Seretide® and Symbicort® are combinations of a long-acting bronchodilator (LAB) with a corticosteroid. For full guidance, see the Trust Intranet.
Practical guidance
Combination products should not be prescribed for in-patients following an exacerbation if they have not been proven to benefit from LABs.
Combination products may benefit patients already on both inhaled steroids and LABs independently for compliance, convenience or practical reasons.
Unless patients remain uncontrolled on all other therapies, the maximum dose of Seretide® (500mcg) should be avoided for cost reasons. Prescribing should only be instigated on the advice of a consultant in chest medicine.
For outpatients, the prescription is not an emergency and should be referred to the general practitioner in most instances.
Patients on inhaled steroids who are not controlled should have an independent trial of adding a LAB and a response documented before considering a combination product.
Managing exacerbations
If a patient on a combination product has an exacerbation the decision to double the dose of inhaled steroids is complex practically.
For patients who are hospitalised it is probably preferable to give a short course of oral steroids.
For outpatients it may be necessary to give an additional inhaled steroid at equivalent dose to that the patient takes in their combination product. This is preferable to changing the inhaler strength unless it is planned to do this as a long-term measure. Patients will get confused with different strength inhalers. A change of inhaler strength may well be maintained long-term and is not usually necessary.
Important note: Ensure that communication to the patient's GP makes it very clear that the addition of a steroid inhaler is a temporary measure only and the patient should be reviewed and stepped down once the exacerbation is over.
For a mild exacerbation in patients on combination products, it may be preferable and acceptable to tide them over with an increased use of reliever inhaler only.