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3. Respiratory System

NICE TA38 - Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years)

NICE TA10 - Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma

NICE NG9 - Bronchiolitis in children

CD&D APC COPD Treatment Guide – Jan 2017

CD&D APC Adult Asthma Inhaler Guide – Nov 2015

CD&D APC Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

CD&D APC “Do Not Prescribe List” and “Grey List – drugs prescribed under limited circumstances” available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

Choice of inhaler device should be dependent on patient ability to use. Metered dose inhalers (MDI) +/- spacer remain the first choice for most patients. Alternative devices such as automatic inhalers and Turbohalers® should be chosen based on availability for the type of drug to be prescribed, the patient’s ability to use and cost.

Salbutamol
BNF | BNFC | SPC

Aerosol inhaler - 100micrograms/metered dose

Breath actuated inhaler - 100micrograms/metered inhalation

Dry powder inhaler - 200micrograms/dose (Accuhaler)

Nebuliser solution 2.5mg, 5mg - 2.5mg nebules recommended for COPD as 5mg have no additional benefit

500 mcg in 1ml & 5mg in 5ml injections - parenteral use is rarely indicated

Terbutaline
BNF | BNFC | SPC

Dry Powder Inhaler - 500micrograms/metered dose (Turbohaler)

Salbutamol Injection
BNF | BNFC | SPC

500 mcg in 1ml & 5mg in 5ml injections

Drug protocols: (CDDFT intranet access only)

Paediatric IV loading dose

Paediatric IV infusion maintenance dose

Formoterol
BNF | BNFC | SPC

Dry Powder for inhalation - 12microgram / metered inhalation

Salmeterol
BNF | BNFC | SPC

Aerosol Inhaler - 25micrograms/metered inhalation

Dry Powder Inhaler - 50micrograms/dose(Accuhaler)

Olodaterol
BNF | BNFC | SPC

Stiverdi respimat

Ephedrine
BNF | BNFC | SPC

15mg tablets

MHRA Drug Safety Update (Sep 2015): Pseudoephedrine and ephedrine: update on managing risk of misuse in the UK

Choice of inhaler device should be dependent on patient ability to use

Tiotropium (Braltus)
BNF | BNFC | SPC

Tiotropium Braltus 10 microgram per delivered dose inhalation powder, hard capsule

For use in COPD.

Spiriva Respimat (Tiotropium)
BNF | BNFC | SPC

Solution for inhalation - 2.5micrograms/metered dose (Respimat)                                                              

MHRA Drug Safety Update (Feb 2015): Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial

Tiotropium Respimat® - For use in asthma should only be prescribed by or on the advice of a respiratory specialist. For used in COPD see local COPD guidelines

Eklira Genuair (Aclidinium)▼
BNF | BNFC | SPC

Inhalation powder - 375micrograms per dose (as aclidinium bromide) delivers 322micrograms aclidinium per dose

 

Incruse Ellipta (Umeclidinium)▼
BNF | BNFC | SPC

Incruse Ellipta® umeclidinium 55 mcg per puff

Seebri Breezhaler (Glycopyrronium Bromide)▼
BNF | BNFC | SPC

Inhalation powder, hard capsules -  44microgram (as Glycopyrronium)

Second line use in COPD when intolerant of Tiotropium

Ipratropium
BNF | BNFC | SPC

Aerosol inhaler - 20microgram/metered dose

Nebuliser solution - 250micrograms/ml

Choice of inhaler device should be dependent on patient ability to use.
Combination inhalers should be prescribed by brand name to avoid confusion.

Anoro Ellipta (umeclidinium/vilanterol)▼
BNF | BNFC | SPC

Ellipta® breath actuated DPI
vilanterol 22 mcg/umeclidinium 55 mcg per puff

Duaklir Genuair (aclidinium/formoterol)▼
BNF | BNFC | SPC

Dry powder inhaler - 340micrograms/12micrograms per metered dose

Spiolto Respimat (tiotropim/olodaterol)▼
BNF | BNFC | SPC

Solution for inhalation - 5micrograms/2.5 microgram per metered dose        

 

Ultibro Breezhaler (glycopyrronium/indacaterol)▼
BNF | BNFC | SPC

Breezhaler® breath actuated DPI
indacaterol 85 mcg/glycopyrronium 43 mcg per puff

Modified release formulations must be prescribed by brand name.
Asthma: consider for patients not controlled on long-acting beta agonist (LABA) plus inhaled corticosteroid - discontinue if no benefit see national guidelines.

First Choice
Theophylline
- Uniphyllin®
- Slo-Phyllin®

Alternatives
Aminophylline

Aminophylline
BNF | BNFC | SPC

MR Tablets - 225mg, 350mg (Phyllocontin Continus)

Theophylline
BNF | BNFC | SPC

200mg m/r, 300mg m/r & 400mg m/r tablets (Uniphyllin®)
60mg, 125mg & 250mg m/r capsules (Slo-Phyllin®)

Aminophylline Injection
BNF | BNFC | SPC

250mg in 10ml injection

COPD: intravenous aminophylline of limited benefit. Injection used in hospital for acute asthma not responding to steroids and continuous inhaled bronchodilators.  NB: plasma levels need to be checked before administration if patient has previously taken theophylline/ aminophylline.

