• Injection 500 micrograms/1ml
• Solution for IV infusion 5mg in 5ml   

• Acute use in hospital / GP surgeries or short term use at home.
• Long term use is generally ineffective and should be used only under specialist guidance. 
• Salbutamol nebuliser solution 2.5mg in 2.5ml, 5mg in 2.5ml

• Turbohaler dry powder inhaler MDI 500 micrograms/dose

• Injection 500 micrograms/ml, 2.5mg/5ml

• Consider if intolerant of salbutamol or uses terbutaline turbohaler. 
• Respules 2.5mg/ml

• No new prescribing. Existing patients only - see notes above.

• Aerosol inhalation MDI 25 micrograms/dose (generic)
• Licensed 4 years +
• Serevent^® Evohaler Aerosol inhalation MDI 25 micrograms/dose
• Serevent^® Accuhaler Dry powder for inhalation 50 micrograms/dose

• No new prescribing. Existing patients only - see notes above.
• Oxis^®Turbohaler dry powder inhaler MDI 6 micrograms/dose,12 micrograms/dose

• Licensed 6 years +
• Note: Formoterol - licensed for use when adequate treatment with corticosteroids is not sufficient.
• Salmeterol 50 micrograms is roughly equivalent to Formoterol 9 micrograms.

• No new prescribing. Existing patients only - see notes above.
• Inhalation powder, hard capsule 150, 300 micrograms (via Onbrez Breezhaler^® device)

• No new prescribing. Existing patients only - see notes above.
• The delivered dose is 2.5 microgram Olodaterol (as hydrochloride) per actuation.

• For patients with manual dexterity problems or an eGFR<30ml/min. 
• Inhalation powder 322 microgram/dose aclidinium

• Each capsule contains 63 micrograms of glycopyrronium bromide equivalent to 50 micrograms of glycopyrronium.
• Each delivered dose (the dose that leaves the mouthpiece of the inhaler) contains 55 micrograms of glycopyrronium bromide equivalent to 44 micrograms of glycopyrronium.

• Monotherapy for existing patients ONLY. For patients who can'tmanage the inhaler devices available as first or second line options. 
• DO NOT use as part of triple therapy with Relvar. Where tripletherapy is needed please prescribe Trelegy if patient prefers the Ellipta device. 
• Inhalation powder 55microgram / dose umeclidinium equivalent to 65 micrograms of umeclidinium bromide.

•  Inhaler 20 micrograms/dose

• Nebuliser solution 250 micrograms in 1 ml, 500micrograms in 2ml

• Modified release tablets 225mg (Phyllocontin^®) m/r
• In asthma - use only at Step 4, after long acting β2 agonists,leukotriene antagonist and high dose steroids.  Referral may be preferable. 
• In COPD - Not recommended for routine use. Referral may be preferable.

• Aminophylline Injection 250 mg/10ml
• For selected patients with acute severe asthma or severe exacerbations of COPD.

• Modified release tablets 200mg, 300mg, 400mg
• In asthma - use only at Step 4, after long acting β2 agonists,leukotriene antagonist and high dose steroids.  Referral may be preferable. 
• In COPD - Not recommended for routine use. Referral may be preferable.

• Combination of Formoterol fumarate / Aclidinium (as bromide)
• Breath actuated dry powder MDI 12/340 Genuair device

• Combination of Indacaterol / Glycopyrronium
• Breezehaler device with inhalation powder hard capsules each capsule contains equivalent of 110 micrograms of indacaterol and 50 micrograms of glycopyrronium

• Combination of Tiotropium (bromide monohydrate) / Olodaterol (hydrochloride)
• Respimat device tiotropium 2.5micrograms / olodaterol 2.5micrograms per inhalation

• Combination of Vilanterol (as trifenatate) / Umeclidinium bromide
• Ellipta device vilanterol 22micrograms / umeclidinium 55micrograms per inhalation

• Ipratropium bromide 500micrograms & salbutamol sulphate 2.5mg/ 2.5ml Unit Dose Vial  (nebulised)
• NB - less suitable for prescribing. Licensed for bronchospasm in patients with COPD. BNF states flexibility of dosing is lost with a compound bronchodilator but it may be appropriate for patients stabilised on the individual components in the same proportion.Consider if compliance an issue.

