Formulary Chapter 3: Respiratory system - Full Chapter
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Notes: |
Inhalers should always be prescribed by their BRAND name.
The patient's ability to use a device should be assessed by a competent healthcare professional and re-assessed as part of structured clinical review. If the patient is unable to use a device satisfactorily, an alternative should be found.
RightBreathe is a free app/website designed to help clinicians and patients use inhaled therapy and devices appropriately https://www.rightbreathe.com/. Asthma.org has patient-friendly videos of inhaler technique here.
In children aged 0-5 years, pMDI and spacer are the preferred delivery method for β2 agonists or inhaled steroids. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece.
Self-care
Many of the products in this chapter are available for purchase over-the-counter, and patients are encouraged to self-care, with the support of their community pharmacist, in the first instance. For further information on self-care & the NHS, please refer to https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/
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Chapter Links... |
NICE CG101: COPD guideline |
NICE TA10: Asthma inhaler devices (children under 5) |
NICE TA38: Asthma inhaler devices (older children) |
Details... |
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03.01.01 |
Adrenoceptor agonists |
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03.01.01.01 |
Selective Beta2 agonists |
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03.01.01.01 |
Short-acting beta2 agonists |
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Salbutamol
(Ventolin ®,Easyhaler®,Salamol Easi-Breathe®)
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First Choice

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- Ventolin Accuhaler® and Salamol Easi-Breathe® existing patients only.
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Salbutamol IV
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Formulary

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- Injection 500 micrograms/1ml
- Solution for IV infusion 5mg in 5ml
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Salbutamol Nebuliser Solution
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Formulary

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- 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
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Terbutaline
(Bricanyl Turbohaler®)
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Formulary

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- Turbohaler dry powder inhaler MDI 500 micrograms/dose
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Terbutaline IV
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Formulary

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- Injection 500 micrograms/ml, 2.5mg/5ml
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Terbutaline Nebuliser Solution
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Formulary

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- Consider if intolerant of salbutamol or uses terbutaline turbohaler.
- Respules 2.5mg/ml
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03.01.01.01 |
Long-acting beta2 agonists |
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Current COPD and Asthma guidance is not in favour of using LABA on its own.
LABAs should be taken only in combination with a corticosteroid to treat asthma.
In COPD LABAs should be offered in a combination with LAMA if there are no
asthmatic features/features suggesting steroid responsiveness or considered in combination with ICS if there are asthmatic features/features
suggesting steroid responsiveness.
For people using long-acting bronchodilators outside of above recommendations
before NICE guideline [NG115] was published (December 2018), explain to them
that they can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change. |
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Salmeterol
(Serevent®)
(pMDI and DPI)
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Formulary

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- 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
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Formoterol
(Oxis Turbohaler®)
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Formulary

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- 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.
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Indacaterol
(Onbrez Breezhaler®)
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Formulary

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

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- No new prescribing. Existing patients only - see notes above.
- The delivered dose is 2.5 microgram Olodaterol (as hydrochloride) per actuation.
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03.01.01.02 |
Other adrenoceptor agonists |
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03.01.02 |
Antimuscarinic bronchodilators |
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Tiotropium
(Braltus Zonda®)
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First Choice

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- First-line long-acting muscarinic receptor antagonist for COPD ONLY
- See MHRA Drug Safety Update May 18 for information on the risk ofcapsule inhalation if capsule placed in mouthpiece.
- Braltus 10 micrograms delivered dose inhalation powder hard capsule(Zonda Inhaler device). Each capsule contains 16 micrograms oftiotropium bromide equivalent to 13 micrograms of tiotropium.
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Tiotropium
(Spiriva Respimat®)
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First Choice

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- First-line long-acting muscarinic receptor antagonist for COPD
- Respimat® (solution for inhalation) 2.5 micrograms/metered inhalation.
- This is the ONLY LAMA licensed for asthma.
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Tiotropium via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial
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Aclidinium
(Eklira Genuair®)
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Second Choice