Drug protocols: (CDDFT intranet access only)

Adult loading & maintenance

Paediatric loading dose

Paediatric maintenance dose

Magnesium Sulphate Injection
BNF | BNFC | SPC

For use in Acute Asthma

Drug protocol: paediatric loading dose (CDDFT intranet access only)

Adults: NICE TA138, Children: NICE TA131

Choice of inhaler device should be dependent on patient ability to use. Metered dose inhalers (MDI) +/- spacer remain the first choice for most patients. Alternative devices such as automatic inhalers and Turbohalers® should be chosen based on availability for the type of drug to be prescribed, the patient’s ability to use and cost.

Beclometasone Dipropionate
BNF | BNFC | SPC

Aerosol inhaler - 50microgram/ 100microgram, 250microgram/ metered dose (Clenil Modulite, QVAR).

Breath actuated inhaler - 50micrograms/metered dose (Autohaler, Easibreathe)

Clenil modulite and QVAR are not interchangeablewith other CFC free inhalers and should be prescribed by brand

N.B. CFC-Free beclometasone must be prescribed by Brand Name. 50 microgram QVAR is equivalent to 100 microgram for a conventional inhaler & 100 microgram is equivalent to 250 microgram conventional beclometasone.

Budesonide
BNF | BNFC | SPC

Dry Powder Inhaler - 100microgram, 200microgram, 400microgram/metered dose (Easyhaler, Turbohaler)

Ciclesonide
BNF | BNFC | SPC

Combination inhalers should be prescribed by brand name to avoid confusion.

Fostair (beclometasone/formoterol)
BNF | BNFC | SPC

Aerosol Inhalation - 100/6micrograms, 200/6 micrograms

 

DuoResp Spiromax (formoterol/budesonide)
BNF | BNFC | SPC

Dry Powder Inhaler - 160 μg / 4.5 μg, 320 μg / 9 μg

Only For Adults aged 18years or older

Relvar Ellipta (fluticasone/vilanterol)▼
BNF | BNFC | SPC

Dry Powder Inhaler - 92microgram, 22microgram

Symbicort (formoterol/budesonide)
BNF | BNFC | SPC

Dry Powder Inhaler - 6/100microgram, 6/200microgram, 12/400microgram/metered dose (turbohaler)

COPD: for use in existing patients only, not for newly initiated patients

Seretide (Fluticasone/salmeterol)
BNF | BNFC | SPC

Accuhaler = Dry Powder Inhaler - 100/50microgram, 250/50microgram, 500/50microgram

Evohaler = MDI - 50/25 microgram, 125/25 microgram, 250/25 microgram

Seretide: COPD: for use in existing patients only, not for newly initiated patients.

Fostair Nexthaler (beclometasone/formoterol)
BNF | BNFC | SPC

DPI (Fostair NEXThaler®)
formoterol 6mcg / beclometasone dipropionate 100mcg
formoterol 6mcg / beclometasone dipropionate 200mcg
- N.B. 100 mcg of beclometasone in Fostair® is equivalent to a 250 mcg dose in a conventional beclometasone metered dose inhaler (e.g. Becloforte, Beclazone and Clenil Modulite).

Fostair Nexthaler: approved for treatment of asthma and Fostair 100/6 NEXThaler approved for use in COPD.

Flutiform (fluticasone/formoterol)
BNF | BNFC | SPC

MDI = 50/5 microgram, 125/5 microgram, 250/10 microgram

Flutiform: approved for treatment of asthma

Sirdupla (fluticasone/salmeterol)
BNF | BNFC | SPC

MDI - 125/25 microgram, 250/25 microgram

Sirdupla: approved for treatment of asthma

Sodium cromoglicate
BNF | BNFC | SPC

Aerosol Inhaler - 5mg/metered dose

Montelukast
BNF | BNFC | SPC

Tablets - 10mg 

Chewable Tablets - 4mg, 5mg 

Granules - 4mg 

Review treatment after 6 weeks of initiation and discontinue if no evidence of improvement.

