Karen Homan NHS Bedfordshire Fostair® Switch Karen Homan NHS Bedfordshire

Fostair® Switch Why the switch? Supporting information Considerations / limitations How have we tackled the switch? Future work

Top 10 products (current 12 months) BNF Name Total Act Cost Proprietary Co Enteral Nutrit £1,448,762 Seretide £1,235,952 Proprietary Co Foods For Spec Diets £569,957 Pioglitazone HCl £496,108 Losartan Pot £415,929 Clenil Modulite £341,751 Valsartan £319,557 Generic Co Prepn Bnf 0912000 £262,866 Enzira £221,755

Seretide® use above SHA average

Alternatives to Seretide®

Project Report Bedfordshire PCT Project: Fostair use first line Description: Fostair should be the first line choice of ICS/LABA combination for adults over the age of 18 with asthma Project Duration Target: 50.00% PCT: 1.46% SHA: 2.41% National: 2.60% Compliant Surgery/PCT: Potential Monthly Savings Non-Compliant Surgery/PCT: 62 Savings To Target: £43532.79 Savings To 100%: £88371.28 Start: 28/01/2011 End: Summary Nov 2010 Aug 2010 May 2010 Total Packs 6,799 6,345 6,295 Total Spend £287,718 £269,447 £266,225 Preferred Packs 99 61 28 Preferred Spend £2,903 £1,789 £821 Restricted Packs 6,700 6,284 6,267 Restricted Spend £284,815 £267,659 £265,404 Compliance 1.46% 0.96% 0.44% 28 January 2011 Fostair use first line [Bedfordshire PCT] 1/10

QIPP Quality budesonide, formoterol opportunity to review asthma management Productivity – cheaper alternative without compromising quality and may improve quality.

Supporting information British guidelines on the management of asthma NICE guidance TAG138 www.nice.org.uk/TA138 Scottish Medicines Consortium Fostair® Summary of Product Characteristics Joint Prescribing Committee Bulletin on Fostair®

British guidelines on the management of asthma “…The addition of a long-acting beta2agonist (LABA) should be considered on an individual trial basis (step 3). However, before starting a new drug or stepping up treatment, the patient’s understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors should be confirmed. Control of asthma should be assessed after an agreed duration, depending on the desire outcome, and the LABA discontinued in the absence of benefit.”

NICE guidance TAG138 “…if treatment with an ICS and LABA is considered appropriate, the decision to use a combination device or separate devices should be made on an individual basis, taking into consideration therapeutic need and the likelihood of treatment adherence. If a combination device is chosen, then the least costly device that is suitable for the individual is recommended. For new patients, starting them on the most cost-effective option is the most straight forward way of achieving this.”

Scottish Medicines Consortium Fostair® should be used in patients for whom beclometasone and formoterol are appropriate choices of corticosteroid and LABA, respectively, and for whom a metered dose inhaler is an appropriate delivery device. It has costs similar to other combination products containing corticosteroid and LABA to which it was clinically non-inferior. The 100mcg dose of beclometasone in Fostair® is not bioequivalent to a 100mcg dose of beclometasone in several other inhaler formulations. The Fostair® summary of product characteristics contains information on transferring from these inhalers to Fostair®.

Considerations / limitations Opportunity to review asthma management Refrigeration 5 month shelf life once dispensed Spacer – AeroChamber Plus Extrafine particle size

Extrafine particle size Beclometasone MDI Non-extra-fine beclometasone equivalent Fostair® MDI beclometasone/ formoterol maintenance therapy options Clenil Modulite® 250 micrograms MDI 2 puffs bd 1000 micrograms Fostair® 100/6 2 puffs bd Qvar® 100 micrograms MDI 2 puffs bd 800-1000micrograms Clenil Modulite® 100 micrograms MDI 2 puffs bd 400 micrograms 1 puff bd 500 micrograms Qvar 50 micrograms MDI 2 puffs bd 400-500 micrograms

Fostair®, Seretide®, Symbicort® comparison –not an exact science! Starting dose (ICS dose changed to equivalent in non-extra fine BDP as per SPC definition) 500mcg BDP daily 12mcg F daily [Fostair® 100/6 1 puff bd] 400mcg BDP daily 12mcg F daily [Symbicort® 200/6 Turbohaler 1 puff bd] 100mcg S daily [Seretide® 50 2 puffs bd] Maximum dose 1000mcg BDP daily 24mcg F daily [Fostair® 100/6 2 puffs bd] 1600mcg BDP daily 48mcg F daily [Symbicort® 200/6 Turbohaler 4puffs bd] 2000mcg BDP daily 100mcg S daily [Seretide® 500 1 puff bd] Key: BDP= Non-extra fine beclometasone dipropionate, F=Formoterol fumarate, S=Salmeterol xinafolate

The Switch Whole system and team approach Bedfordshire and Luton Joint Prescribing Committee bulletin Fostair® PCT Professional Executive Committee JPC communications Two hospital Trust DTC approval PCT / PBC QIPP 2011 Plans

JPC Recommendation “To recommend the use of Fostair® for asthma in new patients who fulfil the licensing and NICE TAG 138 criteria. Patients on existing combination inhalers may be switched if clinically appropriate, but care must be taken as there is potential for error due to dose inequivalencies as the beclometasone in Fostair® is present as extra fine particles and so is not bio or dose equivalent to CFC-containing BDP. In addition, Fostair® has to be stored in a refrigerator prior to dispensing. Once dispensed, a 5 month shelf life is added to the label and the inhaler then does not have to be stored in a refrigerator. The JPC were mindful that this may lead to wastage should prescribers not be aware of this shelf life limitation.”

Future work plans QIPP Plans 2011 Monitor usage using Eclipse Work with Trusts to improve use in new patients Switching S.O.P. COPD

Fostair® switch