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- For patients with manual dexterity problems or an eGFR<30ml/min.
- Inhalation powder 322 microgram/dose aclidinium
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Glycopyrronium
(Seebri breezhaler®)
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Second Choice

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- 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.
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Umeclidinium
(Incruse Ellipta®)
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Third Choice

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- 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.
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Ipratropium Bromide
(Atrovent®)
(Short-acting (SAMA))
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Formulary

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- Inhaler 20 micrograms/dose
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Ipratropium Bromide Nebuliser Solution
(Ipratropium Steri-Neb®)
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Formulary

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- Nebuliser solution 250 micrograms in 1 ml, 500micrograms in 2ml
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Theophylline products are not interchangeable and should be prescribed by BRAND NAME.
Remember narrow therapeutic window and potential for interactions.
The half-life is increased (giving higher theophylline levels) in heart failure,cirrhosis
and viral infections, in the elderly and by drugs as cimetidine,ciprofloxacin,
erythromycin, fluvoxamine, diltiazem, verapamil and oral contraceptives. Vomiting
may indicate a toxic dose.
The half-life is decreased (giving lower theophylline levels) in smokers, in
chronic alcoholism and by drugs as phenytoin, carbamazepine, rifampicine
and barbiturates.
To avoid excessive dosage in obese patients , dose should be calculated in
the basis of ideal body weight.
Plasma-theophylline concentration should be available to guide dosing of
iv aminophylline in patients taking oral theophylline or aminophylline. |
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Aminophylline IV
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Formulary

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- Aminophylline Injection 250 mg/10ml
- For selected patients with acute severe asthma or severe exacerbations of COPD.
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Theophylline
(Uniphyllin® Continus)
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Formulary

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- Modified release tablets 200mg, 300mg, 400mg
- For patients switching to theophylline from aminophylline - Advice and information in the DHSC SDA/2021/003 here should be used to support local decision making and guide dose conversions.
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03.01.04 |
Compound bronchodilator preparations |
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Compound broncodilator preparations are considered to have no place in the management of patients with asthma.
NICE COPD guideline NG115 recommends:
Offer LAMA+LABA[] to people who:
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have spirometrically confirmed COPD and
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do not have asthmatic features/features suggesting steroid responsiveness and
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remain breathless or have exacerbations despite:
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having used or been offered treatment for tobacco dependence if they smoke and
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optimised non-pharmacological management and relevant vaccinations and
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using a short-acting bronchodilator. [2018]
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Aclidinium and formoterol inhaler
(Duaklir Genuair ®)
(LABA/LAMA)
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Formulary

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- Combination of Formoterol fumarate / Aclidinium (as bromide)
- Breath actuated dry powder MDI 12/340 Genuair device
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Glycopyrrolate/ indacaterol inhaler
(Ultibro Breezhaler®)
(LABA/LAMA)
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Formulary

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- 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
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Tiotropium & olodaterol ®
(Spiolto Respimat)
(LABA/LAMA)
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Formulary

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- Combination of Tiotropium (bromide monohydrate) / Olodaterol (hydrochloride)
- Respimat device tiotropium 2.5micrograms / olodaterol 2.5micrograms per inhalation
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Umeclidinium & vilanterol
(Anoro Ellipta®)
(LABA/LAMA)
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Formulary

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- Combination of Vilanterol (as trifenatate) / Umeclidinium bromide
- Ellipta device vilanterol 22micrograms / umeclidinium 55micrograms per inhalation
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Ipratropium bromide with salbutamol
(Combivent®)
(SABA/SAMA)
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Formulary

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- 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.
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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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Standard range peak flow meter
(Mini-Wright®)
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Formulary

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- Available as low range peak flow meter and standard range peak flow meter.
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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 Plus standard with mask cannot be used without the mask.
- Please prescribe standard device with mouthpiece if the mask is not required.
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Volumatic ®
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Formulary