First choice
Non-sedating:
Cetirizine
Loratadine
Levocetirizine


Sedating:
Chlorphenamine

Alternatives
Non-Sedating:
Desloratadine
Fexofenadine

Sedating:
Hydroxyzine
Promethazine
Alimemazine

Alimemazine tartrate
BNF | BNFC | SPC

Tablets - 10mg

Liquid - 7.5mg/5ml

Sedating

Cetirizine
BNF | BNFC | SPC

Tablets - 10mg

Liquid - 5mg/5ml 

Chlorphenamine
BNF | BNFC | SPC

Tablets - 4mg

Liquid - 2mg/5ml

10mg in 1ml injection

Desloratadine
BNF | BNFC | SPC

5mg tablets
2.5mg in 5ml syrup

Fexofenadine
BNF | BNFC | SPC

Tablets - 120mg, 180mg

Hydroxyzine hydrochloride
BNF | BNFC | SPC

Tablets - 10mg, 25mg

Liquid - 10mg/5ml

See MHRA Drug Safety Update (April 2015): Hydroxyzine (Atarax, Ucerax): risk of QT interval prolongation and Torsade de Pointes

Levocetirizine
BNF | BNFC | SPC
Loratadine
BNF | BNFC | SPC

Tablets - 10mg

Liquid - 5mg/5ml 

Promethazine hydrochloride
BNF | BNFC | SPC

Tablets - 10mg,25mg

Liquid - 5mg/5ml

Sedating

Omalizumab
BNF | BNFC | SPC

150mg injection & 75mg & 150mg prefilled syringes

For specialist use in the treatment of severe asthma in adults and children over 12 years of age (NICE guidance)

Asthma (severe, persistent, patients aged 6+, adults) - omalizumab (rev TA133, TA201) (TA278)

For specialist use in treatment of previously treated chronic spontaneous urticarial (NICE Guidance) – NICE TA339

Commissioner: NHS England - NICE TA278

Grazax
BNF | BNFC | SPC

Grass pollen extract 75,000 units oral lyophilisates
(freeze-dried tablets)

Mepolizumab
BNF | BNFC | SPC

100 mg powder for solution for injection

For specialist use in the treatment of severe asthma in adults  as per NICE TA431

Adrenaline auto-injection device
BNF | BNFC | SPC

Jext 150microgram

300microgram autoinjector

Jext is the preferred intramuscular device for self-injection, but Epipen remains an option.

MHRA Safety Alert (May 2014): always call an ambulance after use of an adrenaline auto-injector

C1 Esterase Inhibitor
BNF | BNFC | SPC
Conestat Alfa
BNF | BNFC | SPC
Icatibant
BNF | BNFC | SPC

30mg in 3ml injection

Commissioner: NHS England - Policy - B09/P/b

Doxapram
BNF | BNFC | SPC

2mg per ml 500ml infusion, 100mg in 5ml injection

Caffeine Citrate
BNF | BNFC | SPC

50mg in 5ml injection (equivalent to 25mg caffeine base in 5ml [5mg caffeine base/ ml])u
50mg in 5ml oral solutionu

MHRA Drug Safety Alert (Aug 2013): Caffeine citrate - standardisation of name for prescribing to reduce error risk

Drug protocol: Neonatal respiratory stimulant (CDDFT intranet access only)

Poractant Alfa
BNF | BNFC | SPC

120mg in 1.5ml & 240mg in 3ml vials (Curosurf®)

Commissioner: NHS England

Drug protocol: neonatal (CDDFT intranet access only)

Carbocisteine
BNF | BNFC | SPC

Capsules - 375mg

Liquid - 250mg/5ml

750mg/10ml sugar-free oral solution in sachet

For COPD patients in accordance with local guidelines

Erdosteine
BNF | BNFC | SPC

Capsules - 300mg 

For short term use only

Acetylcysteine
BNF | BNFC | SPC

600mg plain and effervescent tabletsu

For use on specialist advice in the treatment of idiopathic pulmonary fibrosis and for the prevention of x-ray contrast media induced renal damage.

Sodium Chloride 7% solution for nebulisation
BNF | BNFC | SPC

7% solution for nebulisation (Nebusal®)

Initiated by respiratory specialists or on ITU.

Dornase alfa
BNF | BNFC | SPC

2.5mg in 2.5ml solution for nebulisation

Commissioner: NHS England - NICE TA276, Policy - A01/PS/a

Ivacaftor
BNF | BNFC | SPC

150mg film coated tablets

Commissioner: NHS England - Policy - A01/P/b

Mannitol
BNF | BNFC | SPC

40mg capsules for inhalation

Commissioner: NHS England - NICE TA266

Lumacaftor-Ivacafor▼
BNF | BNFC | SPC

Not approved, see NICE TA398

Pholcodeine
BNF | BNFC | SPC

Linctus - 5mg/5ml, 10mg/5ml

Cough and cold remedies (including local anaesthetic throat lozenges) are not included in the formulary as they are not a cost effective use of NHS resources.

Pseudoephedrine
BNF | BNFC | SPC

60mg tablets
30mg in 5ml elixir

MHRA Drug Safety Update (Sep 2015): Pseudoephedrine and ephedrine: update on managing risk of misuse in the UK

Pirfenidone▼
BNF | BNFC | SPC

267mg capsules

For Idiopathic Pulmonary Fibrosis

Commissioner: NHS England - NICE TA282 - tertiary centres only