• Available as low range peak flow meter and standard range peak flow meter. 

• Aerochamber Plus standard with mask cannot be used without the mask.
• Please prescribe standard device with mouthpiece if the mask is not required.

• Nebuliser solution 0.9% 2.5ml

• Respiratory solution 500 micrograms per 2ml, 1mg per 2ml

•  Salisbury ONLY 
• Non-formulary BaNEs & Swindon
• For persistent asthma in exceptional cases e.g in patients withpoor compliance or patients having side effects on standard inhaledcorticosteroids. For initiation by Respiratory consultant and ongoingprescription by GP

• Existing patients ONLY.
• Flixotide^® Accuhaler dry powder for inhalation50,100,250,500 micrograms/dose
• Flixotide^® Evohaler aerosol inhalation MDI50,125,250 micrograms/dose 
• Restricted to use for adult patients for whom other therapyhas proved unsuccessful and are uncontrolled on over 1000mcgdaily of inhaled beclomethasone or budesonide. 
• The evidence for reduced adrenal supression with fluticasone is poor.But, consider use in children of 4 years of age and older, if high dosesof inhaled steroids (30kg 800mcg BD of beclometasone or budesonide)have been used for longer than three months. 
• Prescribe fluticasone at half the dose prescribed for beclometasoneor budesonide. 

• No new prescribing. Existing patients only.
• Low strength can be used in a MART regime.
• Prescribe by brand.
• Combination of budesonide and formoterol fumarate dihydrate
• Dry Powder Inhaler 320micrograms/9 micrograms (equivalent to 400/12)and 160micrograms/4.5 micrograms (equivalent to 200/6)
• For the treatment of asthma and COPD within product licence

• No new prescribing. Existing patients only.
• Can be used in a MART regime. 
• Prescribe by brand.
• Combination of budesonide and formoterol
• Turbohaler dry powder inhaler DPI 100/6; 200/6; 400/12
• Notes: Symbicort Turbohaler is licensed for both asthma and COPD;

•   BaNEs & Salisbury 

• Non-formulary  Swindon
• MDI 100/50, 250/50, 500/50
• No new prescribing
• Review existing patients, to see if could switch to first-line options
• Licensed for COPD but the Evohaler is not-many patients with COPD are using the Seretide 250 Evohaler
• The cost of Seretide Accuhaler 500 (one puff bd) is significantly less than Seretide 250 Evohaler (two puffs bd). It delivers exactly the same medication as for the same number of days but costs £20 less per unit
• NB -Swindon, for use in adults, all strengths have been removed from formulary, it is accepted that there may be a very small amount of non-formulary prescribing in the exceptional circumstance that all formulary options  have been exhausted. 

•  BaNES and Salisbury

• Non-formulary Swindon(except Seretide 50 Evohaler)
• No new prescribing. 
• Review existing patients, to see if could switch to first-line options.
• Airflusal^®aerosol inhalation MDI 25/125, 25/250.For asthma >18years of age. NB only to be used for new patients
• Sirdupla ®aerosol inhalation MDI 125/25, 250/25 For asthma >18years of age - NB no lower strength. Prescribe by brand. 
• Seretide^®Evohaler aerosol inhalation MDI 50/25, 125/25, 250/25
• Notes: The higher doses (125 and 250) are only advised in step 4 of the management of asthma in adults.
• It is envisaged that existing adult patients will be switched to either Sirdupla ^®MDI / AirFluSal or Fostair ^® MDI, depending on indication, although it is accepted that there may be a very small amount of non-formulary prescribing in the exceptional circumstance that all formulary options have been exhausted.  

• Combination of formoterol fumarate, beclametasone diproprionate and glycopyrronium (5/87/9 micrograms per puff) MDI
• 120 doses Two puffs twice a day 
• Maintenance treatment in adult patients with moderat to severe chronic obstructive pulmonary disease who are not adequately treated by a combination of an inhaled corticosteroid  and a long-acting β2 agonist. 

• Combination of Vilanterol, fluticasone furoate and umeclidinium (22/92/55 micrograms per inhalation) 30 doses.
• Breath actuated dry powder inhaler used as maintenance treatment in adult patients with severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long acting B2 agonist.
• A once daily administration.

