| Formulary Chapter 3: Respiratory system - Full Chapter
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| Notes: |
*Important*
The NENC ICB Respiratory Network recommends that all inhalers should be prescribed by brand for patient safety, to ensure that the correct device is dispensed to support correct technique and avoid patient confusion and medication errors.
Choice of inhaler device should be based on patient ability to use. Devices should be chosen based on availability for the type of drug to be prescribed and the patient’s ability to use it.
Refer to local guidelines for information on preferred options.
Note: All new patients should be started on the updated formulary choices as per local/national guidelines.
When inhalers are removed from the formulary, existing, stable, patients should continue to receive the non-formulary device. Treatment should not be changed unless a full face to face review has been conducted. |
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| Chapter Links... |
 BTS/SIGN British Guideline on the Management of Asthma |
| County Durham and Tees Valley COPD Treatment Guide |
| County Durham and Tees Valley Adult Asthma Inhaler Guide |
| County Durham and Tees Valley Paediatric Asthma Inhaler Guide |
 North of Tyne, Gateshead and North Cumbria - Asthma in Children Summary Guideline |
| North of Tyne, Gateshead and North Cumbria - COPD Management Guide |
| North of Tyne, Gateshead and North Cumbria - Paediatric Asthma Inhaler Guidance (Children under 5 years) |
| South Tyneside and Sunderland - Asthma Guidance (RS1) |
| South Tyneside and Sunderland - Guidance for Choice of Inhalers for Asthma (RS2) |
| South Tyneside and Sunderland - Guideline for the treatment of COPD (RS3) |
| South Tyneside and Sunderland - Guideline for the Choice of Inhalers for COPD (RS4) |
| NICE NG80: Asthma: diagnosis, monitoring and chronic asthma management |
| NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management |
| MHRA Drug Safety Update (July 2018): Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects |
| NENC Regional ‘At A Glance Carbon Footprint Guidance’ |
| NICE TA10: Asthma inhaler devices (children under 5) |
| NICE TA38: Asthma inhaler devices (older children) |
| North Cumbria - Paediatric doses of inhaled corticosteroids |
| North East and North Cumbria Clinical Network Guide - Supporting Greener Respiratory Care |
| Details... |
| 03.01 |
Bronchodilators |
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Magnesium Sulphate
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Formulary
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MHRA Drug Safety Update (May 2019): Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy
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| 03.01 |
Asthma |
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| 03.01 |
Chronic obstructive pulmonary disease |
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| 03.01 |
Croup |
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| 03.01.01 |
Adrenoceptor agonists |
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| 03.01.01.01 |
Selective Beta2 agonists |
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**The propellants used in pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate** |
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| 03.01.01.01 |
Short-acting beta2 agonists |
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Salbutamol
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Formulary
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- REFER TO LOCAL GUIDELINES FOR ADVICE ON PREFERRED CHOICE
- Easyhaler® breath actuated dry powder inhaler 100 mcg/puff (DPI)
- Accuhaler® breath actuated dry powder inhaler 200 mcg/puff (DPI)
- 100 mcg/puff CFC-free MDI - Salamol® (pMDI)
- 100 mcg/puff breath actuated CFC-free MDI (pMDI)
- Salamol® Easi-Breathe - alternative for patients hypersensitive to lactose or milk protein
- 2.5mg in 2.5ml & 5mg in 2.5ml nebules (Medicine Supply Notification 028 - Supply issue with salbutamol 2.5mg/2.5ml nebuliser liquid unit dose vials)
- 2mg in 5ml sugar-free oral solution
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National Patient Safety Alert - Shortage of salbutamol 2.5mg/2.5ml and 5mg/2.5ml nebuliser liquid unit dose vials (26 February 2024)
MHRA Drug Safety Update (Aug 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists
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Salbutamol Injection
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Formulary
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- 500 mcg in 1ml & 5mg in 5ml injections
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Terbutaline
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Formulary
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- Turbohaler® 500 mcg/puff (DPI)
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Terbutaline Injection
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Formulary
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Terbutaline Nebules
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Formulary
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- 2.5mg/ml nebuliser solution
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MHRA Drug Safety Update (Aug 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists
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| 03.01.01.01 |
Long-acting beta2 agonists |
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Formoterol
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Formulary
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- 6 mcg & 12 mcg/puff breath actuated dry powder inhaler (DPI) - Turbohaler®
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Salmeterol
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- 50 mcg/puff breath actuated dry powdered inhaler (DPI) - Accuhaler®
- 25 mcg/puff metered dose inhaler (pMDI)
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| 03.01.01.02 |
Other adrenoceptor agonists |
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**The propellants used in pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate** |
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Ephedrine Hydrochloride
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Formulary
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| 03.01.02 |
Antimuscarinic bronchodilators |
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**The propellants used in pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate** |
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Tiotropium (Respimat®)
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Formulary
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- 2.5mg Respimat® inhaler
- Step 4 of the BTS/SIGN Asthma guidelines. Treatment should be stopped if not effective.
