.
• Smoking cessation may increase aminophylline levels, this is independent of any nicotine replacement therapies that may be prescribed.

Prescribing Notes:

• Omalizumab (Xolair) is approved for specialist use only in patients with severe, persistent confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy (a full trial of and, if tolerated, documented compliance with inhaled high-dose corticosteroids, long-acting beta2 agonists, leukotriene receptor antagonists, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate) in people aged 6 years and older who need continuous or frequent treatment with oral corticosteroids (defined as 4 or more courses in the previous year).
• Mepolizumab (Nucala) is approved for specialist use only in adult patients with severe refractory eosinophilic asthma. It is restricted to patients requiring 3 or more courses of prednisolone for exacerbation in the previous 12 months or are on chronic daily oral steroids despite maintenance with high dose inhaled steroids plus one other controller therapy.
• SMC advice restricts mepolizumab use for adult patients as an add-on treatment for severe refractory eosinophilic asthma who have eosinophils of at least 150 cells per microlitre (0.15 x 109/L) at initiation of treatment and have had at least three asthma exacerbations in the preceding year or are receiving maintenance treatment with oral corticosteroids.
• Benralizumab (Fasenra) is specialist use only for add-on maintenance treatment in adult patients with severe eosinophilc asthma inadequately controlled by high dose inhaled corticosteroids plus long-acting β-agonists, blood eosinophils ≥150 cells/microlitre, and either ≥4 prior asthma exacerbations needing systemic corticosteroids in the previous 12 months or treatment with continuous oral corticosteroids over the previous 6 months.
• SMC advice restricts Tezepelumab (Tezpire) as an add on maintenance treatment in adults and adolescents 12 years and older with severe asthma who are inadequately controlled despite high dose inhaled corticosteroids plus another medicinal product for maintenance treatment and either: i) experience at least three exacerbations in the previous year and not receiving maintenance treatment with oral corticosteroids or ii) have a blood eosinophils ≥150 cells/microlitre and are receiving maintenance treatment with oral corticosteroid
• Dupilumab (Dupixent) is available for specialist use only in adults and adolescents 12 years and older as add-on maintenance treatment for severe asthma with type 2 inflammation characterised by raised blood eosinophils and/or raised fraction of exhaled nitric oxide (FeNO), who are inadequately controlled with high dose inhaled corticosteroids (ICS) plus another medicinal product for maintenance treatment. Use is restricted to the treatment of patients with blood eosinophils ≥150 cells/microlitre and FeNO ≥25 parts per billion, and ≥4 exacerbations in the preceding year, who have previously received biologic treatment with anti-IgE or anti-IL-5 therapies.
• Refer to local board prescribing guidelines for further advice.  

Prescribing Notes:

• Prescribing of azithromycin should be on the advice of a respiratory specialist, following sensitivities and investigations in secondary care.

Prescribing Notes:

• Further information is available in the ‘National Guidance and Best Practice for Domiciliary Oxygen Therapy’.
• The Department of Health has issued safety advice through the Central Alerting Service regarding electronic cigarettes and oxygen therapy. Patients and carers should be advised not to use an electronic cigarette whilst a patient is receiving oxygen therapy and batteries of electronic cigarettes should not be charged in the vicinity of a patient receiving oxygen therapy or the oxygen source.

Prescribing Notes:

• A poster has been developed to provide guidance on selecting the correct AeroChamber Plus Flow-Vu Anti-Static valved holding chamber.
• Local advice is that patients should inhale from the spacer device using a single breath with 5-10 second breath hold.
• Spacers should be cleaned no more than weekly, with water and washing-up liquid, or put in a dishwasher, and allowed to air dry. More frequent cleaning affects their performance due to build-up of static.
• AeroChamber Plus Flow-Vu should be replaced every 12 months following regular use.

Prescribing Notes:

• Measurement of peak flow is helpful for patients who are unable to detect deterioration in their asthma, and for those with moderate or severe asthma. Mini-Wright and Vitalograph peak flow meters are the most commonly prescribed.

