| 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... |
| 03.02 |
Corticosteroids |
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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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Budesonide
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Formulary
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Easyhaler 100mcg per inhalation, 200mcg per inhalation, 400mcg per inhalation (asthma only)
Pulmicort® Turbohaler 100mcg per actuation, 200mcg per actuation, 400mcg per actuation (asthma only).
Pulmicort® respules 500mcg / 2ml, 1mg / 2ml (asthma / croup)
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Fluticasone
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Formulary
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Flixotide Evohaler® 50mcg per actuation, 125mcg per actuation, 250mcg per actuation.
Flixotide Accuhaler® 50mcg per actuation, 100mcg per actuation, 250mcg per actuation, 500mcg per actuation.
The maximum licensed dose in children is 200 micrograms twice daily.
Administration of doses above 1000 micrograms (500 micrograms twice daily) should be via a spacer device to help reduce side-effects in the mouth and throat.
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Budesonide / formoterol
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Formulary
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DuoResp Spiromax® 160 micrograms budesonide / 4.5 micrograms formoterol inhalation powder, 320 micrograms budesonide / 9mcg formoterol inhalation powder (asthma and COPD)
Fobumix Easyhaler® 80mcg budesonide / 4.5mcg formoterol per inhalation (asthma / over 18 years only), 160mcg budesonide / 4.5mcg formoterol per inhalation (asthma and COPD / over 18 years only), 320mcg budesonide / 9mcg formoterol per inhalation (asthma and COPD / over 18 years only)
Symbicort Turbohaler® 100mcg budesonide / 6mcg formoterol per inhalation (asthma only), 200mcg budesonide / 6mcg formoterol per inhalation (asthma and COPD), 400mcg budesonide / 12mcg formoterol per inhalation (asthma and COPD)
Symbicort® MDI 100mcg budesonide / 3mcg formoterol per actuation (asthma only), 200mcg budesonide / 6mcg formoterol per actuation (COPD only)
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Beclometasone / formoterol
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Formulary
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Fostair® / Luforbec® 100mcg beclometasone/6mcg formoterol metered dose inhalation (asthma and COPD)
Fostair® / Luforbec® 200mcg beclometasone/6mcg formoterol metered dose inhalation (asthma only)
Fostair / Luforbec are not recommended for children and young people under 18 years of age
Fostair NEXThaler®
Inhaler 100/6 micrograms per dose (asthma and COPD), 200/6 micrograms per dose (asthma only
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Beclometasone / Formoterol / Glycopyrronium
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Formulary
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The LSCMMG adult asthma guidelines only recommend triple inhalers to be initiated by a clinical expert in primary / secondary care, in those patients who are not adequately controlled with a maintenance combination of a long-acting beta 2-agonist and a high dose (Trimbow 172/5/9) or medium dose (Trimbow 87/5/9) of an inhaled corticosteroid, who have experienced one or more asthma exacerbations in the previous year.
In COPD Trimbow is only recommended for maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled long-acting beta 2-agonist and corticosteroid.
Trimbow pMDI 87 micrograms beclometasone/5 micrograms formoterol/9 micrograms glycopyrronium pressurised inhalation, solution (asthma and COPD),
Trimbow pMDI 172 micrograms beclometasone/5 micrograms formoterol/9 micrograms glycopyrronium pressurised inhalation, solution (asthma only),
Trimbow NEXThaler (DPI) 88 micrograms beclometasone /5 micrograms formoterol /9 micrograms glycopyrronium per actuation inhalation powder (COPD only)
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Beclometasone Dipropionate
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Formulary
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Clenil Modulite 50mcg per inhalation, 100mcg per inhalation, 200mcg per inhalation, 250mg per inhalation (asthma only)
Easyhaler 200mcg per inhalation (asthma only)
QVAR® beclometasone inhalers are approximately twice as potent as Clenil Modulite® at the same microgram doses. They are not interchangeable and should be prescribed by brand name.
QVAR Easi-Breathe 50mg per inhalation, 100mcg per inhalation (asthma / over 12 years only)
QVAR Autohaler 50mcg per inhalation, 100mcg per inhalation (asthma / 5 years and over)
QVAR MDI 50mcg per inhalation, 100mcg per inhalation (asthma / 5years and over).
