Corticosteroids (inhaled)

Beclometasone is the first choice because it is as effective but less expensive than alternative steroid inhalers at standard equivalent doses.

Beclometasone, budesonide and fluticasone appear to be equally effective although fluticasone is twice as potent as the other two agents. 

Beclometasone metered dose inhalers should be prescribed by brand name due to differences in potency. Qvar is formulated with extra fine particles of beclometasone and is more potent than other brands.

Spacer: at doses greater than beclometasone 800micrograms daily or equivalent a spacer device should be used. 

Steroid card: higher doses of inhaled corticosteroids do have the potential to induce adrenal suppression. Patients receiving >1500 micrograms beclometasone inhaled daily or equivalent may have systemic side effects and should be given a steroid card.

COMBINATION INHALED STEROIDS AND LONG-ACTING BETA-2 AGONISTS

Fostair is formulated with extra-fine particles of beclometasone and is more potent than other formulations. The beclometasone dose in Fostair is equivalent to Qvar.

Accuhaler devices are formulated for doses of one puff inhaled twice daily

Symbicort 100/6 and 200/6 turbohalers can be used for both asthma maintenance therapy and the relief of acute symptoms. Symbicort pMDI is only licensed for COPD.

Relvar Ellipta contains a more potent fluticasone salt - fluticasone furoate 92 micrograms once daily is equivalent to fluticasone propionate 250 micrograms twice daily.

TRIPLE INHALER THERAPY

Triple inhaler therapy (LABA/LAMA/ICS) is indicated in COPD patients who are in GOLD guidelines D. i.e. patients who are having more than two exacerbations a year, more symptomatic despite on dual bronchodilators with raised eosinophil counts or patients with Asthma COPD overlap syndrome.