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Royal United Hospitals Bath NHS Foundation Trust
Great Western Hospitals NHS Foundation Trust
Salisbury NHS Foundation Trust
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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...
03.02  Expand sub section  Corticosteroids
 note 

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. 
Beclometasone Dipropionate
(Clenil Modulite®, Soprobec® )
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First Choice
traffic lightGreen
  • 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.

 

 
Beclometasone
(Qvar®, Kelhale®)
View adult BNF View SPC online
First Choice
traffic lightGreen

 

 
Budesonide
(Pulmicort®, Easyhaler®)
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First Choice
traffic lightGreen
  • 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

 

 
Budesonide Nebuliser Suspension
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Formulary
traffic lightGreen

 

  • Respiratory solution 500 micrograms per 2ml, 1mg per 2ml
 
 
Ciclesonide (Alvesco®)
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Formulary
  • Amber 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

 

 
 
Fluticasone propionate
(Flixotide®)
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Formulary
traffic lightGreen
  • 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. 
 
 
03.02.02  Expand sub section  Compound Corticosteroid/ Long acting beta-agonist inhalers
Fluticasone furoate & vilanterol
(Relvar Ellipta®)
(DPI)
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First Choice
traffic lightGreen

 

  • 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

 

 
Beclometasone and formoterol
(Fostair®)
(pMDI)
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First Choice
traffic lightGreen
  • First choice ICS/LABA pMDI for asthma and COPD and the only licensed pMDI for COPD
  • Aerosol inhalation MDI 120 dose unit beclometasone100 micrograms, formoterol 6 micrograms dose andbeclometasone 200 micrograms, formoterol 6 micrograms dose 

  • Adults over 18 years only. (dose = 1-2 puffs twice daily,max 4 puffs twice daily) 
 
Beclometasone and formoterol
(Fostair NEXThaler®)
(DPI)
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First Choice
traffic lightGreen
  • 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
 
Budesonide and formoterol
(Fobumix Easyhaler®)
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First Choice
traffic lightGreen
  • 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

 

 
Budesonide and formoterol
(DuoResp Spiromax®)
(DPI)
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Formulary
traffic lightGreen
  • 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

 

 
 
Budesonide and formoterol
(Symbicort®)
(DPI)
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Formulary
traffic lightGreen
  • 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;

 

 
 
Fluticasone propionate and salmeterol
( Seretide Accuhaler®)
(DPI)
View adult BNF View SPC online
Formulary
  • Green  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. 

 

 
 
Fluticasone propionate and salmeterol
(Sirdupla®, Airflusal®,Seretide®)
(pMDI)
View adult BNF View SPC online
Formulary
  • Green 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.  
 
 
03.02.03  Expand sub section  Triple Therapy products for COPD
Formoterol fumarate, beclometasone dipropionate and glycopyrronium bromide
(Trimbow®)
(pMDI)
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Formulary
traffic lightGreen
  • 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. 
 
 
Vilanterol, fluticasone furoate and umeclidinium
(Trelegy®)
(DPI)
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Formulary
traffic lightGreen
  • 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.

 

 

 
 
 ....
 Non Formulary Items
Beclometasone
(Easyhaler®)

View adult BNF View SPC online
Non Formulary
 
Budesonide
(Budelin Novolizer®)

View adult BNF View SPC online
Non Formulary
 
Fluticasone propionate and formoterol
(Flutiform®)

View adult BNF View SPC online
Non Formulary
 
Fluticasone propionate and salmeterol
(Aerivio®Spiromax)

View adult BNF View SPC online
Non Formulary
 
Mometasone Furoate
(Asmanex®)

View adult BNF View SPC online
Non Formulary
 
Zafirlukast
(Accolate®)

View adult BNF View SPC online
Non Formulary
 
  
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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