• Granules 4mg sachets sugar-free (6 months to 5 years of age)
• Chewable tablets 4mg (2 to 5 years of age)
• Chewable tablets 5mg (6 to 14 years of age)
• Tablets 10mg (>14 years of age)
• NICE guidance (NG80, November 2017) recommends an LTRA as the first add-on maintenance therapy with ICS and SABA inhalers for the treatment in asthma. A LABA is an option (with/without the LTRA) in addition to an ICS if asthma remains uncontrolled. This is a more cost effective model. 
• Existing BTS/SIGN continues the long-held view that low dose ICS should be followed by addition of LABA (in line with international guidelines such as GINA).
• Head to head comparisons of ICS/LABA compared to ICS/LTRA have favoured ICS/LABA for effectiveness in adults (inconclusive in children).

Notes:

• Not to be used to relieve an attack of severe acute asthma.
• Leukotriene receptor antagonists should be withdrawn if no significant response after 6 weeks
•  MHRA Drug Safety Update Sept 2019 Montelukast (Singulair):reminder of the risk of neuropsychiatric reactions

• ONLY for initiation by a Respiratory specialist, for the treatment of COPD in adults, in line with NICE TA 461. 
• Tablet 250mcg (for intiation only) 500microgram (maintenance)
• Patients should be referred only if:
  i) the disease is severe, defined as a forced expiratory volume in 1 second (FEV₁ ) after a bronchodilator of less than 50% of predicted normal, and ii) they have had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid.

• Tablets 30mg, 120mg, 180mg
• 30mg and 120mg tablets are included on the BSWformulary for symptomatic relief of seasonal allergic rhinitis and should ONLY be prescribed when loratadine/cetirizine have been trialled and failed to control symptoms. Check BNFC for dosing in children.
• 180mg tablet is included on BSWformulary for the treatment of chronic idiopathic urticaria (adults and children >12 yrs) usually initiated by dermatology specialist) in patients not adequately treated with cetirizine/loratadine.

• Tablets 10mg, 25mg
• Hydroxyzine is favoured by the dermatologists for its anti-itch and

sedating effects.

MHRA Drug Safety Update 29th April 2015: 

• The maximum adult daily dose of hydroxyzine is now 100 mg.

Do not prescribe hydroxyzine to people with a prolonged QT interval

or risk factors for QT interval prolongation.

• Tablets 10mg, 25mg
• Oral Solution 5mg/5ml 100ml

• Injection, 150mg vial
• Commissioned by NHS England (for uncontrolled asthma) in accordance with NICE TA278.
  Patients must be assessed and approved for a 16 weeks trial by
• MDT decision. Trial outcome to be assessed at regional MDTto decide if ongoing treatment is appropriate.
• Blueteq registration and approval is necessary for all new initiations and continuations.

Epipen® brand (150 microgram and 300microgram devices) is considered the first line Adrenaline Auto Injector (AAI) across BSW.

Jext® brand (150 microgram and 300microgram devices) may also be used across BSW if supply issues necessitate.

Emerade ® brand (150microgram, 300microgram and 500microgram devices) were previously included on the formulary but NOT currently available. See further information below.

Injection technique is device specific. To ensure patients receivethe AAI that they have been trained to use, prescribers should prescribe by brand. Resources to support initial training, or when switching device:

Epipen demo video;  Epipen prescriber checklist; Jext demo video;

• Jext prescriber checklist; 

Additional notes:

All healthcare professionals in primary, secondary or specialist healthcare services who prescribe, supply or administer AAIs, or who advise patients and carers should ensure that:

• When patients next request a prescription, they are reviewed to ensure their AAI  prescription is still appropriate.

• Prescribers issue no more than TWO AAIs per patient (exceptions suggested to this in a 2019 DHSC supply disruption alert are ▪ where schools require separate AAI(s) to be kept on the school premises (e.g. in a medical room) in which case prescribers may need to consider issuing more than two but no more than four AAIs per child; ▪ for the rare scenario where patients might need more than two AAIs prescribed (for example, prior severe reaction resistant to treatment with adrenaline), the prescriber may issue additional AAIs).
• Patients are aware to not expose any brand of AAI to temperatures above 25°C. Storage above 25°C may increase the likelihood of a fault occurring with AAIs.
• Patients use their device(s) as instructed until the expiry date/extended expiry date. N.B. a device expiring in ‘March 2020’ does not expire until 31 March 2020.
• Patients are aware of the signs of anaphylaxis and the actions they should immediately take.

