NHS Bath and North East Somerset, Swindon and Wiltshire CCG Royal United Hospitals Bath NHS Foundation Trust Great Western Hospitals NHS Foundation Trust Salisbury NHS Foundation Trust
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.
Cromoglicate, related therapy and leukotriene receptor antagonists
03.03.01
Cromoglicate and related therapy
Please note use of sodium cromoglycate and nedocromil sodium is not recommended.
03.03.02
Leukotriene receptor antagonists
Montelukast (Oral)
Formulary
Granules 4mg sachets sugar-free (6 months to 5 years of age)
Chewable tablets 4mg (2 to 5 years of age)
Chewable tablets 5mg (6 to 14 years of age)
Tablets 10mg (>14 years of age)
NICE guidance (NG80, November 2017) recommends an LTRA as the first add-on maintenance therapy with ICS and SABA inhalers for the treatment in asthma. A LABA is an option (with/without the LTRA) in addition to an ICS if asthma remains uncontrolled. This is a more cost effective model.
Existing BTS/SIGN continues the long-held view that low dose ICS should be followed by addition of LABA (in line with international guidelines such as GINA).
Head to head comparisons of ICS/LABA compared to ICS/LTRA have favoured ICS/LABA for effectiveness in adults (inconclusive in children).
Notes:
Not to be used to relieve an attack of severe acute asthma.
Leukotriene receptor antagonists should be withdrawn if no significant response after 6 weeks
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.
RED - Hospital only – to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.
Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.
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.
These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.
Suitable for patient to be directed to buy themselves
Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.
(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.
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.
