COPD PATHWAY AND PRESCRIBING POLICY IN LAMA options (stop SAMA): PRIMARY CARE Inhaler technique -check inhaler technique and compliance at every opportunity -use dry powder inhaler if able (use Incheck device to check flow rate 30-90L/minute) -MDIs should be used with a spacer Confirmed diagnosis of COPD Smokers -ask about smoking at every opportunity and refer to smoking cessation services SABA options: -salbutamol 100mcg MDI + spacer PRN (200 doses £1.50) -salbutamol 100mcg Easyhaler PRN (200 doses £3.31) -salbutamol 100mcg Easi-Breathe PRN (200 doses £6.30) -terbutaline 500mcg Turbohaler PRN (100 doses £6.92) -salbutamol 200mcg Accuhaler (60 doses £3.00) SAMA -ipratropium 20mcg MDI + spacer PRN (200 doses £5.05 ) SABA or SAMA As required Still symptomatic on SABA Referral to pulmonary rehabilitation -breathless on walking <200m -Solihull CCG refer to community respiratory team for pulmonary rehab Add LAMA (stop SAMA) LAMA options (stop SAMA): First line - ▼glycopyrronium Breezhaler 1 puff OD (£335 p.a) Second line - tiotropium Handihaler 18mcg 1 puff OD (£409 p.a) - ▼tiotropium Respimat 2.5mcg 2 puffs OD (£432 p.a) LABA options: formeterol Easyhaler 12mcg 1 puff BD (£144 p.a) formoterol MDI 12mcg 1 puff BD (£202 p.a) -formeterol Turbohaler 12mcg 1 puff BD (£302 p.a) -salmeterol Accuhaler 50mcg 1 puff BD (£356 p.a) -salmeterol MDI 25mcg 2 puffs BD + spacer (£361 p.a) FEV1 ≥50% FEV1 <50% Persistent breathlessness or exacerbations Persistent breathlessness alone Exacerbations +/- persistent breathlessness Add LABA + ICS combination Add LABA Self management -ensure patient has a COPD action plan Persistent breathlessness or exacerbations Combination LABA and ICS options: First line -Symbicort Turbohaler 400/12 1 puff BD (£462 p.a) Second line -Seretide Accuhaler 500 1 puff BD (£491 p.a) -Fostair 100/6 2 puffs BD + spacer (£356 p.a) Add ICS to current LABA Immunisation -Pneumococcal vaccination and influenza vaccination should be offered to all patients with COPD