| Formulary Chapter 3: Respiratory system - Full Chapter
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| Notes: |
When prescribing inhalers the drug, device (e.g. MDI, Easibreathe, Autohaler, Accuhaler), strength (micrograms per inhalation), number of puffs per dose and frequency MUST be specified |
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| Chapter Links... |
 NICE TA10: Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma |
 Asthma action plan child: Asthma UK |
| Asthma management plan: Asthma UK |
| LSCMMG: Asthma Treatment Guideline for Adults |
| LSCMMG: Asthma Treatment Guideline for Children |
| LSCMMG: Chronic Obstructive Pulmonary Disease (COPD) Desktop Guideline |
| MART asthma plan |
| MHRA Drug Safety Update :Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists |
| MHRA: Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects |
| NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management |
| NICE NG209: Tobacco: preventing uptake, promoting quitting and treating dependence |
| NICE NG80:Asthma: diagnosis, monitoring and chronic asthma management |
| NICE TA38: Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years) |
| Details... |
| 03.01 |
Bronchodilators |
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| 03.01.01 |
Adrenoceptor agonists |
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| 03.01.01.01 |
Selective Beta2 agonists |
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Dry Powder Inhalers (DPIs) are, where clinically appropriate, the preferred devices to be used. In COPD combination inhalers should be used wherever possible. |
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Olodaterol (Striverdi Respimat®)
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Formulary
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2.5micrograms/dose solution for inhalation cartridge with device
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| 03.01.01.01 |
Short-acting beta2 agonists |
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Dry Powder Inhalers (DPIs) are, where clinically appropriate, the preferred devices to be used. In COPD combination inhalers should be used wherever possible. |
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Salbutamol
(short acting)
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Formulary
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Injection 500micrograms/1mL
Solution for intravenous infusion 5mg/5mL
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Salbutamol
(short acting)
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Formulary
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Nebuliser solution 2.5mg/2.5mL, 5mg/2.5mL
Metered dose inhaler 100micrograms/inhalation
Easyhaler® 100micrograms inhalation
Easyhaler® 200micrograms inhalation
Ventolin Accuhaler® 200micrograms/inhalation
Airomir 100µg / inhalation
Airomir 100µg / inhalation Autohaler
First choice reliever in fixed dose regimen
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LSCMMG: Asthma Treatment Guideline for Adults (aged 17 and over)
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Terbutaline
(Short acting)
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Formulary
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Bricanyl Turbohaler® 500micrograms/inhalation
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Salbutamol SR tablets
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Formulary
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| 03.01.01.01 |
Long-acting beta2 agonists |
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In patients with asthma long-acting beta2 agonists SHOULD only be prescribed when they are already receiving inhaled corticosteroids, it is therefore recommended that a combination ICS/LABA is considered for patients with asthma to avoid inadvertent monotherapy with a LABA. In patients with COPD long-acting beta2 agonists it is now recommended that they SHOULD only be prescribed with either an inhaled corticosteroid (if asthmatic features present) or a long acting muscarinic antagonist (if no asthmatic features) REF NICE NG 115, GOLD 2023
Dry Powder Inhalers (DPIs) are, where clinically appropriate, the preferred devices to be used. In COPD combination inhalers should be used wherever possible. |
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Formoterol
(Long acting)
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Formulary
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Oxis 6 Turbohaler® 6micrograms/inhalation
Oxis 12 Turbohaler® 12micrograms/inhalation
Easyhaler® 12 micrograms/metered inhalation
Atimos Modulite® 12 micrograms/metered inhalation
To be used as 1st line LABA when used in combination with ICS for asthma (combination inhalers preferred)
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Salmeterol (Long acting)
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Formulary
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Serevent® metered dose inhaler 25micrograms/inhalation
Serevent Accuhaler® 50micrograms/inhalation
COPD and Asthma
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| 03.01.01.02 |
Other adrenoceptor agonists |
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| 03.01.02 |
Antimuscarinic bronchodilators |
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In patients with COPD it is now recommended that long acting muscarinic antagonist SHOULD only be prescribed with a long-acting beta2 agonists (if no asthmatic features) REF NICE NG 115, GOLD 2023 |
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Ipratropium
(For mild COPD)
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Formulary
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Nebuliser solution 250micrograms/1mL, 500micrograms/2mL
Metered dose inhaler 20micrograms/inhalation
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Aclidinium
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Formulary
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Eklira Genuair® inhalation powder 322micrograms/metered inhalation
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Glycopyrronium (Seebri breezhaler®)
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Formulary
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Hard capsule 44 micrograms per inhalation with Seebri Breezhaler® device
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Tiotropium
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Formulary
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COPD
Spiriva 18 microgram inhalation powder, hard capsule,
Spiriva Respimat 2.5 microgram, inhalation solution,
Tiotropium (Braltus) 10mcg Inhalation Powder
Prescribe by brand
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MHRA: Braltus (tiotropium): risk of inhalation of capsule if placed in the mouthpiece of the inhaler
MHRA: Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial
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Tiotropium
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Formulary
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Asthma
Spiriva Respimat 2.5 microgram, inhalation solution
Only Respimat® device is licensed for asthma
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MHRA Drug Safety Update May 2018: Braltus (tiotropium): risk of inhalation of capsule if placed in the mouthpiece of the inhaler
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Umeclidinium (Incruse Ellipta®)
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Formulary
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55micrograms/dose dry powder inhaler
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| 03.01.03 |
Theophylline |
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Aminophylline (Phyllocontin Continus®)
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Formulary
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M/R tablets 225mg
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SPS: Switching between aminophylline and theophylline in adults
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Aminophylline IV
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Formulary
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Injection 250mg/10ML
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SPS: Switching between aminophylline and theophylline in adults
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Theophylline
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Formulary
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M/R tablets Uniphyllin Continus® 200mg, 300mg, 400mg
Monitoring of plasma theophylline concentrations may be required when: higher dosages are prescribed; patients have co-morbidities resulting in impaired clearance; theophylline is co-administered with medication that reduces theophylline clearance.