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03.01.05 |
Nebuliser Diluent |
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Sodium Chloride
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Formulary
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- Nebuliser solution 0.9% 2.5ml
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August 2020 NPSA Alert: Steroid Emergency Cards Full alert here along with actions for primary and acute care, and community pharmacy. To summarise:
- Prescribers are asked when initiating a new steroid prescription, or undertaking standard/scheduled reviews of patients prescribed corticosteroids, to assess and issue the patient with a Steroid Emergency Card if appropriate. Practices should add ‘Steroid treatment card issued’ SNOMED code to patient’s record to help with audit.
- Further information on adrenal crisis is available from Society of Endocrinology. Cards can be ordered from the PCSE and Xerox portals, or a PDF copy is available here.
- Community and hospital pharmacies should ensure they can source and supply cards to replace those lost by patients or which become damaged.
11 May 2020 - BSW Beclometasone PMDIs Shortages Information
MHRA drug safety update Aug 2017 rare risk of central serous chorioretinopathy with local and systemic administration of coticosteroids.
Oral prednisolone dose regimens:
- Children: 1-2mg/kg (max 40mg) daily, for 1-7 days depending on symptoms.
- Adults: 30-40mg daily.
- In COPD - recommended dose is 30mg daily. Courses longer than 14 days have no benefit.
- In asthma - tailor course to patient . refer to secondary care ifprolonged (28 days) or repeated courses are needed.
- There is no need to taper doses unless course is more than 21 days.
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Beclometasone Dipropionate
(Clenil Modulite®, Soprobec® )
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First Choice

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- Prescribe by brand name
- Clenil® Modulite aerosol inhalation MDI 50, 100, 200, 250 micrograms/dose
- Soprobec® aerosal inhalation MDI 50, 100, 200, 250 micrograms/dose
- Soprobec® is directly equivalent to Clenil Modulite®
- Clenil® and Kelhale®/Qvar® are first line pMDI low dose ICS for asthma.
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Beclometasone
(Qvar®, Kelhale®)
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First Choice

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Budesonide
(Pulmicort®, Easyhaler®)
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First Choice

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- Prescribe by brand name
- Easyhaler dry powder for inhalation MDI
- 100 micrograms/dose, 200 micrograms/dose, 400 micrograms/dose
- Turbohaler dry powder inhaler MDI 100 microgram/dose,
- 200 micrograms/dose, 400 micrograms/dose
- Easyhaler Budesonide® and Pulmicort® are the first line DPI low dose ICS for asthma.
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Budesonide Nebuliser Suspension
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Formulary

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- Respiratory solution 500 micrograms per 2ml, 1mg per 2ml
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Ciclesonide
(Alvesco®)
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Formulary
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 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
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Fluticasone propionate
(Flixotide®)
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Formulary

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- 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.
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03.02.02 |
Compound Corticosteroid/ Long acting beta-agonist inhalers |
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Fluticasone furoate & vilanterol
(Relvar Ellipta®)
(DPI)
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First Choice

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- First choice ICS/LABA DPI for asthma and COPD.
- Use in COPD:
- Combination of fluticasone furoate and vilanterol (92/22)Breath actuated dry powder inhalerApproved for COPD in use with local guidance and in line with NICE FEV1<50%. Once daily administration.
- Use in asthma:
- Combination of fluticasone furoate and vilanterol (92/22, 184/22)Breath actuated dry powder inhaler for uncontrolled asthmatic patients onlyOnce daily administration
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Beclometasone and formoterol
(Fostair®)
(pMDI)
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First Choice

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Beclometasone and formoterol
(Fostair NEXThaler®)
(DPI)
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First Choice

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- First choice ICS/LABA DPI for asthma and COPD.
- Combination of beclometasone and formoterol
- For asthma: dry powder inhaler; beclometasone 100 micrograms,formoterol 6 micrograms dose and beclometasone 200 micrograms,formoterol 6 micrograms dose
- For COPD with FEV1<50%: dry powder inhaler; beclometasone100 micrograms, formoterol 6 micrograms dose only in line with the product guidance
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Budesonide and formoterol
(Fobumix Easyhaler®)
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First Choice

