Fostair Switch Karen Homan NHS Bedfordshire Fostair Switch

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

Seretide® use above SHA average Comparison of Cost per 1000 ICSSTARPU 50 45 40 Fostair PCT 35 Seretide PCT 30 Symbicort PCT 25 Fostair SHA 20 Seretide SHA 15 Symbicort SHA 10 5 0 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10

Alternatives to Seretide® Cost per 30 days treatment [Prices from MIMS/Drug Tariff August 2010] Beclometasone 250 mcg MDI 2 puffs bd £ 11. 23 Formoterol 12 microgram via DPI (Oxis Turbohaler) 1 puff bd £ 24. 80 Salmeterol 25 microgram via MDI 2 puffs bd £ 29. 26 Fostair (Beclometasone extra fine 100 mcg/Formoterol 6 mcg) 2 puffs bd £ 29. 32 Seretide Evohaler 125 (Fluticasone 125 mcg/Salmeterol 25 mcg) 2 puffs bd £ 35. 00 Symbicort 200/6 (Budesonide 200 mcg/Formoterol 6 mcg) 2 puffs bd £ 0. 00 £ 38. 00 £ 5. 00 £ 10. 00 £ 15. 00 £ 20. 00 £ 25. 00 £ 30. 00 £ 35. 00 £ 40. 00

• 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 Start: 28/01/2011 Target: 50. 00% Compliant Surgery/PCT: 0 Potential Monthly Savings PCT: 1. 46% Non-Compliant Surgery/PCT: 62 Savings To Target: £ 43532. 79 SHA: 2. 41% Savings To 100%: £ 88371. 28 National: 2. 60% • • 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 1. 46% 0. 96% 0. 44% Compliance • 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 TAG 138 www. nice. org. uk/TA 138 • 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 beta 2 agonist (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 TAG 138 • “…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 100 mcg dose of beclometasone in Fostair® is not bioequivalent to a 100 mcg 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 – Aero. Chamber Plus • Extrafine particle size

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

Fostair®, Seretide®, Symbicort® comparison – not an exact science! Starting dose (ICS dose changed to equivalent in nonextra fine BDP as per SPC definition) Maximum dose Fostair® Symbicort® Seretide® 500 mcg BDP daily 12 mcg F daily [Fostair® 100/6 1 puff bd] 400 mcg BDP daily 12 mcg F daily [Symbicort® 200/6 Turbohaler 1 puff bd] 400 mcg BDP daily 100 mcg S daily [Seretide® 50 2 puffs bd] 1000 mcg BDP daily 24 mcg F daily [Fostair® 100/6 2 puffs bd] 1600 mcg BDP daily 48 mcg F daily [Symbicort® 200/6 Turbohaler 4 puffs bd] 2000 mcg BDP daily 100 mcg 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