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 Formulary Chapter 3: Respiratory system - Full Chapter
Notes:

Respiratory-related Prescribing Guidance

Please see our Prescribing Guidelines page for all prescribing guidance relating to this chapter.

Respiratory-related Shared Care Agreements

Please see our Shared Care Agreements page for all shared care agreements (SCAs) relating to this chapter.

National guidance - The Respiratory Chapter should be read in conjunction with BTS guidelines , BTS/SIGN Asthma Guidelines  and NICE guidelines on COPD and Asthma

Guidance on inhaler devices 

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/

Chapter Links...
 Details...
03.01  Expand sub section  Bronchodilators
03.01.01  Expand sub section  Adrenoceptor agonists
03.01.01.01  Expand sub section  Selective Beta2 agonists
03.01.01.01  Expand sub section  Short-acting beta2 agonists
Salbutamol
(Ventolin ,Easyhaler,Salamol Easi-Breathe)
View adult BNF View SPC online
First Choice
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  • Ventolin Evohaler® is first line pMDI short-acting betaagonist
  • Salbutamol Easyhaler® is the first line DPI short-acting betaagonist
  • Aerosol inhalation MDI 100 micrograms/dose
  • Dry powder for inhalation MDI 100 micrograms/dose
  • Ventolin Accuhaler® and Salamol Easi-Breathe® existing patients only. 

   

 
Salbutamol IV
View adult BNF View SPC online
Formulary
traffic lightRed
  • Injection 500 micrograms/1ml
  • Solution for IV infusion 5mg in 5ml   
 
 
Salbutamol Nebuliser Solution
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 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
 
 
Terbutaline
(Bricanyl Turbohaler)
View adult BNF View SPC online
Formulary
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  • Turbohaler dry powder inhaler MDI 500 micrograms/dose
 
 
Terbutaline IV
View adult BNF View SPC online
Formulary
traffic lightRed
  • Injection 500 micrograms/ml, 2.5mg/5ml
 
 
Terbutaline Nebuliser Solution
View adult BNF View SPC online
Formulary
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  • Consider if intolerant of salbutamol or uses terbutaline turbohaler. 
  • Respules 2.5mg/ml

 

 
 
03.01.01.01  Expand sub section  Long-acting beta2 agonists to top
 note 

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. 

Salmeterol (Serevent)
(pMDI and DPI)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 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
 
 
Formoterol
(Oxis Turbohaler)
View adult BNF
Formulary
traffic lightGreen
  • 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.

 

 
 
Indacaterol
(Onbrez Breezhaler)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • No new prescribing. Existing patients only - see notes above.
  • Inhalation powder, hard capsule 150, 300 micrograms (via Onbrez Breezhaler® device)

 

 

 
 
Olodaterol
(Striverdi Respimat)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • No new prescribing. Existing patients only - see notes above.
  • The delivered dose is 2.5 microgram Olodaterol (as hydrochloride) per actuation.

 

 
 
03.01.01.02  Expand sub section  Other adrenoceptor agonists
03.01.02  Expand sub section  Antimuscarinic bronchodilators
Tiotropium
(Braltus Zonda)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • 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.

 

 

 
Tiotropium
(Spiriva Respimat)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • 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.

 

 
Aclidinium
(Eklira Genuair)
View adult BNF View SPC online
Second Choice
traffic lightGreen
  • For patients with manual dexterity problems or an eGFR<30ml/min. 
  • Inhalation powder 322 microgram/dose aclidinium

 

 

 

 
 
Glycopyrronium
(Seebri breezhaler)
View adult BNF View SPC online
Second Choice
traffic lightGreen
  • 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.

 

 
 
Umeclidinium
(Incruse Ellipta)
View adult BNF View SPC online
Third Choice
traffic lightGreen
  • 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.

 

 

 

 
 
Ipratropium Bromide
(Atrovent)
(Short-acting (SAMA))
View adult BNF View SPC online
Formulary
traffic lightGreen
  •  Inhaler 20 micrograms/dose

 

 
 
Ipratropium Bromide Nebuliser Solution
(Ipratropium Steri-Neb)
View adult BNF View SPC online
Formulary
traffic lightGreen

 

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

 

 
 
03.01.03  Expand sub section  Theophylline
 note 

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. 

Aminophylline IV
View adult BNF View SPC online
Formulary
traffic lightRed
  • Aminophylline Injection 250 mg/10ml
  • For selected patients with acute severe asthma or severe exacerbations of COPD.
 
 
Theophylline
(Uniphyllin Continus)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 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.
 
 
03.01.04  Expand sub section  Compound bronchodilator preparations
 note 

 

Compound broncodilator preparations are considered to have no place in the management of patients with asthma.

