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3. Respiratory System

CD&D COPD Treatment Guide – Jan 2017

CD&D Adult Asthma Inhaler Guide – July 2018

CD&D Paediatric Asthma Guideline - March 2019

COPD Rescue Medication Plan

Procedural Guidance for Recommending the Issue of Rescue Medication for COPD Exacerbations

Tees CCGs Adult Asthma Treatment Guide

Tees CCGs COPD Treatment Guide

Tees CCGs Stopping Inhaled Corticosteroids in Patients With COPD With FEV1 > 50% Predicted or Gold Group A or B

NICE TA38 - Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years)

NICE TA10 - Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma

NICE NG9 - Bronchiolitis in children

NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management

MHRA Drug Safety Update (July 2018): Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

CD&D Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

NHS England Guidance on “Conditions for which over the counter items should not routinely be prescribed” available at: https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/

Conditions for which over the counter items should not routinely be prescribed in primary care: exception criteria

Prescribing of medicines available to purchase over the counter for self-care

Self-Care and Medicines Available Over The Counter (OTC)

Common medicines available to purchase over the counter (OTC) for minor illnesses and self-limiting conditions

CD&D COPD Treatment Guide – Jan 2017

CD&D Adult Asthma Inhaler Guide – July 2018

CD&D Paediatric Asthma Guideline - March 2019

COPD Rescue Medication Plan

Procedural Guidance for Recommending the Issue of Rescue Medication for COPD Exacerbations

Tees CCGs Adult Asthma Treatment Guide

Tees CCGs COPD Treatment Guide

Tees CCGs Stopping Inhaled Corticosteroids in Patients With COPD With FEV1 > 50% Predicted or Gold Group A or B

Choice of inhaler device should be dependent on patient ability to use. Metered dose inhalers (MDI) +/- spacer remain the first choice for most patients. Alternative devices such as automatic inhalers and Turbohalers® should be chosen based on availability for the type of drug to be prescribed, the patient’s ability to use and cost.

Salbutamol
BNF | BNFC | SPC

Aerosol inhaler - 100micrograms/metered dose

Breath actuated inhaler - 100micrograms/metered inhalation

Dry powder inhaler - 200micrograms/dose (Accuhaler)

Nebuliser solution 2.5mg, 5mg - 2.5mg nebules recommended for COPD as 5mg have no additional benefit

500 mcg in 1ml & 5mg in 5ml injections - parenteral use is rarely indicated

Terbutaline
BNF | BNFC | SPC

Dry Powder Inhaler - 500micrograms/metered dose (Turbohaler)

Salbutamol Injection
BNF | BNFC | SPC

500 mcg in 1ml & 5mg in 5ml injections

Drug protocols: (CDDFT intranet access only)

Paediatric IV loading dose

Paediatric IV infusion maintenance dose

Terbutaline Injection
BNF | BNFC | SPC

0.5mg/ml injection

Terbutaline Nebules
BNF | BNFC | SPC

2.5mg/ml nebuliser solution

Can be used if patient intolerant of salbutamol. 

Formoterol
BNF | BNFC | SPC

Dry Powder for inhalation - 12microgram / metered inhalation

Salmeterol
BNF | BNFC | SPC

Aerosol Inhaler - 25micrograms/metered inhalation

Dry Powder Inhaler - 50micrograms/dose(Accuhaler)

Olodaterol
BNF | BNFC | SPC

Stiverdi respimat

Choice of inhaler device should be dependent on patient ability to use

Tiotropium (Braltus)
BNF | BNFC | SPC

Tiotropium Braltus 10 microgram per delivered dose inhalation powder, hard capsule

For use in COPD.

MHRA Drug Safety Update (May 2018): Braltus (tiotropium): risk of inhalation of capsule if placed in the mouthpiece of the inhaler

Spiriva Respimat (Tiotropium)
BNF | BNFC | SPC

Solution for inhalation - 2.5micrograms/metered dose (Respimat)                                                              

MHRA Drug Safety Update (Feb 2015): Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial

Tiotropium Respimat® - For use in asthma should only be prescribed by or on the advice of a respiratory specialist. For used in COPD see local COPD guidelines

Eklira Genuair (Aclidinium)▼
BNF | BNFC | SPC

Inhalation powder - 375micrograms per dose (as aclidinium bromide) delivers 322micrograms aclidinium per dose

 

Incruse Ellipta (Umeclidinium)▼
BNF | BNFC | SPC

Incruse Ellipta® umeclidinium 55 mcg per puff

Seebri Breezhaler (Glycopyrronium Bromide)▼
BNF | BNFC | SPC

Inhalation powder, hard capsules -  44microgram (as Glycopyrronium)

Second line use in COPD when intolerant of Tiotropium

Ipratropium Nebules
BNF | BNFC | SPC

Nebuliser solution - 250micrograms/ml

Choice of inhaler device should be dependent on patient ability to use.
Combination inhalers should be prescribed by brand name to avoid confusion.

