Optimisation of inhaled corticosteroids (ICS) in COPD

ICS + LABA + LAMA

ICS + LABA
(Triple Therapy

Does the patient have asthma?

• Documented history of asthma, with or without atopy (review if diagnosis is Continue ICS and
correct. Note: consider diagnoses made in people under 40 more likely to be titrate to the lowest
correct) licensed dose in COPD
YES to prevent
• A large degree of reversibility of airflow limitation (>15% and 400mL in post-
bronchodilator FEV1) airways
Does the patient have elevated blood eosinophils (>0.6 X 109/L) (as per exacerbations
specialist) and / or asthma
symptoms and
NO monitor for
potential ICS-related
Further Assessment adverse
Does the patient have a high exacerbation events.
risk?
• >2 exacerbations or >1 exacerbation Continued
No leading to hospitalisation in the previous exacerbation
YES
12 months? despite biomarker
- AND - may indicate lack
Does the patient have elevated of efficacy of ICS
blood eosinophils? or need for
• >0.3 X 109/L? additional therapy

No

See ICS step-down inhaler flow chart guide and record CAT or MRC score before changing treatment

Review every 4 weeks - Consultation with monitoring clinician including assessment of pulmonary function using
spirometry (if deterioration in breathlessness with an increase in the MRC or CAT score)
Interim call with patient (approx. 2 weeks) to check compliance and ensure stability. Patient should be encouraged
to contact monitoring clinician if any worsening of symptoms or conditions.

If stable or Improved Worsening?

Reassess need for ICS use if:

• moderate or severe exacerbations
Continue with LABA/LAMA (optimised bronchodilation) • airflow limitation worsening
(FEV1 decrease >200 mL)
• Increase in MRC or CAT score

At 6 months - Follow-up with monitoring clinician for full clinical review

See the patient
• twice yearly during the first year of ICS withdrawal,
• followed by an annual review if the patient’s COPD is stable and exacerbation-free
If unable to step down ICS therapy, stabilise patient on appropriate ICS dose before considering triple therapy
Adapted with permission from the primary care respiratory society Last updated – January 2023
Date of review – December 2025
Inhaled Corticosteroid (ICS) in COPD Step-down inhaler Guide NOTE: Clenil Modulate and Easyhaler budesonide are unlicensed for monotherapy in COPD.
Choice of LABA/LAMA should be driven by patient choice and device acceptability.
acceptabilityacceptability.

Drug Dose How to Step Down – Step down by approx. 50% every four weeks and follow up with a telephone call after two weeks

1.Seretide/Combisal/AirFluSal250
Evohaler (MDI) 2 puffs BD Switch to LABA/LAMA PLUS
(equivalent to 2000mcg LABA/LAMA PLUS Clenil
(fluticasone propionate + Clenil modulate 200-250 mcg
BDP/Clenil Modulite®) modulate 100 mcg 2puffs BD Maintain LABA/LAMA
salmeterol) 2 puffs BD
BDP= Beclomethasone Dipropionate (equivalent to 400mcg BDP)
1. (equivalent 800-1000mcg BDP)

2. Seretide/AirFluSal/Fusacomb Switch to LABA/LAMA PLUS

/Fixkoh 250 DPIs 1 puff BD
Easyhaler budesonide 200mcg
(fluticasone propionate + (equivalent to 1000mcg BDP/ Maintain LABA/LAMA
1 puff BD
salmeterol) Clenil Modulite®)
(equivalent to 400mcg BDP)

3. Seretide/AirFluSal/Fusacomb Switch to LABA/LAMA PLUS LABA/LAMA PLUS Easyhaler

/Fixkoh 500 DPIs 1 puff BD
Easyhaler budesonide 200mcg budesonide 200mcg
(fluticasone propionate + (equivalent to 2000mcg BDP/ Maintain LABA/LAMA
2 puffs BD 1 puff BD
salmeterol) Clenil Modulite®)
(equivalent 800mcg BDP) (equivalent to 400mcg BDP)

4. Fostair/Luforbec 100/6 MDI Switch to LABA/LAMA PLUS

2 puffs BD Clenil modulate 100 mcg
(beclomethasone dipropionate +
(equivalent to 1000mcg BDP/ 2puffs BD Maintain LABA/LAMA
formoterol)
Clenil Modulite®) (equivalent to 400mcg BDP)
Extra fine particles

5. Fostair 100/6 NextHaler Switch to LABA/LAMA PLUS

(beclomethasone dipropionate + 2 puffs BD
Easyhaler budesonide
formoterol) (equivalent to 1000mcg BDP/ Maintain LABA/LAMA
200mcg 1 puff BD
Clenil Modulite®)
Extra fine particles (equivalent to 400mcg BDP)

