1. Severe breathlessness
Algorithm for Inhaled therapies in the management of COPD
(adapted from GOLD Guidelines January 2015)
Prices taken from Drug Tariff December 2015 and MIMS November 2015 (30 day costs unless otherwise stated).
Use SABA (Salbutamol or Terbutaline) or SAMA (Ipratropium) 2 puffs QDS PRN Cost per device: Salbutamol inhaler £1.50, Salbutamol Easyhaler £3.31, Salbutamol Easibreathe inhaler £6.30, Salbutamol Accuhaler £3.00, Terbutaline turbohaler £6.92, Ipratropium inhaler £5.56
Group A and B: FEV1>50%, 0-1 exacerbations per year with no hospitalisation
Group C: FEV1<50%, >2 exacerbations per year or >1 exacerbation with hospitalisation
either OR
First line choice either / or:
Alternative choice :
LABA+ICS in combination inhaler
Fostair MDI 2 puffs BD Beclometasone/Formoterol £ OR
DuoResp Spiromax 320/9 Breath actuated inhaler 1 puff BD Budesonide/Formoterol £29.97 OR
Symbicort 400/12 Turbohaler 1 puff BD Budesonide/Formoterol£38.00
Seretide 500 Accuhaler 1puff BD
Seretide 500 accuhaler £40.92
LAMA (in place of SAMA)
1st line Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler device, £33.50 refill pack
2nd line Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
LABA+LAMA combination inhaler
Duaklir Genuair Breath actuated inhaler 1 puff BD Formoterol fumarate/aclidinium £32.50 OR
Ultibro Breezhaler 1 puff OD
Indacaterol/Glycopyrronium. Inhaler with:12 caps £13.00; 30 caps £32.50
Salmeterol/ Formoterol plus Tiotropium
LABA
1st line Formoterol 12mcg BD
2nd line Salmeterol 50mcg BD
Indacaterol▼ patients requiring OD prep.
Formoterol easyhaler £23.75
Formoterol mdi inhaler £30.06
Formoterol dry powder-Foradil £28.06,
Formoterol turbohaler (Oxis) £24.80
Salmeterol Accuhaler and Evohaler £29.26;
Indacaterol breezhaler £32.19
LAMA (in place of SAMA)
1st line Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler device, £33.50 refill pack
2nd line Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
Group D: FEV1<50%, >2 exacerbations per year or >1 exacerbation with hospitalisation and Severe breathlessness (CAT score>10 or mMRC grade >2)
Severe breathlessness
(CAT score>10 or
mMRC grade >2)
First line choice either / or:
Alternative choices :
LABA+ICS in combination inhaler
Fostair MDI 2 puffs BD Beclometasone/Formoterol £ OR
DuoResp Spiromax 320/9 Breath actuated inhaler 1 puff BD Budesonide/Formoterol £29.97 OR
Symbicort 400/12 Turbohaler 1 puff BD Budesonide/Formoterol£38.00
Seretide 500 Accuhaler 1puff BD
Seretide 500 accuhaler £40.92
LAMA
1st line Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler device, £33.50 refill pack
2nd line Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
LABA+LAMA combination inhaler
Duaklir Genuair Breath actuated inhaler 1 puff BD Formoterol fumarate/aclidinium £32.50 OR
Ultibro Breezhaler 1 puff OD
Indacaterol/Glycopyrronium. Inhaler with:12 caps £13.00; 30 caps £32.50 OR
Salmeterol/ Formoterol plus Tiotropium
Triple therapy with ICS, LABA and LAMA in a combination suitable for patient.
Please note: If using a LABA/LAMA combination inhaler plus ICS in a separate inhaler then this use of an ICS is unlicensed. Care should also be taken to ensure a therapeutic dose of ICS is given.
LABA+LAMA combination inhaler
Duaklir Genuair Breath actuated inhaler 1 puff BD Formoterol fumarate/aclidinium £32.50 OR
Ultibro Breezhaler 1 puff OD
Indacaterol/Glycopyrronium. Inhaler with:12 caps £13.00; 30 caps £32.50 OR
Salmeterol/ Formoterol plus Tiotropium
*mMRC- Modified British Medical Research Council, CAT- COPD Assessment Test
Although not included within the NICE or GOLD guidance, in patients with severe disease who remain breathless, at the discretion of the Respiratory Specialist, Seretide or Symbicort may be replaced by Indacaterol plus an inhaled corticosteroid plus Tiotropium.
SABA=short acting bronchodilator SAMA=short acting antimuscarinic LABA=long acting bronchodilator LAMA=long acting antimuscarinic ICS=Inhaled corticosteroid

2. Algorithm for Inhaled therapies in the management of COPD
Supporting Information
GOLD classify patients in to one of four groups depending on FEV1%, degree of breathlessness (using CAT score or mMRC grade) and number of exacerbations.
GOLD classification of patient groups
Patient Group
GOLD
classification
Exacerbations
CAT score
mMRC grade A
1 or 2
0-1/year. No hospitalisation
<10
0-1 B
>10
>2 C
3 or 4
>2/year or >1 with hospitalisation D
Classification of severity of Airflow limitation in COPD (GOLD 2015)
GOLD classification
Post-bronchodilator FEV1
1: Mild
FEV1≥80%
2: Moderate
50% ≤ FEV1 <80%
3: Severe
30%≤FEV1<50%
4: Very Severe
FEV1<30%
mMRC grade
Description
‘I only get breathless with strenuous exercise’ 1
‘I get short of breath when hurrying on the level or walking up a slight hill’ 2
‘I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level’ 3
‘I stop for breath after walking about 100 metres or after a few minutes on the level’ 4
‘I am too breathless to leave the house or I am breathless when dressing or undressing’
Guideline adapted December 2015 Dr H Mahdi, Respiratory Consultant, Amina Meer, Specialist Interface Pharmacist, BHNFT and Caron Applebee Medicines Management Pharmacist, Barnsley CCG