Corticosteroids (inhaled)

• The NHS aims to be the world's first net carbon zero health service and metered dose inhalers are a major contributing factor to the carbon footprint of the NHS. Where clinically appropriate, consider a dry powder inhaler for newly diagnosed patients. 
• Following a thorough annual review of existing patients, consider switching from a MDI to a DPI with appropriate inhaler techniques counselling and inspiratory flow assessment. The majority of salbutamol inhalers are prescribed as MDIs, and a switch from Ventolin to Salamol or Airomir would lower the carbon footprint. This can also be achieved by reducing the number of salbutamol inhalers prescribed following thorough review. See Prescqipp for further information regarding the carbon footprint of inhalers. 
• Generic prescribing of inhalers should be avoided as this might lead to patients being given an unfamiliar inhaler device, which they are not able to use properly. Different products and doses are licensed for different age groups and some may be applicable only to older children or adults (aged 18 years and over). Prior to prescribing, the relevant Summary of Product Characteristics (SPC) should be checked.
• Some inhalers contain extra-fine particles (Qvar), making them more potent than others (Clenil). Take care to prescribe by brand.
• Issue a steroid treatment card to people who are using prolonged high doses (more than 1000 micrograms beclomethasone per day,  or equivalent) of inhaled corticosteroids (ICS). Also consider the use of a spacer with medium-high dose inhaled ICS (via a metered dose inhaler) for those patients at risk of developing oral candidiasis.
  

TRIPLE INHALER THERAPY

• Trimbow is now licensed for the treatment of asthma, but this should be specialist initiation only. Trimbow remains available for primary care initiation for the treatment of COPD.
• Trimbow NEXThaler is only licensed for the treatment of COPD.
• Enerzair Breezhaler is only licensed for the treatment of asthma.