| Formulary Chapter 3: Respiratory system - Full Chapter
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| 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. |
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| Chapter Links... |
 NICE NG244: Asthma pathway (BTS, NICE, SIGN) |
| NICE NG245: Asthma: diagnosis, monitoring and chronic asthma management |
| NENC Asthma Prescribing Guidelines for Children and Young People 12 to 17 years |
| NENC Asthma Prescribing Guidelines for Children and Young People 2 to 5 years |
| NENC Asthma Prescribing Guidelines for Children and Young People 6-11 years |
| NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management |
| MHRA Drug Safety Update (July 2018): Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects |
| MHRA: Adrenaline auto-injectors (AAIs): new guidance and resources for safe use |
| NENC Adult Asthma Guideline |
| NENC COPD Guideline |
| NENC Management of COPD Exacerbations – Rescue medication in primary care |
| Details... |
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Magnesium Sulphate
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Formulary
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MHRA Drug Safety Update (May 2019): Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy
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| 03.01 |
Chronic obstructive pulmonary disease |
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| 03.01.01 |
Adrenoceptor agonists |
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| 03.01.01.01 |
Selective Beta2 agonists |
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**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** |
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| 03.01.01.01 |
Short-acting beta2 agonists |
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Salbutamol
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Formulary
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- REFER TO LOCAL GUIDELINES FOR ADVICE ON PREFERRED CHOICE
- Easyhaler® breath actuated dry powder inhaler 100 mcg/puff (DPI)
- Accuhaler® breath actuated dry powder inhaler 200 mcg/puff (DPI)
- 100 mcg/puff CFC-free MDI - Salamol® (pMDI)
- 100 mcg/puff breath actuated CFC-free MDI (pMDI)
- Salamol® Easi-Breathe - alternative for patients hypersensitive to lactose or milk protein
- 2.5mg in 2.5ml & 5mg in 2.5ml nebules
- 2mg in 5ml sugar-free oral solution
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MHRA: Short-acting beta 2 agonists (SABA) (salbutamol and terbutaline): reminder of the risks from overuse in asthma and to be aware of changes in the SABA prescribing guidelines
National Patient Safety Alert - Shortage of salbutamol 2.5mg/2.5ml and 5mg/2.5ml nebuliser liquid unit dose vials (26 February 2024)
MHRA Drug Safety Update (Aug 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists
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Salbutamol Injection
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Formulary
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- 500 mcg in 1ml & 5mg in 5ml injections
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Terbutaline
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Formulary
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- Turbohaler® 500 mcg/puff (DPI)
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MHRA: Short-acting beta 2 agonists (SABA) (salbutamol and terbutaline): reminder of the risks from overuse in asthma and to be aware of changes in the SABA prescribing guidelines
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Terbutaline Nebules
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Formulary
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- 2.5mg/ml nebuliser solution
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MHRA Drug Safety Update (Aug 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists
MHRA: Short-acting beta 2 agonists (SABA) (salbutamol and terbutaline): reminder of the risks from overuse in asthma and to be aware of changes in the SABA prescribing guidelines
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| 03.01.01.01 |
Long-acting beta2 agonists |
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| 03.01.01.02 |
Other adrenoceptor agonists |
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**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** |
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Ephedrine Hydrochloride
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Formulary
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| 03.01.02 |
Antimuscarinic bronchodilators |
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**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** |
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Tiotropium (Respimat®)
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Formulary
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MHRA Drug Safety Update (Feb 2015): Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial
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Ipratropium Nebules
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Formulary
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- 250 microgram/1ml & 500 microgram/1ml nebuliser liquid
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MHRA Drug Safety Update (Aug 2022): Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists
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| 03.01.02 |
Short Acting Anti-muscarinic Bronchodilators |
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| 03.01.02 |
Long Acting Anti-muscarinic Bronchodilators |
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Seldom indicated. Modified release formulations must be prescribed by brand name.
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Aminophylline Injection
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Formulary
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- 250mg/10ml injection
- COPD: intravenous aminophylline of limited benefit.
- Injection used in hospital for acute asthma not responding to steroids and continuous inhaled bronchodilators.
- Plasma levels need to be checked before administration if patient has previously taken theophylline/ aminophylline.