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- First choice ICS/LABA DPI for asthma.
- Can be used in a MART regime.
- Prescribe by brand
- Combination of budesonide and formoterol fumarate dihydrate
- Breath-actuated dry powder inhaler 80 micrograms/4.5micrograms,160 micrograms/ 4.5 micrograms and 320 micrograms/9 micrograms
- For the treatment of asthma and COPD within product licence
- Most cost effective option July 2018
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Budesonide and formoterol
(DuoResp Spiromax®)
(DPI)
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Formulary

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- 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
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Budesonide and formoterol
(Symbicort®)
(DPI)
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Formulary

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- 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;
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Fluticasone propionate and salmeterol
( Seretide Accuhaler®)
(DPI)
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Formulary
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-
 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.
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Fluticasone propionate and salmeterol
(Sirdupla®, Airflusal®,Seretide®)
(pMDI)
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Formulary
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 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.
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03.02.03 |
Triple Therapy products for COPD |
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Formoterol fumarate, beclometasone dipropionate and glycopyrronium bromide
(Trimbow®)
(pMDI)
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Formulary

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- 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.
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Vilanterol, fluticasone furoate and umeclidinium
(Trelegy®)
(DPI)
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Formulary

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- 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 moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long acting B2 agonist or a combination of a LABA and a LAMA.
- A once daily administration.
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03.03 |
Cromoglicate, related therapy and leukotriene receptor antagonists |
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03.03.01 |
Cromoglicate and related therapy |
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Please note use of sodium cromoglycate and nedocromil sodium is not recommended. |
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03.03.02 |
Leukotriene receptor antagonists |
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Montelukast
(Oral)
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Formulary

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- 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:
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03.03.03 |
Phosphodiesterase type-4 inhibitors |
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Roflumilast
(Daxas®)
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Formulary

|
- 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.
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For Roflumilast guidance see page 7-8 of the BSW COPD guidance
NICE TA461 : Roflumilast for treating chronic obstructive pulmonary disease
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03.04 |
Antihistamines, hyposensitisation, and allergic emergencies |
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03.04.01 |
Non-sedating antihistamines |
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Cetirizine
(Oral)
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First Choice

|
 Self Care Medicine for primary care.
- Tablets 10mg
- Oral solutionSF 5mg in 5ml
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Loratadine
(Oral)
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First Choice

|
 Self Care Medicine for primary care.
- Tablets 10mg
- Oral solution 5mg in 5ml
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Fexofenadine
(Oral)
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Formulary

|
- 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.
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03.04.01 |
Sedating antihistamines |
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Chlorphenamine
(Oral/Injection)
|
First Choice

|
- Tablets 4mg
- Oral solution 2mg/5ml
- Injection 10mg/ml
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Hydroxyzine
(Oral)
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Formulary

|
- Tablets 10mg, 25mg
- Hydroxyzine is favoured by the dermatologists for its anti-itch and
sedating effects.
MHRA Drug Safety Update 29th April 2015:
Do not prescribe hydroxyzine to people with a prolonged QT interval
or risk factors for QT interval prolongation.
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Anticholinergic medicines (information leaflet for patients)
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Promethazine
(Phenergan®)
(Oral)
|
Formulary

|
- Tablets 10mg, 25mg
- Oral Solution 5mg/5ml 100ml
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Anticholinergic medicines (information leaflet for patients)
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03.04.02 |
Allergen Immunotherapy |
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Omalizumab
(Xolair®)
(Injection: uncontrolled asthma)
|
Restricted



|
- 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.
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MHRA Dec 2014: Omalizumab: potential risk of arterial thrombotic events
NICE TA278: Omalizumab for treating allergic asthma
|
03.04.03 |
Allergic emergencies |
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Adrenaline / epinephrine
(EpiPen® Jext® )
(for IM self administration)
|
Formulary

