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Sample Topic: Asthma

Asthma : Last revised in December 2013

Key prescribing information

Which delivery device should I prescribe?

When choosing an inhaler device for a person with asthma, consider:

  • The availability of the drug and dose in the specific device.
  • The ability of the person to develop and maintain an effective technique with the specific device — this may depend on such factors as age, dexterity, coordination, and inspiratory flow.
  • The suitability of the device to the person’s (and carer’s) lifestyles, considering such factors as portability and convenience.
  • The person’s preference for and willingness to use a particular device.
  • Cost — choose the device with the lowest overall cost (taking into account daily required dose and product price per dose).

Good technique is essential in ensuring the correct use of inhaler devices. Only prescribe inhalers after the person using them (or their carer) has received training in the use of the device and has demonstrated acceptable technique.

Additional information

  • A wide variety of devices, masks, and spacers are used to deliver inhaled drugs, including:
    • Pressurized metered-dose inhalers.
    • Breath-actuated metered-dose inhalers.
    • Dry-powder inhalers.
    • Spacer devices with a variety of different volumes.
    • Face masks with a variety of designs.
    • Nebulizers, driven by air or oxygen.
  • For a full list of available devices, see BNF.
  • Prescribers should familiarize themselves with a selection of these devices so they can inform, supervise, and assist patients appropriately.
  • Dry-powder devices and breath-actuated metered-dose inhalers require an inspiratory flow of at least 30 L/min to activate the device. Some frail people and younger children cannot consistently achieve the required minimum inspiratory flow rate [NICE, 2002].
  • The table below shows suggested minimum age requirements for the correct use of inhaled drug delivery devices.

Age requirements for correct use of inhaler delivery devices.

Delivery system Minimum age
pMDI > 5 years
pMDI with spacer > 4 years
pMDI with spacer and mask 4 years or younger
Breath-actuated metered-dose inhaler > 5 years
Dry-powder inhaler 5 years or older
pMDI = pressurized metered-dose inhaler.

Basis for recommendation
A number of factors guiding the choice of inhaler device have been identified in the literature [MeReC, 2002; Dolovich et al, 2005; SIGN and BTS, 2011].

  • Systematic reviews have found no evidence that alternative inhaler devices are clinically more effective than standard pressurized metered-dose inhalers (pMDIs) for delivering beta2-agonist bronchodilators or inhaled corticosteroids [Brocklebank et al, 2001; Ram et al, 2001]. On this basis, if used correctly, pMDIs are the most cost-effective inhaler devices:
  • Studies often select for people who can use each of the devices appropriately, or they provide intensive training to ensure that the appropriate technique is used [Dolovich et al, 2005]. Therefore, in practice, efficacy may differ among individuals.

Which delivery system is recommended for adults?

  • A pressurized metered-dose inhaler (pMDI) with or without a spacer device is recommended for delivery of inhaled corticosteroids and bronchodilators in adults, provided that the person can use the method adequately. For more information on spacer devices, see section titled ‘Which spacer device should I prescribe?’ below.
  • A dry-powder inhaler (DPI) or a breath-actuated metered-dose inhaler may be more acceptable to people who are unable or unwilling to use a standard pMDI and spacer:
    • Because large-volume spacer devices are not easily portable, a DPI or a breath-actuated metered-dose inhaler (which are smaller and therefore more portable) may be appropriate for bronchodilator (reliever) use during the day or when travelling.
    • Using such a device for portable bronchodilation does not necessitate use of the same device for inhaled corticosteroid treatment or for bronchodilator treatment at home.
  • Nebulizers are rarely required for the routine management of asthma in primary care:
    • If available, a nebulizer may be used in a severe exacerbation of asthma for the combined delivery of short-acting bronchodilators and anticholinergic drugs.

Basis for recommendation
Good evidence from systematic reviews shows that, when used correctly, pressurized metered-dose inhalers (pMDIs) and alternative inhaler devices do not differ clinically in effectiveness [Brocklebank et al, 2001; Ram et al, 2001]. The pMDIs are generally less expensive than alternative inhaler devices.

  • Up to 70% of people cannot use a pMDI correctly. A common problem is the timing of actuation with inspiration [Giraud and Roche, 2002; Molimard et al, 2003]. Use of a spacer with a pMDI largely overcomes problems with poor technique.

Which delivery system is recommended for children aged 5 to 15 years?

  • A pressurized metered-dose inhaler (pMDI) with a suitable spacer device is recommended for the delivery of inhaled corticosteroids.
  • If the child’s use of the pMDI and spacer is likely to be so poor as to undermine effective asthma control, consider alternative devices (e.g. dry-powder inhaler [DPI] or breath-actuated metered-dose inhaler [MDI]), bearing in mind the need to minimize the adverse effects of corticosteroids.
  • For bronchodilators, consider a wider range of devices (for example DPI, breath-actuated MDI), which allow for more frequent spontaneous use and greater portability.

These recommendations are based on the National Institute for Health and Clinical Excellence guidance Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years), and are based on findings from limited evidence, clinical opinion, and pharmacological considerations [NICE, 2002].

Which delivery system is recommended for children younger than 5 years?

  • A pressurized metered-dose inhaler (pMDI) plus suitable spacer device, with a face mask where necessary, is recommended for the delivery of inhaled corticosteroid and bronchodilators in children younger than 5 years.
    • A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Most children older than 3 years can use a mouthpiece.
  • If this is not clinically effective for the child, consider nebulized therapy. Few children younger than 5 years can use a dry-powder inhaler adequately.

Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence, Guidance on the use of inhaler systems in children under the age of 5 years with chronic asthma, and are based on limited evidence from small, poor-quality studies [NICE, 2000].

When should a spacer device be used?