Prescribing Notes:

• Best practice is to prescribe all inhalers by brand name (except salbutamol) and device type. 
• All DPI inhalers should be prescribed by brand to ensure continuity of treatment. 
• It is good practice for Healthcare professionals to use all interactions to assess inhaler technique and revise training as necessary.
• Take care to ensure the correct product is prescribed and dispensed.
• Assessment of a patient’s inhaler technique is required before an inhaler is prescribed as this will determine the choice of product. Information on assessing inhaler technique and counselling on the correct method can be found at the Asthma and Lung UK inhaler technique videos. 
• Refer to Lothian Respiratory resources for Healthcare professionals for inhaler technique, inhaler training guide and inhaled therapies guidance poster.
• All inhalers have different ‘in use’ expiry, this can lead to unintended wastage. Ensure patients are given adequate advice on effective use of the device. For example, an inhaler with an in use expiry of 6 weeks: one inhaler lasts 1 month with regular use. If 2 inhalers are prescribed and dispensed and both opened at the same time, they will both expire 6 weeks later, but if opened one at a time they would have lasted 2 months.
• Inhaler-induced cough by MDI may be alleviated by use of a spacer or change of device. 
• It is essential to specify inhaler device, strength and dose. 
• Not all spacers are compatible with all inhalers; users should seek advice from their local pharmacist regarding the appropriate spacer to be used. Please refer to RightBreathe.
• The choice of inhaler device should take into consideration; the ability of the child, their age, their developmental skills and convenience of use. All children require a MDI reliever and spacer for acute treatment of wheeze unless they are established on an AIR or MART regime using a dry powder inhaler. All children and carers should be properly trained on the use of the inhaler device.
• When clinically appropriate prescribe a dry powder inhaler (DPI) as first choice (as a guide children under 10yrs old may find it difficult to use a DPI).  
• In general terms a child of 10 to 12 yrs or above, with the appropriate training, is competent to use a dry powder inhaler. 
• Training should include checking the child has the correct device for their individual needs and explanation of how to use the device. 

Prescribing Notes:

• All new patients with a diagnosis of asthma and symptoms that occur three or less times a week should be started on AIR therapy. 
• More regular doses can be taken for short periods of time such as season allergies or a chest infection.  This should be clear in the Action Plan.  
• Symbicort can have higher maximum doses listed in the BNF when under medical review. 
• AIR regimen: Your AIR Asthma Action Plan 

Prescribing Notes:

• All new patients with a diagnosis of asthma who are experiencing regular symptoms should be started on an appropriate dose of MART and NOT given a salbutamol inhaler.
• Some MART preparations have higher maximum doses listed in the BNF when under medical review. 
• Check adherence and inhaler technique at every asthma-related healthcare review. Consider referral if asthma symptoms still uncontrolled. 
• Montelukast should be taken at bedtime; those patients that experience sleep disturbance will still get a clinical benefit by switching the dose to the morning. 
• Montelukast has been associated with a risk of neuropsychiatric reactions and prescribers should be alert for reactions. Please see MHRA Drug Safety Update.  
• Following a trial of Montelukast or Tiotropium for 8 to 12 weeks unless there are side effects, if asthma control has improved but remains inadequate, continue treatment and add the other medication (Montelukast or Tiotropium). If control has not improved stop the Montelukast or Tiotropium and start a trial of the alternative medicine.
• Remind patients to rinse their mouth after using an ICS to avoid oral thrush.  
• MART regimen: Asthma Lung UK MART Asthma Action Plan or Asthma Right Care MART Asthma Action Plan 

Prescribing Notes:

• Please see the NICE CKS: Asthma for further information. 
• Check adherence and inhaler technique at every asthma-related healthcare review. Consider referral if asthma symptoms still uncontrolled. 
• A short-acting beta2-agonist bronchodilator when required for symptomatic relief and rescue therapy, should be prescribed at all steps of the traditional pathway. 
• Prescribers should be aware of the change in guidance that no longer recommends prescribing SABA without an inhaled corticosteroid. See MHRA alert. 
• Inhalation of a short-acting beta2-agonist bronchodilator using a pressurised metered-dose inhaler (pMDI) with a spacer is more effective in emergency use.  
• Beclometasone is first choice because it is as effective but less expensive than alternative steroid inhalers at standard equivalent doses. 
• Remind patients to rinse their mouth after using an ICS to avoid oral thrush.  
• A spacer device should also be used with all pMDI. 
• Children receiving more than 400micrograms daily of beclometasone or equivalent should be given a steroid card as they may suffer some systemic effects. For information on equivalent steroid doses refer to Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline.  A steroid card may be provided at lower inhaled corticosteroid doses if intranasal and/or topical corticosteroids are also administered. 
• There is virtually no difference in efficacy between salbutamol and terbutaline; currently salbutamol is less expensive and available in a wider range of devices.   
• Patients with asthma using a short-acting beta2-agonist bronchodilator, three times or more per week, should have their asthma control re-assessed.  
• Caution in patients who may be overusing short-acting beta2-agonist inhalers – patients prescribed more than 3 SABAs in a 12-month period should be offered a review to assess asthma symptoms and control (taking into account social circumstances e.g. needing multiple devices for school, carers locations, nursery etc). This should be reviewed to assess asthma symptoms and control. 
• Montelukast should be taken at bedtime; those patients that experience sleep disturbance will still get a clinical benefit by switching the dose to the morning. 
• Montelukast has been associated with a risk of neuropsychiatric reactions and prescribers should be alert for reactions. Please see MHRA Drug Safety Update.  
• Following a trial of Montelukast or Tiotropium for 8 to 12 weeks unless there are side effects, if asthma control has improved but remains inadequate, continue treatment and add the other medication (Montelukast or Tiotropium). If control has not improved stop the Montelukast or Tiotropium and start a trial of the alternative medicine.