|
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;
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.
|
MAY 2020 - Class 2 Medicines Recall: Emerade 500 micrograms solution for injection in pre-filled syringe NOTE THIS IS IN ADDITION TO ALERTS ISSUED IN MARCH AND APRIL 2020
October 2019 - Adrenaline auto-injectors: MHRA Summary of recent action taken to support safety
Resuscitation Council anaphylaxis guidelines
MHRA Patient Info Leaflet - Adrenaline auto-injectors and advice on use
NICE CG134: Anaphylaxis: Assessment and referral after emergency treatment
Epipen - Risk minimisation education materials
Jext - Risk minimisation education materials
|
Adrenaline / Epinephrine
(Adrenaline 1 in 1000)
(Injection ampoules)
|
Formulary

|
|
|
Adrenaline / Epinephrine
(Adrenaline 1 in 1000)
(Injection minijet)
|
Formulary
|
 - GWH
- Non-formulary - RUH
- Non-formulary - SFT
|
|
Adrenaline / epinephrine 1 in 10,000
(Injection)
|
Formulary

|
- 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.
|
|
|
|
C1 esterase inhibitor
(Cinryze® /Berinert®)
(Injection)
|
Restricted



|
|
NHSE policy 2013: Clinical Commissioning Policy: Treatment of Acute Attacks in Hereditary Angiodema (Adult)
NHSE policy July 2016: Clinical Commissioning Policy: Plasma-derived C1-esterase inhibitor for prophylactic treatment of hereditary angioedema (HAE) types I and II
|
Icatibant
(Firazyr®)
|
Restricted



|
-
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
|
|
03.05 |
Respiratory stimulants and pulmonary surfactants |
|
|
03.05.01 |
Respiratory stimulants |
|
|
Doxapram
(Dopram®)
(Injection)
|
Formulary

|
|
|
03.05.02 |
Pulmonary surfactants |
|
|
Poractant Alfa
(Curosurf®)
(Suspension)
|
Formulary

