CD&Tees COPD Treatment Guide – July 2020
CD&Tees Adult Asthma Inhaler Guide – July 2020
CD&Tees Paediatric Asthma Guideline - July 2020
Procedural Guidance for Recommending the Issue of Rescue Medication for COPD Exacerbations
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 NG80: Asthma: diagnosis, monitoring and chronic asthma management
NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management
NICE NG166: COVID-19 rapid guideline: severe asthma
NICE NG168: COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD)
NICE NG170: COVID-19 rapid guideline: cystic fibrosis
NICE NG177: COVID-19 rapid guideline: interstitial lung disease
MHRA Drug Safety Update (July 2018): Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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/
Prescribing of medicines available to purchase over the counter for self-care
CD&D COPD Treatment Guide – Jan 2017
CD&D Adult Asthma Inhaler Guide – July 2018
CD&D Paediatric Asthma Guideline - March 2019
Procedural Guidance for Recommending the Issue of Rescue Medication for COPD Exacerbations
Tees CCGs Adult Asthma Treatment Guide
Tees CCGs COPD Treatment Guide
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.
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
500 mcg in 1ml & 5mg in 5ml injections
Drug protocols: (CDDFT intranet access only)
Choice of inhaler device should be dependent on patient ability to use
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
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
Inhalation powder - 375micrograms per dose (as aclidinium bromide) delivers 322micrograms aclidinium per dose
Inhalation powder, hard capsules - 44microgram (as Glycopyrronium)
Second line use in COPD when intolerant of Tiotropium
Choice of inhaler device should be dependent on patient ability to use.
Combination inhalers should be prescribed by brand name to avoid confusion.
Ellipta® breath actuated DPI
vilanterol 22 mcg/umeclidinium 55 mcg per puff
Dry powder inhaler - 340micrograms/12micrograms per metered dose
Solution for inhalation - 5micrograms/2.5 microgram per metered dose
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
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
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
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)
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
Procedural Guidance for Recommending the Issue of Rescue Medication for COPD Exacerbations
Tees CCGs Adult Asthma Treatment Guide
Tees CCGs COPD Treatment Guide
Aerosol inhaler - 50microgram/ 100microgram, 250microgram/ metered dose
Clenil modulite is not interchangeable with other CFC free inhalers and should be prescribed by brand
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.
Dry Powder Inhaler - 100microgram, 200microgram, 400microgram/metered dose (Easyhaler, Turbohaler)
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Combination inhalers should be prescribed by brand name to avoid confusion.
Dry Powder Inhaler - 160 μg / 4.5 μg, 320 μg / 9 μg
Only For Adults aged 18years or older
MDI = 50/5 microgram, 125/5 microgram, 250/10 microgram
Flutiform: approved for treatment of asthma
Aerosol Inhalation - 100/6micrograms, 200/6 micrograms
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.
Dry Powder Inhaler - 92microgram, 22microgram
MDI - 125/25 microgram, 250/25 microgram
Sirdupla: approved for treatment of asthma
Dry Powder Inhaler - 6/100microgram, 6/200microgram, 12/400microgram/metered dose (turbohaler)
COPD: for use in existing patients only, not for newly initiated patients
Combination inhalers should be prescribed by brand name to avoid confusion.
Formoterol fumarate dihydrate 5 microgram, beclometasone dipropionate 87 microgram, glycopyrronium (as bromide) 9 microgram per puff MDI
Tablets - 10mg
Chewable Tablets - 4mg, 5mg
Granules - 4mg
Review treatment after 6 weeks of initiation and discontinue if no evidence of improvement.
MHRA Drug Safety Update (Sept 2019): Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions
First choice
Non-sedating:
Cetirizine
Loratadine
Sedating:
Chlorphenamine
Alternatives
Non-Sedating:
Fexofenadine
Sedating:
Hydroxyzine
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.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
30mg solution for injection in prefilled syringe
Approved for use in accordance with the following NICE TAs:
Grass pollen extract 75,000 units oral lyophilisates
(freeze-dried tablets)
100 mg powder for solution for injection
For specialist use in the treatment of severe asthma in adults as per NICE TA431
150mg injection & 75mg & 150mg prefilled syringes
Commissioner: NHS England
Approved for use in accordance with the following NICE TAs
10mg/ml conc for soln for inf in vial. 2.5ml and 10ml vials
NICE TA479 Reslizumab for treating severe eosinophilic asthma
300mg/2ml soln for inj in pre-filled syringe
Not approved in accordance with the following NICE TAs:
Commissioner: CCG
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
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
300 mg solution for injection
Approved for use in accordance with the following NICE TAs:
Commissioner: NHS England
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)
Capsules - 375mg
Liquid - 250mg/5ml
750mg/10ml sugar-free oral solution in sachet
For COPD patients in accordance with local guidelines
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
7% solution for nebulisation (Nebusal®)
Initiated by respiratory specialists or on ITU.
2.5mg in 2.5ml solution for nebulisation
Commissioner: NHS England - NICE TA276, Policy - A01/PS/a
150mg film coated tablets
Commissioner: NHS England - Policy - A01/P/b
Approved as per NHSE Clinical Commissioning Urgent Policy Statement: Cystic Fibrosis Modulator Therapies NHS England URN: 190137P
267mg capsules
267mg, 534mg, 801mg film coated tablets
Commissioner: NHS England
Approved for use in accordance with the following NICE TAs