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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...
03.04  Expand sub section  Antihistamines, hyposensitisation, and allergic emergencies
03.04.01  Expand sub section  Antihistamines
 note 

Please note other specialities may require other preparations for specific uses eg sedation in children. Refer to CNS chapter 4 and Skin chapter 13

Self Many of the products in this section are available to 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 NHS England:Conditions for which over-the-counter items should not be routinely prescribed in primary care 2018

SPS article - which medicines can be used to treat intermittent allergic rhinitis during pregnancy

03.04.01  Expand sub section  Non-sedating antihistamines
Cetirizine
(Oral)
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First Choice
traffic lightGreen
  • Self Self Care Medicine for primary care.
  • Tablets 10mg
  • Oral solutionSF 5mg in 5ml
 
Loratadine
(Oral)
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First Choice
traffic lightGreen
  • Self Self Care Medicine for primary care.
  • Tablets 10mg
  • Oral solution 5mg in 5ml
 
Fexofenadine
(Oral)
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Formulary
traffic lightGreen
  • 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.

 

 
 
03.04.01  Expand sub section  Sedating antihistamines
Chlorphenamine
(Oral/Injection)
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First Choice
traffic lightSelf

 

  • Tablets 4mg
  • Oral solution 2mg/5ml
  • Injection 10mg/ml
 
Hydroxyzine
(Oral)
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Formulary
traffic lightGreen
  • 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.

 
Link  Anticholinergic medicines (information leaflet for patients)
 
Promethazine
(Phenergan®)
(Oral)
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Formulary
traffic lightGreen
  • Tablets 10mg, 25mg
  • Oral Solution 5mg/5ml 100ml
 
Link  Anticholinergic medicines (information leaflet for patients)
 
03.04.02  Expand sub section  Allergen Immunotherapy to top
03.04.02  Expand sub section  Omalizumab
Omalizumab (Xolair®)
(Injection: uncontrolled asthma)
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Restricted Drug Restricted
traffic lightRed
High Cost Medicine
NHS England
BlueTeq

 

  • 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.
 
Link  MHRA Dec 2014: Omalizumab: potential risk of arterial thrombotic events
Link  NICE TA278: Omalizumab for treating allergic asthma
 
03.04.03  Expand sub section  Allergic emergencies
03.04.03  Expand sub section  Anaphylaxis
Adrenaline / epinephrine
(EpiPen® Jext® )
(for IM self administration)
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Formulary
traffic lightGreen

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. 
 
Link  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
Link  October 2019 - Adrenaline auto-injectors: MHRA Summary of recent action taken to support safety
Link   Resuscitation Council anaphylaxis guidelines
Link  MHRA Patient Info Leaflet - Adrenaline auto-injectors and advice on use
Link  NICE CG134: Anaphylaxis: Assessment and referral after emergency treatment
Link  Epipen - Risk minimisation education materials
Link  Jext - Risk minimisation education materials
 
Adrenaline / Epinephrine
(Adrenaline 1 in 1000)
(Injection ampoules)
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Formulary
traffic lightGreen
 
 
Adrenaline / Epinephrine
(Adrenaline 1 in 1000)
(Injection minijet)
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Formulary
  • Red - GWH
  • Non-formulary - RUH
  • Non-formulary - SFT
 
 
Adrenaline / epinephrine 1 in 10,000
(Injection)
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Formulary
traffic lightRed
  • 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. 
 
 
03.04.03  Expand sub section  Angioedema
C1 esterase inhibitor
(Cinryze® /Berinert®)
(Injection)
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Restricted Drug Restricted
traffic lightRed
High Cost Medicine
NHS England
BlueTeq
  • Injection podwer for reconstitution, 500 unit vial
  • Acute Treatment or Short-term prophylaxis prior to planned procedures for Hereditary Angioedema and Acquired Angioedema

  • In accordance with NHS England commissioning policy
  • May only be initiated by (or on advice of) Specialist Centres
  • Drug costs for emergency use in other hospitals will be reimbursed through the Specialist Centre
  • Prophylactic treatment of hereditary angioedema (HAE) types I and II
  • In accordance with NHS England commissioning policy in patients who fail, are intolerant or have contra-indications to oral prophylactic therapies.
  • May only be supplied by Specialist Centres
  • Prior approval must be given via Blueteq system
 
Link  NHSE policy 2013: Clinical Commissioning Policy: Treatment of Acute Attacks in Hereditary Angiodema (Adult)
Link  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®)
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Restricted Drug Restricted
traffic lightRed
High Cost Medicine
NHS England
BlueTeq
  • 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.

    Restricted Item 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
 
 
 ....
 Non Formulary Items
Acrivastine

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Non Formulary
 
Alimemazine (Vallergan®)

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Non Formulary
  • Please note alimemazine has been removed from formulary,

           as it is prohibitively expensive.

  • Prescribers are asked to utilise other formulary options.
 
Bee and Wasp Allergen Extracts
(Pharmalgen®)

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Non Formulary
NHS England

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)

 
Bilastine (Ilaxten®)

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Non Formulary
 
Clemastine (Tevegil®)

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Non Formulary
 
Conestat Alfa
(Ruconest®)

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Non Formulary
High Cost Medicine
 
Cyproheptadine
(Periactin®)

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Non Formulary
 
Desloratadine
(Neoclarityn®)

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Non Formulary
 
Diphenhydramine
(Nytol® Simply Sleep Hot Chocolate)

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Non Formulary
 
Grass and Tree Pollen Extract
(Pollinex®)

View adult BNF View SPC online
Non Formulary
NHS England

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®)

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Non Formulary
NHS England

 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®)

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Non Formulary
 
Ketotifen (Zaditen®)

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Non Formulary
 
Levocetirizine (Xyzal®)

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Non Formulary
 
Mepolizumab (Nucala®)
(Injection)

View adult BNF View SPC online
Restricted Drug Restricted
Red
High Cost Medicine
NHS England
BlueTeq
  • Commissioned by NHS England in accordance with NICE TA431 at specialist centres only.
  • Not commissioned from RUH and SFT
Link  NICE TA431 : Mepolizumab for treating severe refractory eosinophilic asthma
 
Mizolastine
(Mizollen®)

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Non Formulary
 
Reslizumab (Cinqaero®)
(Injection)

View adult BNF View SPC online
Restricted Drug Restricted
Red
High Cost Medicine
NHS England
BlueTeq
  • Commissioned by NHS England in accordance with NICE TA479 at specialist centres only.
  • Not commissioned from RUH and SFT
Link  NICE TA479: Reslizumab for treating severe eosinophilic asthma
 
Rupatadine (Rupafin®)

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.  

netFormulary