Anoro Ellipta (umeclidinium/vilanterol)▼
BNF | BNFC | SPC

Ellipta® breath actuated DPI
vilanterol 22 mcg/umeclidinium 55 mcg per puff

Duaklir Genuair (aclidinium/formoterol)▼
BNF | BNFC | SPC

Dry powder inhaler - 340micrograms/12micrograms per metered dose

Spiolto Respimat (tiotropim/olodaterol)▼
BNF | BNFC | SPC

Solution for inhalation - 5micrograms/2.5 microgram per metered dose        

 

Ultibro Breezhaler (glycopyrronium/indacaterol)▼
BNF | BNFC | SPC

Breezhaler® breath actuated DPI
indacaterol 85 mcg/glycopyrronium 43 mcg per puff

Modified release formulations must be prescribed by brand name.
Asthma: consider for patients not controlled on long-acting beta agonist (LABA) plus inhaled corticosteroid - discontinue if no benefit see national guidelines.

First Choice
Theophylline
- Uniphyllin®
- Slo-Phyllin®

Alternatives
Aminophylline

Aminophylline
BNF | BNFC | SPC

MR Tablets - 225mg, 350mg (Phyllocontin Continus)

Must be prescribed by brand (brands are not interchangeable)

Aminophylline has many interactions, check before prescribing new medication. Aminophylline interactions  

Theophylline
BNF | BNFC | SPC

200mg m/r, 300mg m/r & 400mg m/r tablets (Uniphyllin®)
60mg, 125mg & 250mg m/r capsules (Slo-Phyllin®)

Must be prescribed by brand (brands are not interchangeable)

Theophylline has many interactions, check before prescribing new medication. Theophylline interactions  

Aminophylline Injection
BNF | BNFC | SPC

250mg in 10ml injection

COPD: intravenous aminophylline of limited benefit. Injection used in hospital for acute asthma not responding to steroids and continuous inhaled bronchodilators.  NB: plasma levels need to be checked before administration if patient has previously taken theophylline/ aminophylline.

Drug protocols: (CDDFT intranet access only)

Adult loading & maintenance

Paediatric loading dose

Paediatric maintenance dose

Magnesium Sulphate Injection
BNF | BNFC | SPC

For use in Acute Asthma

Drug protocol: paediatric loading dose (CDDFT intranet access only)

MHRA Drug Safety Update (May 2019): Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy

Adults: NICE TA138, Children: NICE TA131

Choice of inhaler device should be dependent on patient ability to use. Metered dose inhalers (MDI) +/- spacer remain the first choice for most patients. Alternative devices such as automatic inhalers and Turbohalers® should be chosen based on availability for the type of drug to be prescribed, the patient’s ability to use and cost.

MHRA Drug Safety Update (Aug 2017): Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration

CD&D COPD Treatment Guide – Jan 2017

CD&D Adult Asthma Inhaler Guide – July 2018

CD&D Paediatric Asthma Guideline - March 2019

COPD Rescue Medication Plan

Procedural Guidance for Recommending the Issue of Rescue Medication for COPD Exacerbations

Tees CCGs Adult Asthma Treatment Guide

Tees CCGs COPD Treatment Guide

Tees CCGs Stopping Inhaled Corticosteroids in Patients With COPD With FEV1 > 50% Predicted or Gold Group A or B

Clenil Modulite (beclomethasone dipropionate)
BNF | BNFC | SPC

Aerosol inhaler - 50microgram/ 100microgram, 250microgram/ metered dose

Clenil modulite is not interchangeable with other CFC free inhalers and should be prescribed by brand

 

Qvar (Beclometasone Dipropionate)
BNF | BNFC | SPC

Aerosol inhaler - 50microgram/ 100microgram metered dose

Breath actuated inhaler - 50micrograms/ 100microgram metered dose (Autohaler, Easibreathe)

QVAR is not interchangeable with other CFC free inhalers and should be prescribed by brand

N.B. CFC-Free beclometasone must be prescribed by Brand Name. 50 microgram QVAR is equivalent to 100 microgram for a conventional inhaler & 100 microgram is equivalent to 250 microgram conventional beclometasone.

Budesonide
BNF | BNFC | SPC

Dry Powder Inhaler - 100microgram, 200microgram, 400microgram/metered dose (Easyhaler, Turbohaler)

Ciclesonide
BNF | BNFC | SPC
Fluticasone
BNF | BNFC | SPC

Aerosol Inhaler 50microgram, 125microgram/metered dose

Dry Powder Inhaler 50microgram, 100microgram, 250microgram/metered dose (Accuhaler)

Combination inhalers should be prescribed by brand name to avoid confusion.