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BNF: Theophylline
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| 03.01.04 |
Compound bronchodilator preparations |
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Dry Powder Inhalers (DPIs) are, where clinically appropriate, the preferred devices to be used. In COPD combination inhalers should be used wherever possible. |
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Aclidinium/ Formoterol
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Formulary
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Duaklir Genuair inhalation powder 340/12
Licensed for COPD only
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Glycopyrronium / Formoterol
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Formulary
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Bevespi Aerosphere 7.2 micrograms glycopyrronium /5 micrograms formoterol pressurised inhalation, suspension
Licensed for COPD only
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Glycopyrronium / Indacaterol
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Formulary
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Ultibro Breezhaler 85 micrograms indacaterol /43 micrograms glycopyrronium inhalation powder hard capsules
Licensed for COPD only
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Tiotropium bromide / Olodaterol
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Formulary
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Spiolto Respimat 2.5 microgram tiotropium /2.5 microgram olodaterol inhalation solution
Licensed for COPD only
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Umeclidinium bromide / Vilanterol
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Formulary
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Anoro Ellipta 55 micrograms umeclidinium /22 micrograms vilanterol inhalation powder, pre-dispensed
Licensed for COPD only
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| 03.01.05 |
Peak flow meters, inhaler devices and nebulisers |
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| 03.01.05 |
Peak flow meters |
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Low range peak flow meter (Mini-Wright®)
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Formulary
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Low range peak flow meter 30-400 litres/minute
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Standard range peak flow meter (Mini-Wright®)
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Formulary
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Standard range peak flow meter 60-800 litres/minute
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| 03.01.05 |
Drug delivery devices |
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If you are prescribing any spacer device to a patient for the first time, these patients should be monitored frequently in the normal way for the emergence of or worsening of symptoms of disease or adverse effects. Any patients who are switched to a different device should be regarded in the same way as new patients, and the same careful monitoring is required.
For inhaled ß2 agonist bronchodilators the most frequent signs of toxicity are headache, tremor and palpitations;
for inhaled corticosteroids the most serious concern from over exposure is adrenal suppression and particularly when high doses are administered to children and adolescents. |
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Drug Delivery Device (AeroChamber Plus®)
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Formulary
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Standard device (blue)
Child device with mask (yellow),
Infant device with mask (orange)
For use with any metered dose inhaler
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Drug Delivery Device (Easy Chamber®)
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Formulary
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First line spacer device in primary care for ADULTS
For ADULTS only, Paediatric patients should only be prescribed Aerochamber Plus Flow-vu or Volumatic spacers
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Drug Delivery Device (Volumatic®)
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Formulary
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For use with Flixotide®, Seretide®, Serevent® and Ventolin® metered dose inhalers
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Drug Delivery Device for paediatric use (AeroChamber Plus Flow-Vu®)
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Formulary
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For use in Paediatric patients in primary and secondary care as a replacement for Aerochamber Plus spacer and in addition to Volumatic spacer
- Small mask (orange)
- Medium mask (yellow)
- Youth mouthpiece (green)
- Adult small mask (purple)
For use with any metered dose inhaler
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| 03.01.05 |
Nebulisers |
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| 03.01.05 |
Nebuliser Diluent |
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Sodium Chloride
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Formulary
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Sodium chloride 0.9% nebuliser liquid 2.5ml unit dose containers
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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