| 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... |
| 03.07 |
Mucolytics |
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Carbocisteine
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Formulary
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Capsules 375mg
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Carbocisteine
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Formulary
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250mg/5ml oral solution and 750mg/10ml oral solution in sachet
Restriction: only to be used for those with swallowing difficulties who can't take capsules.
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Erdosteine
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Formulary
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Ivacaftor (Kalydeco®)
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Formulary
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Tablets 150mg
Granules sachets 13.4mg, 25mg, 50mg, 75mg
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NHSE: Clinical Commissioning Policy: Ivacaftor for Cystic Fibrosis (named mutations)
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Ivacaftor–Tezacaftor–Elexacaftor (Kaftrio®)
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Formulary
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MHRA: Ivacaftor, tezacaftor, elexacaftor (Kaftrio▼) in combination with ivacaftor (Kalydeco): risk of serious liver injury; updated advice on liver function testing
NICE TA988: Ivacaftor–tezacaftor–elexacaftor, tezacaftor–ivacaftor and lumacaftor–ivacaftor for treating cystic fibrosis
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Lumacaftor–Ivacaftor (Orkambi®)
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Formulary
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MHRA: Ivacaftor, tezacaftor, elexacaftor (Kaftrio▼) in combination with ivacaftor (Kalydeco): risk of serious liver injury; updated advice on liver function testing
NICE TA988: Ivacaftor–tezacaftor–elexacaftor, tezacaftor–ivacaftor and lumacaftor–ivacaftor for treating cystic fibrosis
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Mannitol (Bronchitol ®)
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Formulary
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Inhalation powder, hard capsule with device 40mg
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NICE TA266: Mannitol dry powder for inhalation for treating cystic fibrosis
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Tezacaftor–Ivacaftor (Symkevi®)
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Formulary
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MHRA: Ivacaftor, tezacaftor, elexacaftor (Kaftrio▼) in combination with ivacaftor (Kalydeco): risk of serious liver injury; updated advice on liver function testing
NICE TA988: Ivacaftor–tezacaftor–elexacaftor, tezacaftor–ivacaftor and lumacaftor–ivacaftor for treating cystic fibrosis
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Acetylcysteine
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Formulary
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Capsules
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| 03.07 |
Dornase alfa |
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Dornase Alfa
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Formulary
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Pulmozyme® 2500 U/ 2.5ml, nebuliser solution
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NHS England Clinical Commissioning Policy:Inhaled Therapy for Adults and Children with Cystic Fibrosis
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| 03.07 |
Hypertonic Sodium Chloride |
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Sodium chloride
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Formulary
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Nebuliser solution 3%, 6%, 7%
Inhaled hypertonic sodium chloride for mucociliary clearance in the lower airways.
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Sodium chloride 3% (Hypertonic) (MucoClear®)
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Formulary
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Nebuliser solution
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Sodium chloride 7% (Hypertonic) (Respease®)
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Formulary
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Nebuliser solution
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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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