| 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... |
| 03.01 |
Bronchodilators |
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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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| 03.01.03 |
Theophylline |
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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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| .... |
| Non Formulary Items |
Aminophylline
(Phyllocontin Continus®)
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Non Formulary
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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. |
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Bambuterol
(Bambec®)
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Non Formulary
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Duovent
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Non Formulary
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Ephedrine Hydrochloride
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Non Formulary
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Fenoterol
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Non Formulary
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Formoterol Fumarate
(Atimos® Modulite)
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Non Formulary
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Formoterol Fumarate
(Foradil®)
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Non Formulary
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Ipratropium
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Non Formulary
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Ipratropium Bromide
(Respontin®)
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Non Formulary
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Nedocromil
(Tilade® CFC-free inhaler)
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Non Formulary
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Orciprenaline Sulphate
(Alupent®)
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Non Formulary
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Salbutamol
(Asmasal Clickhaler®)
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Non Formulary
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Salbutamol
(Salamol®Easi-Breathe)
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Non Formulary
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Salbutamol
(Ventmax® SR)
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Non Formulary
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Salbutamol
(Ventolin®)
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Non Formulary
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Salbutamol
(Volmax®)
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Non Formulary
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Sodium Cromoglicate
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Non Formulary
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Sodium Cromoglicate
(Comogen Easi-Breathe®)
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Non Formulary
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Sodium Cromoglicate
(Intal®)
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Non Formulary
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Theophylline
(Slo-Phyllin®)
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Non Formulary
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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. |
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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High Cost Drug Approval System |
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Traffic Light Status Information
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