Prescribing Notes:

• Please see the NICE CKS: Asthma guidance for further information.
• See Lothian Guidance in Inhaled and Oral Therapies: Asthma (Children) or Fife Guidance on Inhaled and Oral Therapies: Asthma (Children) for further information.
• Check adherence and inhaler technique at every asthma-related healthcare review. Consider referral if asthma symptoms still uncontrolled.
• Remind patients to rinse their mouth after using ICS to avoid oral thrush.
• Beclometasone is first choice because it is as effective, but less expensive than alternative steroid inhalers at standard equivalent dose. 
• A spacer device should also be used with all pMDI.
• Inhalation of a short-acting beta2-agonist bronchodilator using a pressurised metered-dose inhaler (pMDI) with a spacer is more effective in emergency use.
• Children receiving more than 400micrograms daily of beclometasone (or equivalent) should be given a steroid card as they may suffer some systemic effects. For information on equivalent steroid doses, refer to Inhaled corticosteroids dose for the BTS, NICE, and SIGN asthma guideline. A steroid card may be provided at lower inhaled corticosteroid doses if intranasal and/or topical corticosteroids are also administered. 
• Patients with asthma using a short-acting beta2-agonist bronchodilator, three times or more per week, should have their asthma control re-assessed.
• Caution in patients who may be overusing short-acting beta2-agonist inhalers - patients prescribed more than 3 SABAs in a 12-month period should be offered a review to assess asthma symptoms and control (taking into account social circumstances e.g. needing multiple devices for school, carer's locations, nursery etc.). This should be reviewed to assess asthma symptoms and control.
• Prescribers should be aware of the change in guidance that no longer recommends prescribing SABA without an inhaled corticosteroid. See MHRA alert.
• Montelukast should be taken at bedtime. Those patients who experience sleep disturbance will still receive a clinical benefit by switching the dose to the morning. 
• Montelukast has been associated with a risk of neuropsychiatric reactions and prescribers should be alert for these reactions. Please see MHRA Drug Safety Update. Review after 4 weeks for ongoing benefit.

Prescribing Notes:

• See Lothian Guidance on Inhaled and Oral Therapies: Asthma (Children) or Fife Guidance on Inhaled and Oral Therapies: Asthma (Children) for further information.
• Theophylline should be initiated on hospital advice.
• For patients who are unable to swallow Uniphyllin Continus prolonged release tablets or for lower doses consider the use of theophylline oral syrup 50mg/5ml (immediate release) unlicensed special. The usual dose of immediate release theophylline is 5mg/kg 3-4 times a day.
• Theophylline is a bronchodilator used for reversible airways obstruction, which may have an additive effect when used with small doses of beta2-adrenoceptor stimulants; this combination may increase the risk of side-effects including hypokalaemia.
• Theophylline has a narrow margin between therapeutic and toxic effects; therapy should be monitored after 2 weeks initially and then ideally every 6 months in hospital.
• Plasma-theophylline concentration should be measured 5 days after starting oral treatment and at least 3 days after any dose adjustment.
• A blood sample should usually be taken 4-6 hours after an oral dose of a modified-release preparation (sampling times may vary-consult local guidelines), for immediate release products samples should be taken 1-2 hours after administration. In most individuals, a plasma-theophylline concentration of 10-20 mg/litre (55-110 micromole/litre) is required for satisfactory bronchodilation, although a lower plasma-theophylline concentration of 5-15 mg/litre may be effective.
• Adverse effects can occur within the range 10-20 mg/litre and both the frequency and severity increase at concentrations above 20 mg/litre.
• Different brands of modified-release theophylline have different bioavailability; modified-release preparations should be prescribed by brand name.
• Theophylline and aminophylline interact with many drugs; see BNF for details.
• Children receiving more than 400micrograms daily of beclometasone (or equivalent) should be given a steroid card as they may suffer some systemic effects. For information on equivalent steroid doses, refer to Inhaled corticosteroid doses for the BTS, NICE, and SIGN asthma guideline. A steroid card may be provided at a lower inhaled corticosteroid doses if intranasal and/or topical corticosteroids are also administered. 