Administration of doses above 1000 micrograms (500 micrograms twice daily) should be via a VOLUMATIC spacer device to help reduce side-effects in the mouth and throat.
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Budesonide / Formoterol / Glycopyrronium
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Formulary
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(Trixeo Aerosphere® )
MDI - Each single actuation (delivered dose, ex-actuator) contains 5 micrograms of formoterol fumarate dihydrate, glycopyrronium bromide 9 micrograms, equivalent to 7.2 micrograms of glycopyrronium, and budesonide 160 micrograms.
Restriction: Triple therapy should be reserved for patients who have failed to achieve or maintain an adequate response to an appropriate course of dual therapy.
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Ciclesonide
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Formulary
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Alvesco® 80mcg per actuation, 160mcg per actuation (asthma / over 12 years only)
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Fluticasone / formoterol
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Formulary
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Flutiform® 50mcg fluticasone / 5mcg formoterol (asthma 5 years and above), 125 mcg fluticasone /5 mcg formoterol (asthma 12 years and above), 250mcg fluticasone / 10mcg formoterol per actuation (asthma adults only)
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Fluticasone / vilanterol
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Formulary
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Relvar Ellipta® 92 micrograms fluticasone /22 micrograms vilanterol inhalation powder (asthma and COPD)
Relvar Ellipta® 184 micrograms fluticasone /22 micrograms vilanterol inhalation powder (asthma only)
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Fluticasone / Vilanterol / Umeclidinium
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Formulary
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(Trelegy Elipta®) Dry powder inhaler - Fluticasone furoate 92 microgram per 1 dose, Umeclidinium bromide 65 microgram per 1 dose, Vilanterol (as Vilanterol trifenatate) 22 microgram per 1 dose
Restriction: Triple therapy should be reserved for patients who have failed to achieve or maintain an adequate response to an appropriate course of dual therapy. The restriction should be the same for all triple inhalers for use in COPD.
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Fluticasone and salmeterol
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Formulary
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AirFlu Sal Forspiro® 50mcg salmeterol / 500mcg fluticasone per actuation (asthma and COPD / adults only)
AirFluSal® MDI 25mcg salmeterol / 125mcg fluticasone per inhalation (asthma / adults only), 25mcg salmeterol / 250mcg fluticasone per inhalation (asthma / adults only)
Seretide Accuhaler® (asthma and COPD) 50mcg salmeterol / 100mcg fluticasone per actuation, 50mcg salmeterol / 250mcg fluticasone per actuation, 50mcg salmeterol / 500mcg fluticasone per actuation
Seretide Evohaler® (asthma only) 25mcg salmeterol / 50mcg fluticasone per actuation, 25mcg salmeterol / 125mcg fluticasone per actuation, 25mcg salmeterol / 250mcg fluticasoneper actuation
Sirdupla® (asthma only) 25mcg salmeterol / 125mcg fluticasone per inhalation, 25mcg salmeterol / 250mcg fluticasone per inhalation
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Glycopyrronium bromide and formoterol fumarate dihydrate (Bevespi Aerosphere ®)
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Formulary
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Mometasone / Indacaterol
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Formulary
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Atectura Breezhaler 125 micrograms indacaterol /62.5 micrograms mometasone inhalation powder, hard capsules
Atectura Breezhaler 125 micrograms indacaterol /127.5 micrograms mometasone inhalation powder, hard capsules
Atectura Breezhaler 125 micrograms indacaterol /260 micrograms mometasone inhalation powder, hard capsules
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Mometasone / Indacaterol / Glycopyrronium
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Formulary
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(Enerzair® Breezhaler® ) 114 micrograms/46 micrograms/136 micrograms inhalation powder, hard capsules
The LSCMMG adult asthma guidelines only recommend triple inhalers to be initiated by a clinical expert in primary / secondary care, in those patients who are not adequately controlled with a maintenance combination of a long-acting beta 2-agonist and a high dose of an inhaled corticosteroid, who have experienced one or more asthma exacerbations in the previous year
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Mometasone (Asmanex®)
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Formulary
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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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