  • A large-volume spacer is recommended for the administration of inhaled corticosteroids in all children younger than 16 years, and for giving high doses of inhaled corticosteroids (> 800 micrograms of beclometasone or equivalent daily) in adults.
  • Consider spacer devices for people who have difficulty coordinating actuation of a pressurized metered-dose inhaler with inhalation.
  • Use a pressurized metered-dose inhaler plus a large-volume spacer device as an alternative to a nebulizer in an acute exacerbation of asthma.

Basis for recommendation
By filtering out larger particles, large-volume spacer devices reduce oropharyngeal deposition of the drug and the amount of drug absorbed from the gastrointestinal tract at all doses [DTB, 2000]. This is particularly important for inhaled corticosteroids because:

  • Reducing oropharyngeal deposition of inhaled corticosteroids decreases the incidence of local adverse effects, such as oral candidiasis.
  • Reducing the amount of drug absorbed from the gut reduces the risk of systemic adverse effects.

Which spacer device should I prescribe?

  • Where possible, prescribe the spacer that the manufacturer recommends as suitable for use with the particular pressurized metered-dose inhaler.
  • Table 1 shows which spacer devices are compatible with which pressurized metered-dose inhalers.

Table 1. Specific compatibilities of pressurized metered-dose inhalers (pMDIs) and spacer devices.

pMDI Spacer recommended
Bronchodilator Corticosteroid
Airomir® (salbutamol)Atrovent® (ipatropium) Qvar® (beclometasone)Alvesco® (ciclesonide) AeroChamber Plus®
Ventolin Evohaler® (salbutamol)Serevnt Evohaler® (salmeterol) Clenil Modulite® (beclometasone)Flixotide Evohaler® (fluticasone) Volumatic®
Data from: [BNF 53, 2007]

Basis for recommendation

The Committee on the Safety of Medicines has raised concerns that drug delivery to the lung may be changed if alternative spacer devices are used [MHRA, 2006b]. This is most likely to be clinically significant with high-dose inhaled corticosteroids.

What advice should I give regarding using the spacer device?

  • Drugs should be administered as single actuations into the spacer and inhaled with minimum delay after each actuation, repeating until the prescribed number of puffs has been given. The canister should be shaken between actuations.
  • When multiple puffs are being given, as during exacerbations, there should be a short pause between puffs to avoid hyperventilation.
  • Spacer devices should be washed before they are first used, and once a month thereafter. They should be replaced every 6–12 months.
  • Plastic or polycarbonate spacers (including Volumatic®, AeroChamber®, and Nebuhaler®) should be washed in washing-up liquid and allowed to air-dry (without rinsing or wiping). Any residual detergent should be wiped from the mouthpiece.

Basis for recommendation
This recommendation is based on expert opinion in a review article [DTB, 2000].

  • Multiple actuations of the metered-dose inhaler into the spacer before inhalation may reduce the proportion of the drug inhaled [DTB, 2000].
  • Static charge builds up on the walls of the spacer, potentially reducing the output of medication from the spacer. Washing the spacer as advised reduces this charge for at least 4 weeks, increasing the delivery of drug to the lungs [DTB, 2000].

What is the role of combination inhalers in asthma?

  • In general, inhaled corticosteroid/long-acting beta2-agonist (LABA) combination inhalers are recommended in preference to an inhaled steroid and a long-acting beta2 agonist in separate inhalers. Combination inhalers should be used in people who are stabilized on the component drugs in the same dose ratio. A combination inhaler is recommended to:
    • Guarantee that the long-acting beta2-agonist is not taken without an inhaled steroid.
    • Improve adherence.
  • Three combined products are available in the UK:
    • Symbicort® is a combination of budesonide and formoterol delivered as a dry-powder inhaler.
    • Seretide® is a combination of fluticasone and salmeterol and is delivered by a dry-powder inhaler or pressurized metered-dose inhaler (pMDI).
    • Fostair® is a combination of beclometasone and formoterol delivered as a CFC-free pMDI. It is licensed for use only in adults aged 18 years and older. It is not dose equivalent to beclometasone delivered by CFC pMDI; Fostair® 100/6 may be substituted for Clenil Modulite® (CFC-free beclometasone pMDI) at 1:2 dosing.
  • The Symbicort SMART® regimen (a combination inhaler as maintenance and reliever therapy) may be considered in adults who respond to LABAs but still have inadequate control of their asthma (step 3).

Basis for recommendation

  • Provided adherence is good, efficacy and adverse effects do not differ according to whether inhaled corticosteroids (ICS) and long-acting beta2-agonists (LABA) for maintenance therapy are given in combination or in separate inhalers [SIGN and BTS, 2011].
  • In clinical practice, however, combination inhalers may improve adherence. Combination inhalers are therefore recommended by the National Institute for Health and Clinical Excellence [NICE, 2008] and the Medicines and Healthcare products Regulatory Agency [MHRA, 2008] as they:
    • Guarantee that the long-acting beta2-agonist is not taken without an inhaled corticosteroid. There is therefore a lower risk of serious asthma-related adverse effects, which can occur when a LABA inhaler is used on its own.
    • Improve adherence to drug treatment, as fewer inhalations and inhaler devices are needed [Currie et al, 2005]. However, no direct evidence substantiates this theory.
  • The main disadvantage of the combination inhalers is that the doses of the component drugs cannot be individually titrated without changing the inhaler (e.g. during stepping-up or stepping-down of ICS). This is more easily done with separate inhalers.
  • There is evidence that using the combination inhaler, Symbicort® (budesonide and formoterol) as a maintenance and reliever therapy (Symbicort SMART®) is similarly effective to conventional methods at reducing exacerbation rates in people with moderate to severe asthma symptoms. It is recommended for use as Step 3 of the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].