Prescribing Notes:

• See Lothian Guidance on Inhaled and Oral Therapies: Asthma (Children) or Fife Guidance on Inhaled and Oral Therapies (Children) for further information.
• All MDI inhalers should be given with spacer device.
• Children receiving more than 400micrograms daily of beclometasone (or equivalent) should be given a steroid card as they may suffer some systemic side effects. For information on equivalent steroid dose, refer to Inhaled corticosteroid doses for the BTS, NICE, and SIGN asthma guideline. A steroid may be provided at a lower inhaled corticosteroid doses if intranasal and/or topical corticosteroids are also administered. 
• Patients who receive more than 2 courses of oral steroids per year should be considered for referral to their local Asthma clinic.
• All children should have their height and weight checked at their regular reviews.
• The aim of treatment should be to use the lowest possible steroid dose to control symptoms.
• Montelukast should be taken at bedtime. Those patients who experience sleep disturbance will still receive a clinical benefit by switching the dose to the morning. 
• Montelukast has been associated with a risk of neuropsychiatric reactions and prescribers should be alert for reactions. Please see MHRA Drug Safety Update. Review after 4 weeks for ongoing benefit. 

Prescribing Notes:

SABA

• In acute severe asthma, salbutamol may be administered by ‘emergency doses’ as 10 puffs MDI via a spacer device. Each actuation should be followed by 5 tidal breaths in and out using mouthpiece or by holding the face mask in place and watching the valve above the nose moving in and out 5 times. Wait 30 seconds between each actuation.
• Doses may be increased in hospital with monitoring as per acute wheeze management guideline. In acute severe asthma, continuous doses may be given in hospital with monitoring.
• On discharge from hospital, children will receive salbutamol 4 puffs 4 times a day for 4 days, this is not a course and parents will be advised to continue this at home for as long as they feel is needed. They may also complete at least a 3-day course of oral prednisolone.
• First choice short-acting beta2-agonist bronchodilator choices should be used with oxygen – adjust flow to maintain an oxygen saturation of 94-98%.

Steroids

• Prednisolone oral solution 5mg/5mL, single-dose unit presentation should not be prescribed for doses exceeding 30mg daily.
• See the Medicines for Children leaflet: Prednisolone for asthma.
• Local advice is that children who receive a single course of systemic corticosteroids for up to 5 days do not routinely require a reducing course.
• Weaning/reduction of steroid doses are required for those that;
  
  • are likely to relapse on withdrawal
  • have received a course of oral corticosteroids within the last 4 weeks
  • are on long-term (>1month) oral corticosteroids or stopped within the last 12 months
  • have proven adrenocortical insufficiency
  • are administered repeated evening doses
  • require a prolonged course (>7 days) or who have multiple recent courses
• See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
• Prednisolone oral solution and soluble tablets are restricted to use in patients who are unable to swallow tablets. These preparations are considerably more expensive than the standard tablets.
• Prednisolone tablets may be dispersed in water as an alternative to soluble or liquid preparations. This is a more cost-effective option.
• Normally short courses of steroids can be stopped abruptly but in certain cases they should be tapered - see BNF for more information.
• Regarding gastrointestinal effects, there is no advantage by using enteric coated prednisolone tablets; plain tablets should be used.
• Intravenous hydrocortisone is used in the management of acute severe asthma.
• Hydrocortisone sodium succinate is recommended in preference to hydrocortisone sodium phosphate which has been associated with perineal irritation.

Equivalent doses

Theophylline

• Theophylline levels should be measured 6 hours after initiating intravenous aminophylline.
• Aminophylline has a narrow margin between therapeutic and toxic effects; therapy should be monitored.
• Intravenous aminophylline is not a recommended drug in primary care having been superseded by nebulised beta2-agonists.
• Theophylline and aminophylline interact with many drugs; see BNF for details.