6. Fostair/Luforbec 200/6 MDI Switch to LABA/LAMA PLUS Switch to LABA/LAMA PLUS

(beclomethasone dipropionate + 2 puffs BD
Clenil modulate 200-250 mcg Clenil modulate 100 mcg
(equivalent to 2000mcg BDP/ Maintain LABA/LAMA
formoterol) Extra fine particles 2 puffs BD 2puffs BD
Clenil Modulite®)
Not licensed for COPD (equivalent 800-1000mcg BDP) (equivalent to 400mcg BDP)

7. Fostair 200/6 NextHaler Switch to LABA/LAMA PLUS Switch to LABA/LAMA PLUS

(beclomethasone dipropionate + 2 puffs BD
Easyhaler budesonide 200mcg Easyhaler budesonide
(equivalent to 2000mcg BDP/ Maintain LABA/LAMA
formoterol) Extra fine particles 2 puffs BD 200mcg 1 puff BD
Clenil Modulite®)
Not licensed for COPD (equivalent to 800mcg BDP) (equivalent to 400mcg BDP)
 Drug Dose How to Step Down – Step down by 50% every four weeks and follow up with a telephone call after two weeks

8. Symbicort 100/6 2 puffs BD

Switch to LABA/LAMA
Fobumix 80/4.5 (equivalent to 400mcg BDP/
No need to step down ICS
(budesonide + formoterol) Clenil Modulite®)

9. Symbicort 200/6 Switch to LABA/LAMA PLUS

Fobumix 160/4.5 2 puffs BD
Easyhaler budesonide 200mcg
DuoResp 160/4.5 (equivalent to 800mcg BDP/ Maintain LABA/LAMA
1 puff BD
WockAIR 160/4.5 Clenil Modulite®)
(equivalent to 400mcg BDP)
(budesonide + formoterol)

10. Symbicort 400/12 Switch to LABA/LAMA PLUS

Fobumix 320/9 1 puff BD
Easyhaler budesonide 200mcg
DuoResp 320/9 (equivalent to 800mcg BDP/ Maintain LABA/LAMA
1 puff BD
WockAIR 320/9 Clenil Modulite®)
(equivalent to 400mcg BDP)
(budesonide + formoterol)

11. Symbicort 400/12 Switch to LABA/LAMA PLUS LABA/LAMA PLUS Easyhaler

Fobumix 320/9 2 puffs BD
Easyhaler budesonide 200mcg 2 budesonide 200mcg
DuoResp 320/9 (equivalent to 1600mcg BDP/ Maintain LABA/LAMA
puffs BD 1 puff BD
WockAIR 320/9 Clenil Modulite®)
(equivalent to 800mcg BDP) (equivalent to 400mcg BDP)
(budesonide + formoterol)

12. Trimbow Switch to LABA/LAMA PLUS

(beclomethasone dipropionate 2 inhalations BD
Clenil modulate 100 mcg
87mcg, formoterol 5mcg + (equivalent to 1000mcg BDP/ Maintain LABA/LAMA
2 puffs BD
glycopyrronium 9mcg) Clenil Modulite®)
(equivalent to 400mcg BDP)
Extra fine particles

13. Trelegy Ellipta Switch to LABA/LAMA PLUS

(Fluticasone furoate 92mcg, 1 inhalation OD Easyhaler budesonide 200mcg
umeclidinium bromide 65mcg + (equivalent to 1000mcg BDP 1 puff BD Maintain LABA/LAMA
vilanterol 22mcg) /Clenil Modulite®) (equivalent to 400mcg BDP)

This step down document should be used as a guide and care should
be individualised for each patient. It is important to ensure the dose
of LABA/LAMA is maintained and not stepped down at the same
time. Please ensure the following are checked prior to prescribing:
Inhaler technique and use of in-check device.
 Steroid Dose Comparison
Table 1 demonstrates the variation in BDP equivalence across different inhaled corticosteroids

Table 1: VARIATIONS IN BDP EQUIVALENCE

Inhaled Corticosteroid Equivalence to 400mcg beclometasone
dipropionate (BDP)/day
Beclometasone - Clenil® 400mcg
Beclometasone - Fostair® /Luforbec No 400mcg equivalent: 200mcg Fostair®= 500mcg BDP
Extra fine particles
Beclometasone - Qvar®/ Kelhale 200mcg Qvar® = 400-500mcg BDP (refer to SPC)
Extra fine particles
Budesonide - 400mcg
Pulmicort®/DuoResp®/Symbicort/WockAIR/Fobumix
Fluticasone propionate – 200mcg
Flixotide®/AirFluSal/Seretide/Fixkoh /Fusacomb/ Combisal/
Ciclesonide - Alvesco® 160-240mcg

Mometasone - Asmanex® 200mcg