|
|
|
|
|
NEW 03/04/2020 Use of Oxygen in
COVID-19 patients/palliative - Key Messages
There has been no specific information published about the use of oxygen for
patients in primary care with suspected COVID-19.
Therefore current provision of oxygen is as per current arrangements
(using a Part A HOOF on https://www.airliquidehomehealth.co.uk/hcp/HOOFA )
and criteria for use.
BTS guidance should be followed.
- The BSW Primary Care model and guide during COVID-19 (Patient aged >12) states that if a patient with suspected COVID-19 would not benefit from
admission to hospital that the GP can consider Palliative Care/ Home Oxygen
if available & appropriate. GPs should be mindful of oxygen supplies and that
oxygen providers might struggle with demands during this crisis.
- Only institute a home oxygen prescription for patients who are hypoxic
- (sats ≤ 92%), rather than simply those with breathlessness who are not necessarily hypoxic.
- All patients should be given appropriate ‘just in case’ meds (e.g. opiates),
- which may well control their symptoms better than oxygen, even in hypoxic patients. See COVID-19 palliative care guidance
- Local COPD guidance found here; p5 for oxygen information.
Wiltshire Health & Care:
- WH&C staff are only visiting home oxygen patients who are unstable.
- All stable patients have had their time to the next visit extended.
- WH&C are reviewing all their oxygen patients virtually & removing oxygen
- from those considered “non-essential” to help preserve supplies.
BaNES CCG:
- GPs should liaise with the BaNES IMPACT team as usual for all oxygen
- requests.
SFT Respiratory clinic (oxygen):
- No face to face oxygen clinic currently running (no routine patients).
- Telephone advice still available. Patients would be seen if clinically urgent
- but would need to come into the hospital. Dealt with on a case by case basis.
Swindon CCG:
- Routine reviews are not currently happening. Advice can be sought from
- the team for acute problems.
Contacts for oxygen referrals:
BaNES – IMPACT team BATHNES.impactservice@virgincare.co.uk 01225 831 808
Swindon – Community COPD team
gwh.communitycopdoxygenspecialistservices@nhs.net 01793 646436
South Wiltshire
http://www.mg.salisbury.nhs.uk/media/1719/oxygenservicereferral.doc to the
resp. dept. at SFT
North, East and West Wiltshire – referral forms:
https://prescribing.wiltshireccg.nhs.uk/?wpdmdl=653 to Wiltshire
Health and Care community respiratory team GWH.WiltsO2@nhs.net
01249 456607
SECONDARY CARE ONLY
MHRA Alert - important information about High flow Oxygen therapy devices
(including wall CPAP and high flow face mask or nasal oxygen) during COVID-19 epidemic
---------------------------------------------
General Information around prescribing OXYGEN
Home oxygen comes in many forms. Used appropriately it can improve mortality
in selected patients. However, it is often overprescribed and can pose a fire risk to
patients and those around them if used incorrectly.
Home oxygen should not be used to treat acute hypoxia or acute on chronic hypoxia.
If home oxygen does need to be prescribed you will need to complete a Part A Home Oxygen Order Form (HOOF) that will allow a temporary supply of oxygen to be
installed prior to a formal assessment by the community Home Oxygen Assessment Service.
When completing a Part A HOOF you will be asked what type of oxygen equipment
you require:
- Concentrator or static cylinder
- Flow rate required (in litres per minute) – this should be maximum 2 litres
- per minute
- Expected usage (in hours/day) – this should be maximum 16 hours per day
- Consumables required (nasal cannulae or mask) – usually nasal cannulae
When completing a Part A HOOF you will also be asked how quickly you need the
oxygen equipment installed. It is costly to request an urgent (ie 4 hours) installation
so please order ‘next day’ or ‘standard’ installation (ie 3 days).
Please check the patient has someone available to let the provider in to their home to install the oxygen equipment.
The Part A portal can be accessed using: https://www.airliquidehomehealth.co.uk/hcp/portal_a/ The webpage includes a
detailed guide on how to complete the Part A HOOF.
No password is required to complete a Part A HOOF.
Remember - Home oxygen is a fire risk, both to those who use it and to those
who live nearby. Patients who smoke, or have relatives who live with them and
smoke, should not be given home oxygen unless agreed after a detailed
multidisciplinary risk assessment has taken place.
|
|
|
|
https://www.nice.org.uk/guidance/ng115/chapter/Recommendations
Consider mucolytic drug therapy for people with a chronic cough productive of sputum.
Only continue mucolytic therapy if there is symptomatic improvement (for
example, reduction in frequency of cough and sputum production).
Do not routinely use mucolytic drugs to prevent exacerbations in people with
stable COPD. |
|
Carbocisteine
(Oral)
|
Formulary

|
- Capsules 375mg
- Oral liquid 250mg/5ml
- Sachets 750mg/10ml Sugar free oral solution
- Note: liquid must still be used in patients with feeding tubes
|
|
Ivacaftor
(Kalydeco ®)
|
Formulary


|
|
|
03.07 |
Dornase alfa |
|
|
Dornase Alfa
(Pulmozyme®)
(Nebulised)
|
Formulary

|
- 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.
|
NHSE policy Dec 2014: Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis
|
03.07 |
Hypertonic Sodium Chloride |
|
|
Hypertonic Sodium chloride for nebulisation
(MucoClear®, PulmoClear®, Nebusal®)
|
Formulary

|
- Nebuliser solution, sodium chloride 3%, 6%, 7%
- To be started on Specialist respiratory advice only
|
|
|
Mannitol inhalation
(Osmohale ®/Aridol®)
(DPI)
|
Formulary

|
- For inhalation for mannitol bronchial challenge test
|
|
Mannitol inhalation
(Bronchitol ®)
|
Formulary


|
- 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.
|
NHSE Dec 2014: Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis
NICE TA266: Cystic fibrosis - mannitol dry powder for inhalation
|
03.08 |
Aromatic inhalations |
|
|
|
Menthol and Eucalyptus Inhalation BP 1980
|
Formulary

|
|
|
|
|
03.09.01 |
Cough suppressants |
|
|
Pholcodine Linctus, BP
|
Formulary
|
 - BaNES
 - Salisbury
- Non-formulary -Swindon
|
|
03.09.02 |
Expectorant and demulcent cough preparations |
|
|
Simple Linctus, BP
|
Formulary
|