Prescribing Notes:

• Omalizumab (Xolair) is approved for specialist use only in patients with severe, persistent confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy (a full trial of and, if tolerated, documented compliance with inhaled high-dose corticosteroids, long-acting beta2 agonists, leukotriene receptor antagonists, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate) in people aged 6 years and older who need continuous or frequent treatment with oral corticosteroids (defined as 4 or more courses in the previous year).
• Mepolizumab (Nucala) is approved as an add on treatment for severe refractory eosinophilic asthma in adolescents and children aged 6 years and older. It is restricted to patients who have eosinophils of at least 150 cells per microlitre (0.15 x 10⁹/L) at initiation of treatment and have had at least three asthma exacerbations in the preceding year or are receiving maintenance treatment with oral corticosteroids.
• SMC advice restricts Tezepelumab (Tezpire) as an add on maintenance treatment in adults and adolescents 12 years and older with severe asthma who are inadequately controlled despite high dose inhaled corticosteroids plus another medicinal product for maintenance treatment and either:(i) experience at least three exacerbations in the previous year and not receiving maintenance treatment with oral corticosteroids or (ii) have a blood eosinophils ≥150 cells/microlitre and are receiving maintenance treatment with oral corticosteroid 
• Dupilumab (Dupixent) is available for specialist use only in adults and adolescents 12 years and older as add-on maintenance treatment for severe asthma with type 2 inflammation characterised by raised blood eosinophils and/or raised fraction of exhaled nitric oxide (FeNO), who are inadequately controlled with high dose inhaled corticosteroids (ICS) plus another medicinal product for maintenance treatment. Use is restricted to the treatment of patients with blood eosinophils ≥150 cells/microlitre and FeNO ≥25 parts per billion, and ≥4 exacerbations in the preceding year, who have previously received biologic treatment with anti-IgE or anti-IL-5 therapies.
• Dupilumab may be used in 6 yrs and above but there needs to have been treatment failure with a trial of mepolizumab or omalizumab.
• Refer to local board prescribing guidelines for further advice. 

Prescribing Notes:

• Further information is available in the ‘National Guidance and Best Practice for Domiciliary Oxygen Therapy’.
• The Department of Health has issued safety advice through the Central Alerting Service regarding electronic cigarettes and oxygen therapy. Patients and carers should be advised not to use an electronic cigarette whilst a patient is receiving oxygen therapy and batteries of electronic cigarettes should not be charged in the vicinity of a patient receiving oxygen therapy or the oxygen source.

Prescribing Notes:

• A poster has been developed to provide guidance on selecting the correct AeroChamber Plus Flow-Vu Anti-Static valved holding chamber.
• Local advice is that patients should inhale from the spacer device using 5 tidal breaths.
• Aerochamber plus Flow-Vu is antistatic coated. Spacers should be cleaned weekly as per manufacturers guidelines.
• AeroChamber Plus Flow-Vu should be replaced every 12 months following regular use. Volumatic should be changed every 6 months with regular use.
• Spacer devices should be used for all children.
• Local advice is that patients should inhale from the spacer device using 5 breaths per actuation according to age and ability. Only one actuation should be delivered at one time. Wait 30 seconds between each actuation.
• When using a face mask the parent/ carer should hold the spacer gently over their child’s nose and mouth. The child should take 5 breaths in and out per actuation. The parent/carer should observe the valve above the nose move in and out with each breath.
• AeroChamber Plus Flow-Vu is compatible with all metered dose inhalers. Volumatic is not.
• A suitable AeroChamber Plus Flow-Vu spacer appropriate for age should be selected.
• There are 3 different Aerochamber Plus Flow-Vu spacer devices available for children; orange (small with mask) for age 0-12 months, yellow (medium with mask) for age 1-5 years, green (youth with mouthpiece) for ages >5 years. For young adults there are 3 different Aerochamber Plus Flow-Vu spacer devices available: purple (small with mask), blue (large with mask), blue with mouthpiece. It is recommended that young adults use a spacer with mouthpiece unless they have a neuro or learning disability.
  
  

Prescribing Notes:

• Measurement of peak flow is helpful for patients who are unable to detect deterioration in their asthma, and for those with moderate or severe asthma. Mini-Wright and Vitalograph peak flow meters are the most commonly prescribed. Children up to age 7 or 8 years should receive a low range peak flow meter.

Prescribing Notes:

• Nebulisers are not currently prescribable in general practice; patients should be referred for respiratory assessment and if suitable they will be leased a machine. A spacer should be tried before considering a nebuliser.
• See MHRA warning on home use of nebulisers in paediatric asthma.
• All nebulisers should be serviced regularly. However, difficulties are often encountered in the servicing of privately owned nebulisers. Patients should be discouraged from buying a nebuliser.