DuoResp Spiromax (formoterol/budesonide)
BNF | BNFC | SPC

Dry Powder Inhaler - 160 μg / 4.5 μg, 320 μg / 9 μg

Only For Adults aged 18years or older

Flutiform (fluticasone/formoterol)
BNF | BNFC | SPC

MDI = 50/5 microgram, 125/5 microgram, 250/10 microgram

Flutiform: approved for treatment of asthma

Fobumix (budesonide / formoterol)
BNF | BNFC | SPC

Easyhaler 80/4.5, 160/4.5, 320/9 microgram

Fostair (beclometasone/formoterol)
BNF | BNFC | SPC

Aerosol Inhalation - 100/6micrograms, 200/6 micrograms

 

Fostair Nexthaler (beclometasone/formoterol)
BNF | BNFC | SPC

DPI (Fostair NEXThaler®)
formoterol 6mcg / beclometasone dipropionate 100mcg
formoterol 6mcg / beclometasone dipropionate 200mcg
- N.B. 100 mcg of beclometasone in Fostair® is equivalent to a 250 mcg dose in a conventional beclometasone metered dose inhaler (e.g. Becloforte, Beclazone and Clenil Modulite).

Fostair Nexthaler: approved for treatment of asthma and Fostair 100/6 NEXThaler approved for use in COPD.

Relvar Ellipta (fluticasone/vilanterol)▼
BNF | BNFC | SPC

Dry Powder Inhaler - 92microgram, 22microgram

Sereflo (Fluticasone / Salmeterol)
BNF | BNFC | SPC

pMDI 125/25 and 250/25 mcg

Sirdupla (fluticasone/salmeterol)
BNF | BNFC | SPC

MDI - 125/25 microgram, 250/25 microgram

Sirdupla: approved for treatment of asthma

Symbicort (formoterol/budesonide)
BNF | BNFC | SPC

Dry Powder Inhaler - 6/100microgram, 6/200microgram, 12/400microgram/metered dose (turbohaler)

COPD: for use in existing patients only, not for newly initiated patients

Seretide
BNF | BNFC | SPC

Combination inhalers should be prescribed by brand name to avoid confusion.

Trimbow
BNF | BNFC | SPC

Formoterol fumarate dihydrate 5 microgram, beclometasone dipropionate 87 microgram, glycopyrronium (as bromide) 9 microgram per puff MDI

Trelegy Ellipta
BNF | BNFC | SPC

Vilanterol (as trifenatate)/fluticasone furoate/umeclidinium (as bromide)
22 microgram/92 microgram/55 microgram per inhalation,
Breath-actuated dry powder inhaler.

Montelukast
BNF | BNFC | SPC

Tablets - 10mg 

Chewable Tablets - 4mg, 5mg 

Granules - 4mg 

Review treatment after 6 weeks of initiation and discontinue if no evidence of improvement.

Roflumilast▼
BNF | BNFC | SPC

500 microgram tablets

As per NICE TA461

First choice
Non-sedating:
Cetirizine
Loratadine
Levocetirizine


Sedating:
Chlorphenamine

Alternatives
Non-Sedating:
Desloratadine
Fexofenadine

Sedating:
Hydroxyzine
Promethazine
Alimemazine

CD&D APC Grey List: Hay fever symptoms can be self-treated and do not need intervention by a GP or
practice nurse. A community pharmacist can support with advice and guidance.
Several products have now been declassified and are available to purchase over the counter for less than the cost of a prescription charge. Continue to prescribe for children or patients with chronic allergic conditions although patients should be reminded that these medications are also available to purchase.

Alimemazine tartrate
BNF | BNFC | SPC

Tablets - 10mg

Liquid - 7.5mg/5ml

Sedating

Cetirizine
BNF | BNFC | SPC

Tablets - 10mgOTC

Liquid - 5mg/5ml OTC

Chlorphenamine
BNF | BNFC | SPC

Tablets - 4mgOTC

Liquid - 2mg/5mlOTC

10mg in 1ml injection

Fexofenadine
BNF | BNFC | SPC

Tablets - 120mg, 180mg

Hydroxyzine hydrochloride
BNF | BNFC | SPC

Tablets - 10mg, 25mg

Liquid - 10mg/5ml

See MHRA Drug Safety Update (April 2015): Hydroxyzine (Atarax, Ucerax): risk of QT interval prolongation and Torsade de Pointes

Levocetirizine
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Loratadine
BNF | BNFC | SPC

Tablets - 10mgOTC

Liquid - 5mg/5ml OTC

Benralizumab▼
BNF | BNFC | SPC

30mg solution for injection in prefilled syringe

Approved for use in accordance with the following NICE TAs:

  • NICE TA565: Benralizumab for treating severe eosinophilic asthma

 

