Asthma

Prescribing Notes:

• Best practice is to prescribe all inhalers by brand name and device type, specifying strength and dose.
• 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.
• Regularly checking inhaler technique is recommended to ensure patients are still able to use 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.
• 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 the RightBreathe website for guidance on compatibility and training material.

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.
• There is currently no licensed metered dose inhaler for the AIR indication.
• Shelf-life of inhaler devices is important to consider – particularly for AIR indications. Symbicort Turbohaler has the longest shelf life of 3 years, with DuoResp next at 12 months when opened, and Fobumix having the shortest shelf life of 4 months when opened (however Fobumix has a smaller 60 dose version option compared to 120 dose versions for the others). Fobumix is the most cost effective of the three AIR licensed inhalers, so device choice should be tailored to patients needs considering cost, usage and future escalation requirements.
• 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.
• The AIR Asthma Action Plan and the MART Asthma Action Plan leaflets from Asthma and Lung UK can be used to support patients so they can benefit from an effective, safe, and personalised self-management plan.
• Symbicort can have higher maximum doses listed in the BNF when under medical review.
• If patient remains uncontrolled or treatment is not tolerated – refer to an asthma specialist.
• Refer to national guidelines for support on stepping down treatment.
• Proxor is only licensed in patients aged 18 years and above.

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.
• The MART Asthma Action Plan leaflet from Asthma and Lung UK can be used to support patients so they can benefit from an effective, safe, and personalised self-management plan.
• Symbicort can have higher maximum doses listed in the BNF when under medical review.
• If patient remains uncontrolled or treatment is not tolerated – refer to an asthma specialist.
• Refer to SIGN 245 Asthma: diagnosis, monitoring and management for support on stepping down treatment.
• Proxor is only licensed in patients aged 18 years and above.

Prescribing Notes:

• Check adherence and inhaler technique at every asthma-related healthcare review. Consider referral if asthma symptoms still uncontrolled.
• Prescribers should be aware of the change in guidance that no longer recommends prescribing SABA without an inhaled corticosteroid. See MHRA Drug Safety Update (April 2025).
• A spacer device should also be used with all pMDI.
• Patients receiving more than 1000micrograms daily of beclometasone or equivalent may have some systemic effects and should be given a steroid card and monitored for adrenal suppression. See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
• Remind patients to rinse their mouth after using an ICS to avoid oral thrush.
• Montelukast has been associated with a risk of neuropsychiatric reactions and prescribers should be alert for reactions: please see MHRA Drug Safety Update (September 2019).
• The Asthma Action Plan leaflet from Asthma and Lung UK can be used to support patients so they can benefit from an effective, safe, and personalised self-management plan.

Prescribing Notes:

• 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.
• Normally short courses of steroids can be stopped abruptly but in certain cases they should be tapered - see BNF for more information.
• See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
• 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.
• Smoking cessation may increase aminophylline levels. This is independent of any nicotine replacement therapies that may be prescribed.

Prescribing Notes:

• Refer to SMC advice for details on restrictions for each of these medicines – omalizumab, benralizumab, mepolizumab, tezepelumab and dupilumab – a link can be found beside each medicine. 
• The most cost-effective biosimilar for omalizumab is Omlyclo.

Prescribing Notes:

• Further information is available in the ‘National Guidance and Best Practice for Domiciliary Oxygen Therapy’ and Public Health Scotland website.
• 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:

• 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 the RightBreathe website for guidance on compatibility and training material.
• The Asthma+Lung UK website provides guidance on different breathing techniques with a spacer – the single breath and hold technique, or the tidal/multiple breath technique.
• 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 and Volumatic 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.