NICE COPD guideline NG115 recommends: 

Offer LAMA+LABA[2] to people who:

  • have spirometrically confirmed COPD and

  • do not have asthmatic features/features suggesting steroid responsiveness and

  • remain breathless or have exacerbations despite:

     

    • having used or been offered treatment for tobacco dependence if they smoke and

    • optimised non-pharmacological management and relevant vaccinations and

    • using a short-acting bronchodilator. [2018]

Aclidinium and formoterol inhaler
(Duaklir Genuair )
(LABA/LAMA)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Combination of Formoterol fumarate / Aclidinium (as bromide)
  • Breath actuated dry powder MDI 12/340 Genuair device

 

 
 
Glycopyrrolate/ indacaterol inhaler
(Ultibro Breezhaler)
(LABA/LAMA)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 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

 

 

 
 
Tiotropium & olodaterol
(Spiolto Respimat)
(LABA/LAMA)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Combination of Tiotropium (bromide monohydrate) / Olodaterol (hydrochloride)
  • Respimat device tiotropium 2.5micrograms / olodaterol 2.5micrograms per inhalation

 

 

 
 
Umeclidinium & vilanterol
(Anoro Ellipta)
(LABA/LAMA)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Combination of Vilanterol (as trifenatate) / Umeclidinium bromide
  • Ellipta device vilanterol 22micrograms / umeclidinium 55micrograms per inhalation

 

 

 

 
 
Ipratropium bromide with salbutamol
(Combivent)
(SABA/SAMA)
View adult BNF View SPC online
Formulary
traffic lightGreen

 

  • 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.

 

 
 
03.01.05  Expand sub section  Peak flow meters, inhaler devices and nebulisers to top
 note 

Rightbreathe website (compatibility and cleaning instructions)

03.01.05  Expand sub section  Peak flow meters
Standard range peak flow meter
(Mini-Wright)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Available as low range peak flow meter and standard range peak flow meter. 
 
 
03.01.05  Expand sub section  Drug delivery devices
AeroChamber Plus
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Aerochamber Plus standard with mask cannot be used without the mask.
  • Please prescribe standard device with mouthpiece if the mask is not required.
 
 
Volumatic
View adult BNF View SPC online
Formulary
traffic lightGreen
 
 
03.01.05  Expand sub section  Nebuliser Diluent
Sodium Chloride
View adult BNF View SPC online
Formulary
  • Nebuliser solution 0.9% 2.5ml
 
 
 ....
 Non Formulary Items
Aminophylline
(Phyllocontin Continus)

View adult BNF View SPC online
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. 

 
Bambuterol (Bambec)

View adult BNF View SPC online
Non Formulary
 
Duovent

View adult BNF View SPC online
Non Formulary
 
Ephedrine Hydrochloride

View adult BNF View SPC online
Non Formulary
 
Fenoterol

View adult BNF View SPC online
Non Formulary
 
Formoterol Fumarate
(Atimos Modulite)

View adult BNF View SPC online
Non Formulary
 
Formoterol Fumarate
(Foradil®)

View adult BNF View SPC online
Non Formulary
 
Ipratropium

View adult BNF View SPC online
Non Formulary
 
Ipratropium Bromide
(Respontin)

View adult BNF View SPC online
Non Formulary
 
Nedocromil
(Tilade® CFC-free inhaler)

View adult BNF View SPC online
Non Formulary
 
Orciprenaline Sulphate
(Alupent®)

View adult BNF View SPC online
Non Formulary
 
Salbutamol
(Asmasal Clickhaler®)

View adult BNF View SPC online
Non Formulary
 
Salbutamol
(Salamol®Easi-Breathe)

View adult BNF View SPC online
Non Formulary
 
Salbutamol
(Ventmax® SR)

View adult BNF View SPC online
Non Formulary
 
Salbutamol
(Ventolin®)

View adult BNF View SPC online
Non Formulary
 
Salbutamol (Volmax®)

View adult BNF View SPC online
Non Formulary
 
Sodium Cromoglicate

View adult BNF View SPC online
Non Formulary
 
Sodium Cromoglicate
(Comogen Easi-Breathe®)

View adult BNF View SPC online
Non Formulary
 
Sodium Cromoglicate
(Intal®)

View adult BNF View SPC online
Non Formulary
 
Theophylline
(Slo-Phyllin)

View adult BNF View SPC online
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.

 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG
Blueteq
High Cost Drug Approval System

Traffic Light Status Information

Status Description

Traffic LightRed

RED - Hospital only to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.  

Traffic LightAmber

Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.  

Traffic LightAmber with Shared Care

Shared Care - these medicines require specialist initiation and stabilisation. Ongoing division of responsibility for drug and disease monitoring between specialist and GP by a Shared Care Guideline (SCG). If no SCG in place status reverts to red.  

Traffic LightGreen

These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.  

Traffic LightSelf

Suitable for patient to be directed to buy themselves  

Traffic LightGrey

Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.   

Traffic LightBlack

(In use from Oct 2020) Used where a decision has been made by the BSW APC not to routinely commission this preparation for its licensed indications. Do not prescribe.   

Traffic LightRed Specialist Centre

Not currently used. We intend to include this TLS in future to highlight where this medicine and indication is ONLY available through a Specialist Centre according to a NICE Highly Specialised Technology or NHSE Specialised Commission Circular / Policy.  

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