Grazax
BNF | BNFC | SPC

Grass pollen extract 75,000 units oral lyophilisates
(freeze-dried tablets)

Mepolizumab▼
BNF | BNFC | SPC

100 mg powder for solution for injection

For specialist use in the treatment of severe asthma in adults  as per NICE TA431

Omalizumab
BNF | BNFC | SPC

150mg injection & 75mg & 150mg prefilled syringes

Commissioner: NHS England

Approved for use in accordance with the following NICE TAs

  • NICE TA278: Omalizumab for treating severe persistent allergic asthm
  • NICE TA339: Omalizumab for previously treated chronic spontaneous urticaria
Pharmalgen
BNF | BNFC | SPC

Bee and Wasp Allergen Extracts

Reslizumab▼
BNF | BNFC | SPC

10mg/ml conc for soln for inf in vial. 2.5ml and 10ml vials

NICE TA479 Reslizumab for treating severe eosinophilic asthma

Adrenaline auto-injection device
BNF | BNFC | SPC

Jext 150microgram autoinjector

Jext 300microgram autoinjector

Emerade 500microgram autoinjector - Specialist immunologist initiation only. Approved for use in the emergency treatment of anaphylaxis for patients with a BMI of >40 or who have required more than one auto-injector previously to control symptoms. Specialist immunologist initiation only

Jext is the preferred intramuscular device for self-injection, but Epipen remains an option.

Oct 2018 - during the current supply issues Jext, Epipen, and Emerade 150microgram and 300microgram autoinjectors are on the formulary. See advice from DHSC: 

https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102802

 

It is recommended that 2 adrenaline auto-injectors are prescribed, which patients should carry at all times

MHRA Safety Alert (May 2014): always call an ambulance after use of an adrenaline auto-injector

MHRA Drug Safety Update (Aug 2017): Adrenaline auto-injectors: updated advice after European review

 

C1 Esterase Inhibitor
BNF | BNFC | SPC

500 IU powder and solvent for solution for injection

See Letter Sent to Healthcare Professionals (June 2017) - Cinryze▼ (C1 esterase inhibitor [human]): recommendations to prescribers in view of a potential supply shortage

Conestat Alfa
BNF | BNFC | SPC
Icatibant
BNF | BNFC | SPC

30mg in 3ml injection

Commissioner: NHS England - Policy - B09/P/b

Doxapram
BNF | BNFC | SPC

2mg per ml 500ml infusion, 100mg in 5ml injection

Caffeine Citrate
BNF | BNFC | SPC

50mg in 5ml injection (equivalent to 25mg caffeine base in 5ml [5mg caffeine base/ ml])u
50mg in 5ml oral solutionu

MHRA Drug Safety Alert (Aug 2013): Caffeine citrate - standardisation of name for prescribing to reduce error risk

Drug protocol: Neonatal respiratory stimulant (CDDFT intranet access only)

Poractant Alfa
BNF | BNFC | SPC

120mg in 1.5ml & 240mg in 3ml vials (Curosurf®)

Commissioner: NHS England

Drug protocol: neonatal (CDDFT intranet access only)

Beractant
BNF | BNFC | SPC

25mg/ml suspension for intratracheal administration

Carbocisteine
BNF | BNFC | SPC

Capsules - 375mg

Liquid - 250mg/5ml

750mg/10ml sugar-free oral solution in sachet

For COPD patients in accordance with local guidelines

Acetylcysteine
BNF | BNFC | SPC

600mg plain and effervescent tabletsu

For use on specialist advice in the treatment of idiopathic pulmonary fibrosis and for the prevention of x-ray contrast media induced renal damage.

Injection can be used in a Nebuliser
Renal protection prior to administration of contrast media. Injection can be used orally

Sodium Chloride 7% solution for nebulisation
BNF | BNFC | SPC

7% solution for nebulisation (Nebusal®)

Initiated by respiratory specialists or on ITU.

Dornase alfa
BNF | BNFC | SPC

2.5mg in 2.5ml solution for nebulisation

Commissioner: NHS England - NICE TA276, Policy - A01/PS/a

Ivacaftor
BNF | BNFC | SPC

150mg film coated tablets

Commissioner: NHS England - Policy - A01/P/b

Mannitol
BNF | BNFC | SPC

40mg capsules for inhalation

Commissioner: NHS England - NICE TA266

Lumacaftor-Ivacafor▼
BNF | BNFC | SPC

Not approved, see NICE TA398

Pirfenidone
BNF | BNFC | SPC

267mg capsules

267mg, 534mg, 801mg film coated tablets

Commissioner: NHS England 

Approved for use in accordance with the following NICE TAs

  • NICE TA504: Pirfenidone for treating idiopathic pulmonary fibrosis
Flutter Device
BNF | BNFC | SPC