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 Formulary Chapter 3: Respiratory system - Full Chapter
Notes:

*Important*

The NENC ICB Respiratory Network recommends that all inhalers should be prescribed by brand for patient safety, to ensure that the correct device is dispensed to support correct technique and avoid patient confusion and medication errors.

Choice of inhaler device should be based on patient ability to use. Devices should be chosen based on availability for the type of drug to be prescribed and the patient’s ability to use it.

Refer to local guidelines for information on preferred options.

Note: All new patients should be started on the updated formulary choices as per local/national guidelines.

When inhalers are removed from the formulary, existing, stable, patients should continue to receive the non-formulary device. Treatment should not be changed unless a full face to face review has been conducted.
Chapter Links...
Link   NICE NG244: Asthma pathway (BTS, NICE, SIGN)
Link   NICE NG245: Asthma: diagnosis, monitoring and chronic asthma management
Link   NENC Asthma Prescribing Guidelines for Children and Young People 12 to 17 years
Link   NENC Asthma Prescribing Guidelines for Children and Young People 2 to 5 years
Link   NENC Asthma Prescribing Guidelines for Children and Young People 6-11 years
Link   NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management
Link   MHRA Drug Safety Update (July 2018): Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects
Link   MHRA: Adrenaline auto-injectors (AAIs): new guidance and resources for safe use
Link   NENC Adult Asthma Guideline
Link   NENC COPD Guideline
Link   NENC Management of COPD Exacerbations – Rescue medication in primary care
 Details...
03.01  Expand sub section  Bronchodilators
 link Link    NICE NG9: Bronchiolitis in children: diagnosis and management
03.01  Expand sub section  Asthma
03.01  Expand sub section  Chronic obstructive pulmonary disease
03.01  Expand sub section  Croup
03.01.01  Expand sub section  Adrenoceptor agonists to top
03.01.01.01  Expand sub section  Selective Beta2 agonists
 note 

**The propellants used in pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate**
03.01.01.01  Expand sub section  Short-acting beta2 agonists
03.01.01.01  Expand sub section  Long-acting beta2 agonists
03.01.01.02  Expand sub section  Other adrenoceptor agonists
 note 

**The propellants used in pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate**
03.01.02  Expand sub section  Antimuscarinic bronchodilators to top
 note 

**The propellants used in pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate**
03.01.02  Expand sub section  Short Acting Anti-muscarinic Bronchodilators
03.01.02  Expand sub section  Long Acting Anti-muscarinic Bronchodilators
03.01.03  Expand sub section  Theophylline
 note 

Seldom indicated. Modified release formulations must be prescribed by brand name. 

 
03.01.04  Expand sub section  Compound bronchodilator preparations
 note 

**The propellants used in Pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate**
03.01.05  Expand sub section  Peak flow meters, inhaler devices and nebulisers to top
03.01.05  Expand sub section  Peak flow meters
03.01.05  Expand sub section  Drug delivery devices
03.01.05  Expand sub section  Nebulisers
03.01.05  Expand sub section  Nebuliser Diluent
03.02  Expand sub section  Corticosteroids to top
 note 

 **The propellants used in pressurised Metered Dose Inhalers (pMDIs) have a high carbon footprint. Dry Powder Inhalers (DPIs) are now first choice for all of the different inhaler classes and should be used wherever this is clinically appropriate**
 link Link    MHRA Drug Safety Update (Aug 2017): Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration
03.02.01  Expand sub section  Long-acting beta2 agonists (ICS/LABA)
03.02.02  Expand sub section  long-acting muscarinic antagonist (ICS/LABA/LAMA)
03.02.02  Expand sub section  Low dose
03.02.02  Expand sub section  Moderate dose
03.02.02  Expand sub section  High dose to top
03.02.03  Expand sub section  Combination products (ICS+LABA)
03.02.03  Expand sub section  Triple Therapy products
03.03  Expand sub section  Cromoglicate, related therapy and leukotriene receptor antagonists
03.03.01  Expand sub section  Cromoglicate and related therapy
03.03.01  Expand sub section  Related therapy to top
03.03.02  Expand sub section  Leukotriene receptor antagonists
03.03.03  Expand sub section  Phosphodiesterase type-4 inhibitors
03.04  Expand sub section  Antihistamines, hyposensitisation, and allergic emergencies
03.04.01  Expand sub section  Antihistamines
03.04.01  Expand sub section  Non-sedating antihistamines to top
03.04.01  Expand sub section  Sedating antihistamines
03.04.02  Expand sub section  Allergen Immunotherapy
03.04.02  Expand sub section  Monoclonal antibodies
03.04.03  Expand sub section  Allergic emergencies
03.04.03  Expand sub section  Anaphylaxis to top
03.04.03  Expand sub section  Angioedema
03.04.03  Expand sub section  Intramuscular adrenaline (epinephrine)
03.04.03  Expand sub section  Intravenous adrenaline (epinephrine)
03.04.03  Expand sub section  Self-administration of adrenaline (epinephrine)
03.05  Expand sub section  Respiratory stimulants and pulmonary surfactants to top
03.05.01  Expand sub section  Respiratory stimulants
03.05.02  Expand sub section  Pulmonary surfactants
03.06  Expand sub section  Oxygen
03.06  Expand sub section  Long-term oxygen therapy
03.06  Expand sub section  Short burst oxygen therpary to top
03.06  Expand sub section  Ambulatory oxygen therapy
03.06  Expand sub section  Oxygen therapy equipment
03.06  Expand sub section  Arrangements for supplying oxygen
03.07  Expand sub section  Mucolytics
03.07  Expand sub section  Dornase alfa to top
03.07  Expand sub section  Hypertonic Sodium Chloride
03.07  Expand sub section  Mannitol
03.08  Expand sub section  Aromatic inhalations
03.09  Expand sub section  Cough preparations
03.09.01  Expand sub section  Cough suppressants to top
03.09.01  Expand sub section  Palliative care
03.09.02  Expand sub section  Expectorant and demulcent cough preparations
03.10  Expand sub section  Systemic nasal decongestants
03.11  Expand sub section  Antifibrotics
03.12  Expand sub section  Miscellaneous to top
 ....
Key
Restricted Drug Restricted Drug
Unlicensed Drug Unlicensed
click to search medicines.org.uk
 Link to adult BNF
click to search medicines.org.uk
 Link to children's BNF
click to search medicines.org.uk
 Link to SPCs
Cytotoxic Drug
 Cytotoxic Drug
CD
 Controlled Drug
High Cost Medicine
 High Cost Medicine
NHSE
 NHS England
Homecare
 Homecare
CCG
 ICB
Green Low Carbon

Low carbon footprint
Amber Medium Carbon

Medium carbon footprint
Red High carbon footprint

High carbon footprint
Status Description

Red

 Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing.   

Amber

 Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic. The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible. SCGs are available or are being developed for most of the drugs listed as AMBER.   

Green plus

 Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria. These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary. In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary. If the drug requires urgent initiation, it is expected that the specialist provides the first prescription from the inpatient/outpatient setting, of sufficient supply for a patient’s immediate needs. The quantity provided should cover at least up to the point where the discharge/clinic letter has reached the GP, plus reasonable time for the practice to manage the document and issue further supplies. A GREEN+ drug can only be recommended to primary care for initiation if it does not need to be initiated urgently, taking into account clinical need.  

Green

 Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible.  

OTC

 Self-care – available OTC, can be purchased as part of self-care for self-limiting conditions as per NHSE policy guidance  

Brown

 UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.  

Not Recomended

 Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care.  

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