|
|
03.10 |
Systemic nasal decongestants |
|
|
|
Acetylcysteine
(Oral/IV)
|
Formulary

|
- 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
|
NICE CG163 May 17 update: Idiopathic pulmonary fibrosis in adults: diagnosis and management
|
.... |
Non Formulary Items |
Acrivastine

|
Non Formulary
|
|
|
Alimemazine
(Vallergan®)

|
Non Formulary
|
- Please note alimemazine has been removed from formulary,
as it is prohibitively expensive.
- Prescribers are asked to utilise other formulary options.
|
|
Aminophylline
(Phyllocontin Continus®)

|
Non Formulary
|
Removed from formulary Feb 2021 as Manufacture of Phyllocontin® (Aminophylline) 225mg and 350mg MR tablets are being discontinued in the UK with supplies expected to be exhausted by April 2021.
See here for DHSC Supply Disruption Alert for advice on the management of patients currently using this medicine. |
|
Ammonia and Ipecacuanha Mixture BP

|
Non Formulary
|
|
|
Bambuterol
(Bambec®)

|
Non Formulary
|
|
|
Beclometasone
(Easyhaler®)

|
Non Formulary
|
|
|
Bee and Wasp Allergen Extracts
(Pharmalgen®)

|
Non Formulary
|
Highly specialised allergy services and prescribing fall under the
remit of NHSE
https://www.england.nhs.uk/wp-content/uploads/2017/10/prescribed-specialised-services-manual.pdf
(page 172 / 173) |
|
Beractant
(Survanta®)

|
Non Formulary
|
|
|
Bilastine
(Ilaxten®)

|
Non Formulary
|
|
|
Budesonide
(Budelin Novolizer®)

|
Non Formulary
|
|
|
Clemastine
(Tevegil®)

|
Non Formulary
|
|
|
Codeine Linctus BP

|
Non Formulary
|
|
|
Codeine Linctus, Paediatric BP

|
Non Formulary
|
|
|
Codeine Phosphate

|
Non Formulary
|
Injection Only |
|
Conestat Alfa
(Ruconest®)

|
Non Formulary
|
|
|
Cyproheptadine
(Periactin®)

|
Non Formulary
|
|
|
Desloratadine
(Neoclarityn®)

|
Non Formulary
|
|
|
Dextromethorphan / quinidine
(Nuedexta®)

|
Non Formulary
|
|
|
Diphenhydramine
(Nytol® Simply Sleep Hot Chocolate)

|
Non Formulary
|
|
|
Duovent

|
Non Formulary
|
|
|
Ephedrine Hydrochloride

|
Non Formulary
|
|
|
Fenoterol

|
Non Formulary
|
|
|
Fluticasone propionate and formoterol
(Flutiform®)

|
Non Formulary
|
|
|
Fluticasone propionate and salmeterol
(Aerivio®Spiromax)

|
Non Formulary
|
|
|
Formoterol Fumarate
(Atimos® Modulite)

|
Non Formulary
|
|
|
Formoterol Fumarate
(Foradil®)

|
Non Formulary
|
|
|
Grass and Tree Pollen Extract
(Pollinex®)

|
Non Formulary
|
Highly specialised allergy services and prescribing fall under the
remit of NHSE
https://www.england.nhs.uk/wp-content/uploads/2017/10/prescribed-specialised-services-manual.pdf
(page 172 / 173) |
|
Grass pollen extract
(Grazax®)

|
Non Formulary
|
Highly specialised allergy services and prescribing fall
under the remit of NHSE https://www.england.nhs.uk/wp-content/uploads/2017/10/prescribed-specialised-services-manual.pdf
(page 172 / 173)
|
|
House dust mite allergen immunotherapy
(Mitizax®)

|
Non Formulary
|
|
|
Ipratropium

|
Non Formulary
|
|
|
Ipratropium Bromide
(Respontin®)