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MHRA Drug Safety Update (Feb 2015): Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial
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Umeclidinium (Incruse Ellipta®)
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Formulary
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- 55 microgram/dose (equivalent to umeclidinium bromide 65m microgram/dose) dry powder inhaler (DPI)
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Tiotropium (Handihaler®)
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Formulary
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- 18 mcg inhalation powder capsule (Handihaler®) (DPI)
- For existing COPD patients only and those unable to use the other LAMA devices. Consideration should be given to switching at next review, providing adequate training / counselling is provided in device use.
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MHRA Drug Safety Update (Feb 2015): Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial
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Glycopyrronium (Seebri Breezhaler®)
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Formulary
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- 44microgram (equivalent to 55 micrograms of glycopyrronium bromide) powder capsule with device (DPI)
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Aclidinium (Eklira Genuair®)
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Formulary
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- 322 microgram/dose (equivalent to aclidinium bromide 375 microgram/dose) inhalation powder (DPI)
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Ipratropium Nebules
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Formulary
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- 250 microgram/1ml & 500 microgram/1ml nebuliser liquid
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MHRA Drug Safety Update (Aug 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists
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| 03.01.02 |
Short Acting Anti-muscarinic Bronchodilators |
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| 03.01.02 |
Long Acting Anti-muscarinic Bronchodilators |
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| 03.01.03 |
Theophylline |
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Seldom indicated. Modified release formulations must be prescribed by brand name.
Asthma: consider for patients not controlled on LABA plus inhaled corticosteroid (ICS) discontinue if no benefit see national guidelines. |
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Aminophylline Injection
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Formulary
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- 250mg/10ml injection
- COPD: intravenous aminophylline of limited benefit.
- Injection used in hospital for acute asthma not responding to steroids and continuous inhaled bronchodilators.
- Plasma levels need to be checked before administration if patient has previously taken theophylline/ aminophylline.
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Theophylline (Uniphyllin ®)
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Formulary
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- 200mg, 300mg and 400mg MR tablet
- Green plus50 mg/5 mL oral solution -
 unlicensed
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MHRA Drug Safety Update (Dec 2014): Smoking and smoking cessation: clinically significant interactions with commonly used medicines
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| 03.01.04 |
Compound bronchodilator preparations |
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**The propellants used in Pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate** |
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Glycopyrronium & formoterol (Bevespi Aerosphere®)
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Formulary
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- Glycopyrronium 7.2 microgram/dose & formoterol 5 microgram/dose (equivalent to Glycopyrronium (as Glycopyrronium bromide) 7.2 microgram /dose & formoterol fumarate dihydrate 5 microgram/dose) pressurised metered dose inhaler - (pMDI)
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Glycopyyronium & indacaterol (Ultibro Breezhaler®)
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Formulary
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- Glycopyrronium 43 microgram/dose & indacaterol 85 microgram/dose (equivalent to glycopyrronium bromide 54 microgram/dose & indacaterol maleate 85 microgram/dose) inhalation powder capsules (DPI)
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Tiotropium & olodaterol (Spiolto Respimat®)
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Formulary
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- Tiotropium 2.5 microgram/dose & olodaterol 2.5 microgram/dose pressurised metered dose inhaler - (pMDI)
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Umeclidinium & vilanterol (Anoro Ellipta®)
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Formulary
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- Umeclidinium55 microgram/dose & vilanterol 22 microgram/dose (equivalent to umeclidinium bromide 65 microgram/dose & vilanterol (as vilanterol trifenatate) 22 microgram/dose) dry powder inhaler (DPI)
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Aclidinium & formoterol (Duaklir Genuair®)
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Formulary
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- Aclidinium 340 microgram/dose & formoterol 12 microgram/dose (equivalent to aclidinium bromide 396 microgram/dose, formoterol fumarate dihydrate 11.8 microgram/dose) inhalation powder (DPI)
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| 03.01.05 |
Peak flow meters, inhaler devices and nebulisers |
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| 03.01.05 |
Peak flow meters |
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| 03.01.05 |
Drug delivery devices |
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AeroChamber Plus®
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Formulary
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AeroChamber® Flow-Vu
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Formulary
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Space Chamber Plus®
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Formulary
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Volumatic®
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Formulary
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| 03.01.05 |
Nebulisers |
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| 03.01.05 |
Nebuliser Diluent |
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
| Status |
Description |
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Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment.
In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances.
For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing. |
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Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement.
The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber.
If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care. |
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Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs. |
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Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care. |
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NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria. |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status. |
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