June 2020 -AAIs Supply Issues. 

Emerade® 150, 300 and 500 microgram AAI devices will be

unavailable for the foreseeable future. Patient and/or carers

should return Emerade AAIs to their local pharmacy once they have

obtained a prescription for, and been supplied with, an alternative brand.

While Emerade® remains unavailable, alternative devices should be considered

• Emerade® is the only AAI available in 500microgram formulation but The MHRA note that there is evidence to suggest that a single EpiPen® (300 microgram) or Jext® (300 microgram) device will be a suitable replacement for a single Emerade® 500 microgram device. 

• - GWH
• Non-formulary - RUH
• Non-formulary - SFT

• 1 in 10, 000 ampoules and minijet.
• Slow IV inj reserved for severely ill patients where there is doubt about adequacy of the circulation and absorption from the IM site with ECG monitoring.
• Ensure that the correct strength of adrenaline injection is used. 

• Injection podwer for reconstitution, 500 unit vial

• Acute Treatment or Short-term prophylaxis prior to planned procedures for Hereditary Angioedema and Acquired Angioedema

• In accordance with NHS England commissioning policy
• May only be initiated by (or on advice of) Specialist Centres
• Drug costs for emergency use in other hospitals will be reimbursed through the Specialist Centre
• Prophylactic treatment of hereditary angioedema (HAE) types I and II
• In accordance with NHS England commissioning policy in patients who fail, are intolerant or have contra-indications to oral prophylactic therapies.
• May only be supplied by Specialist Centres
• Prior approval must be given via Blueteq system

• Injection 10mg/ml - 3ml pre-filled syringe

• Non Formulary RUH 
• Available from SFT

• Commissioned by NHS England for Hereditary Angioedema and Acquired Angioedema for acute treatment or short-term prophylaxis prior to planned procedures. See NHS England Policy: B09/P/b.
  
   May only be initiated by (or on advice of) Specialist Centres where:

• C1inh is unsuitable due to adverse effects or administration difficulties the specialist clinician determines that Icatibant is the most suitable or cost-effective preparation for the patient
  Drug costs for emergency use in other hospitals will be reimbursed through the Specialist Centre

• Injection 100mg in 5ml

• Suspension 80mg/ml (Curosurf^®)

• Commissioned by NHS England (for Respiratory Distress Syndrome in neonates). Use product with lowest procurement cost in line with Trust guidelines. Hospital only.  

• Capsules 375mg
• Oral liquid 250mg/5ml
• Sachets 750mg/10ml Sugar free oral solution
• Note: liquid must still be used in patients with feeding tubes

• RED via NHSE agreed specialist centre
• Commissioned by NHS England Specialised Services Commissioning
• See NHS England Clinical Commissioning Policy: Ivacaftor for Cystic Fibrosis (A01/P/a)

• Nebuliser solution 2500 units in 2.5ml 

• Notes:

• A Jet Nebuliser used exclusively for dornase alfa is required for administration
• To improve pulmonary function in cystic fibrosis patients with a FVC of greater than 40% predicted.
• Use on specialist respiratory advice only.
• Requirement for dornase alfa should be reviewed every 3 days.

• Nebuliser solution, sodium chloride 3%, 6%, 7%
• To be started on Specialist respiratory advice only

• For inhalation for mannitol bronchial challenge test

• Non Formulary at RUH and SFT
• Inhalation powder, hard capsule (for use with disposable inhaler device) mannitol 40mg 
• Commissioned by NHS England for use in CF as per policy A01/P/b and NICE TA266.

• - BaNES 
•   - Salisbury
•  Non-formulary -Swindon

• 600mg effervescent tablets (licensed) (Swindon only)
• 600mg Tablets (unlicensed)
• 200mg/1ml 10ml ampoules Infusion (Also used for treatment of poisoning)
• Interstitial pneumonia (unlicensed)/ Idiopathic Pulmonary Fibrosis (unlicensed)
• Also used as renal protection before CT scan with contrast agent
• NHS England Specialised Commissioning - Respiratory Interstital Lung Disease Adults