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Prescribing and Quality improvement - Respiratory
Step down from highest dose inhaled corticosteroids (ICS) in adult asthma
Rationale
High dose ICS of fluticasone 1000mcg daily (~2000mcg BDP) should be reserved for the most
severe of asthmatics not controlled by other means and the evidence would expect that such a
dose would only be appropriate in around 1% of all asthma patients. The numbers of patients on
this dose in Somerset is significantly in excess of the expected value. This includes patients on
separate inhalers e.g Flixotide or on combination Seretide or Flutiform
The MeReC Bulletin Vol.22 No.03 suggests 1000 mcg/day of inhaled fluticasone has about the
same effect on 8am serum cortisol levels as 10 mg/day of oral prednisolone.
The MHRA advised that the prolonged use of high doses of ICS (as with the use of oral
corticosteroids) carries a risk of systemic side effects, adrenal suppression, decrease in bone
mineral density, cataracts and glaucoma. More recently, the MHRA warned that inhaled (and
intranasal) corticosteroids can be associated with a range of psychological or behavioural effects
(for example, psychomotor hyperactivity, sleep disorders, anxiety, depression and aggression).
ICS have also been associated with a dose-related increased risk of both diabetes onset and
progression.
It is therefore a both a patient safety and cost effectiveness concern if asthma patients in
Somerset are receiving excessive high dose inhaled corticosteroids.
The BTS/SIGN guideline on the management of asthma recommends that reductions in ICS dose
should be considered every 3 months, decreasing the dose by approximately 25-50% each time.
Data suggest that this is realistic and possible without compromising patient care (see Stepping
down inhaled corticosteroids in asthma: randomised controlled trial, Hawkins et al. 2003
Medications to review
 Flixotide Evohaler 250mcg
 Seretide Evohaler 250/25
 Flutiform 250/10
Data for just one month (January 2015) in Somerset showed 1365 inhalers prescribed at a cost of
£76,053
Main objectives
 To step down the Inhaled corticosteroid dose of stable asthma patients currently
prescribed 1000mcg fluticasone daily.
 Prescribe a combination inhaler where Flixotide and a LABA are being used separately.
Specific exclusion criteria
Patients attended A&E or admitted for asthma in 12 months or
Patients needing ITU care for asthma ever
Patients coded for COPD
Patients with a course of oral steroids in last 12 months
Cautions
 Ensure that a check of inhaler technique is offered after any dose adjustments are made
and that the patient is offered an alternative device which they find convenient to use
 Check compliance of existing treatment, particularly in patients using excessive
medication exceeding a dose of 1000mcg/day of fluticasone or >12 salbutamol inhalers in
last 12 months.


The licensed dosage for the combination products are all two puffs bd in order to
maintain the therapeutic LABA dose, therefore step-down by inhaler strength not number
of puffs
Evohalers are unlicensed in COPD and such patients should be switched to the licensed
Accuhaler if possible re patient inhaler technique.
Follow-up



Agree duration of subsequent follow-up and ensure the patient is aware of how to seek
help if their asthma deteriorates.
Ensure patient has an Asthma management plan
The MHRA advises that a steroid treatment cards should be routinely provided for people
(or their parents or carers) who need prolonged treatment with high doses of ICS. The
London Respiratory Network has produced a corticosteroid card that is specifically
tailored for people who are using high doses of ICS greater than 1000mcg BDP equivalent.
Key communication issues
Studies have shown that telephone reviews are effective in improving care delivery and reducing
cost .[3]
Appendix 1. Sample text for letter
Dear patient,
Our records show that you have been taking a high dose preparation of steroid inhaler for your
asthma for greater than 12 months.
You may know your steroid as fluticasone, which you may be taking singly (Flixotide), or in a
combination inhaler with another ingredient, such as in Seretide or Flutiform.
As your condition has remained stable for the last three months, we would like to step down
your strength of inhaler, as we believe it will still control your symptoms and reduce the risk of
side effects of this potent medicine. Your next prescription will be for the lower strength
inhaler. In the event you notice a change in your asthma symptoms, please discuss with your
doctor or asthma nurse. We recommend you make every effort to attend your regular asthma
check so that we can ensure your medication is exactly as you need it.
We also recommend that you visit your pharmacist for an inhaler technique check if you have
not had one recently. Good inhaler technique makes a big difference in how much medicine you
need to take.
Old medication options
Flixotide 250 microgram
Two puffs twice a day
New medication options
Flixotide 250 microgram
One puff twice a day
Or
Seretide 250 microgram
Two puffs twice a day
Or
Seretide 250 microgram
One puff twice a day
Seretide 125microgram
Two puffs twice a day
or
Seretide 50microgram
Two Puffs twice a day
Or
Flutiform 250 microgram
Two puffs twice a day
Flutiform 125 microgram
Two puffs twice a day
Should you have any questions about this change please contact the practice and speak to……xxx
Yours faithfully,
On behalf of Surgery X
Biggest ICS prescribers (all strength)