|
Non Formulary
|
|
|
Karvol

|
Non Formulary
|
|
|
Ketotifen
(Zaditen®)

|
Non Formulary
|
|
|
Levocetirizine
(Xyzal®)

|
Non Formulary
|
|
|
Lumacaftor + Ivacaftor
(Orkambi®)

|
Non Formulary
|
|
NICE TA398: Lumacaftor–ivacaftor for treating cystic fibrosis homozygous for the F508del mutation
|
Mecysteine
(Visclair®)

|
Non Formulary
|
|
|
Mepolizumab
(Nucala®)
(Injection)

|
Restricted


|
- Commissioned by NHS England in accordance with NICE TA431 at specialist centres only.
- Not commissioned from RUH and SFT
|
NICE TA431 : Mepolizumab for treating severe refractory eosinophilic asthma
|
Mizolastine
(Mizollen®)

|
Non Formulary
|
|
|
Mometasone Furoate
(Asmanex®)

|
Non Formulary
|
|
|
Nedocromil
(Tilade® CFC-free inhaler)

|
Non Formulary
|
|
|
Nintedanib
(Ofev®)
(Oral)

|
Restricted


|
- Commissioned by NHS England for idiopathic pulmonary fibrosis as per TA379 via specialist centres only.
- 150mg capsules
|
NICE TA379:Nintedanib for treating idiopathic pulmonary fibrosis
|
Orciprenaline Sulphate
(Alupent®)

|
Non Formulary
|
|
|
Pholcodine
(Galenphol®)

|
Non Formulary
|
|
|
Pholcodine Linctus, Strong, BP

|
Non Formulary
|
|
|
Pirfenidone
(Esbriet®)
(Oral)

|
Restricted


|
- Commissioned by NHS England for idiopathic pulmonary fibrosis as per TA504 via specialist centres only.
|
MHRA DSU Nov 2020 - Pirfenidone (Esbriet): risk of serious liver injury; updated advice on liver function testing
NICE TA504: Pirfenidone for treating idiopathic pulmonary fibrosis
|
Pseudoephedrine Hydrochloride
(Gulpseud®)

|
Non Formulary
|
|
|
Pseudoephedrine Hydrochloride
(Sudafed®)

|
Non Formulary
|
|
|
Reslizumab
(Cinqaero®)
(Injection)

|
Restricted


|
- Commissioned by NHS England in accordance with NICE TA479 at specialist centres only.
- Not commissioned from RUH and SFT
|
NICE TA479: Reslizumab for treating severe eosinophilic asthma
|
Rupatadine
(Rupafin®)

|
Non Formulary
|
|
|
Salbutamol
(Asmasal Clickhaler®)

|
Non Formulary
|
|
|
Salbutamol
(Salamol®Easi-Breathe)

|
Non Formulary
|
|
|
Salbutamol
(Ventmax® SR)

|
Non Formulary
|
|
|
Salbutamol
(Ventolin®)

|
Non Formulary
|
|
|
Salbutamol
(Volmax®)

|
Non Formulary
|
|
|
Simple Linctus, Paediatric BP

|
Non Formulary
|
|
|
Sodium Cromoglicate

|
Non Formulary
|
|
|
Sodium Cromoglicate
(Comogen Easi-Breathe®)

|
Non Formulary
|
|
|
Sodium Cromoglicate
(Intal®)

|
Non Formulary
|
|
|
Theophylline
(Slo-Phyllin®)

|
Non Formulary
|
Removed from formulary Nov 2019 as manufacture of Slo-Phyllin® (Theophylline) 60mg/125mg/500mg capsules has ceased.
See here for MHRA Supply Disruption Alert for advice on the management of patients currently using this medicine. |
|
Zafirlukast
(Accolate®)

|
Non Formulary
|
|
|
|
Key |
|
|
Cytotoxic Drug
|
|
Controlled Drug
|
|
High Cost Medicine
|
|
Cancer Drugs Fund
|
|
NHS England |
|
Homecare |
|
CCG |
|
High Cost Drug Approval System |
|
Traffic Light Status Information
|
|
|