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Theophylline (Uniphyllin ®)
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Formulary
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- 200mg, 300mg and 400mg MR tablet
- 50 mg/5 mL oral solution -
 unlicensed
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MHRA Drug Safety Update (Dec 2014): Smoking and smoking cessation: clinically significant interactions with commonly used medicines
NENC Deprescribing considerations for adults with asthma currently prescribed theophylline
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| 03.01.04 |
Compound bronchodilator preparations |
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**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** |
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Glycopyrronium & formoterol (Bevespi Aerosphere®)
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Formulary
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- Glycopyrronium 7.2 microgram/dose & formoterol 5 microgram/dose (equivalent to Glycopyrronium (as Glycopyrronium bromide) 7.2 microgram /dose & formoterol fumarate dihydrate 5 microgram/dose) pressurised metered dose inhaler - (pMDI)
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Glycopyyronium & indacaterol (Ultibro Breezhaler®)
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Formulary
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- Glycopyrronium 43 microgram/dose & indacaterol 85 microgram/dose (equivalent to glycopyrronium bromide 54 microgram/dose & indacaterol maleate 85 microgram/dose) inhalation powder capsules (DPI)
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Tiotropium & olodaterol (Spiolto Respimat®)
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Formulary
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- Tiotropium 2.5 microgram/dose & olodaterol 2.5 microgram/dose pressurised metered dose inhaler - (pMDI)
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Umeclidinium & vilanterol (Anoro Ellipta®)
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Formulary
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- Umeclidinium55 microgram/dose & vilanterol 22 microgram/dose (equivalent to umeclidinium bromide 65 microgram/dose & vilanterol (as vilanterol trifenatate) 22 microgram/dose) dry powder inhaler (DPI)
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Aclidinium & formoterol (Duaklir Genuair®)
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Formulary
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- Aclidinium 340 microgram/dose & formoterol 12 microgram/dose (equivalent to aclidinium bromide 396 microgram/dose, formoterol fumarate dihydrate 11.8 microgram/dose) inhalation powder (DPI)
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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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| 03.01.05 |
Drug delivery devices |
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AeroChamber Plus®
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Formulary
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AeroChamber® Flow-Vu
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Formulary
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Space Chamber Plus®
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Formulary
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Volumatic®
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Formulary
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| 03.01.05 |
Nebuliser Diluent |
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| 03.02 |
Corticosteroids |
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**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** |
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| 03.02.01 |
Long-acting beta2 agonists (ICS/LABA) |
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| 03.02.02 |
long-acting muscarinic antagonist (ICS/LABA/LAMA) |
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| 03.02.02 |
High dose |
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| 03.02.03 |
Combination products (ICS+LABA) |
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| 03.02.03 |
Triple Therapy products |
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| 03.03 |
Cromoglicate, related therapy and leukotriene receptor antagonists |
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| 03.03.01 |
Cromoglicate and related therapy |
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| 03.03.01 |
Related therapy |
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| 03.03.02 |
Leukotriene receptor antagonists |
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| 03.03.03 |
Phosphodiesterase type-4 inhibitors |
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| 03.04 |
Antihistamines, hyposensitisation, and allergic emergencies |
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| 03.04.01 |
Non-sedating antihistamines |
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Cetirizine
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First Choice
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Loratadine
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First Choice
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Desloratadine
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Alternatives
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Fexofenadine
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Alternatives
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| 03.04.01 |
Sedating antihistamines |
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Chlorphenamine
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First Choice
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Promethazine
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Second Choice
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Hydroxyzine
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Alternatives
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MHRA Drug Safety Update (April 2015): Hydroxyzine (Atarax, Ucerax): risk of QT interval prolongation and Torsade de Pointes
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Alimemazine
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Alternatives
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- Hospital only for the following indications
- Enteral sedation in paediatric ITU setting
- Use in patients where promethazine has failed
- Existing patients can continue to be prescribed in primary care until a treatment review has taken place
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| 03.04.02 |
Allergen Immunotherapy |
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| 03.04.02 |
Monoclonal antibodies |
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| 03.04.03 |
Allergic emergencies |
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| 03.04.03 |
Anaphylaxis |
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| 03.04.03 |
Intramuscular adrenaline (epinephrine) |
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| 03.04.03 |
Intravenous adrenaline (epinephrine) |
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| 03.04.03 |
Self-administration of adrenaline (epinephrine) |
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| 03.05 |
Respiratory stimulants and pulmonary surfactants |
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| 03.05.01 |
Respiratory stimulants |
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Doxapram
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Formulary
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Caffeine Citrate
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Unlicensed
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- 50mg in 5ml injection (equivalent to 25mg caffeine base in 5ml).
- 50mg in 5ml oral solution.
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MHRA Drug Safety Update (Dec 2014): Caffeine citrate: 2 products of different strengths now available
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| 03.05.02 |
Pulmonary surfactants |
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| 03.06 |
Long-term oxygen therapy |
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| 03.06 |
Short burst oxygen therpary |
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| 03.06 |
Ambulatory oxygen therapy |
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| 03.06 |
Oxygen therapy equipment |
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| 03.06 |
Arrangements for supplying oxygen |
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| 03.07 |
Dornase alfa |
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| 03.07 |
Hypertonic Sodium Chloride |
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| 03.08 |
Aromatic inhalations |
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| 03.09.01 |
Cough suppressants |
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Codeine
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Formulary
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- Codeine S/F linctus 15mg/5ml
- Non-sugar free product has a considerably higher cost, therefore S/F products preferred.
- Approved for cough suppression in palliative care patients unable to take tablets
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MHRA Drug Safety Update (February 2024): Codeine linctus (codeine oral solutions): reclassification to prescription-only medicine
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| 03.09.02 |
Expectorant and demulcent cough preparations |
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| 03.10 |
Systemic nasal decongestants |
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| 03.12 |
Miscellaneous |
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| .... |
| Non Formulary Items |
Gefapixant 
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Non Formulary
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- Gefapixant for treating refractory or unexplained chronic cough (terminated appraisal)
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NICE TA969: Gefapixant for treating refractory or unexplained chronic cough (terminated appraisal)
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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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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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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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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. |
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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. |
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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. |
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Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible. |
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Self-care – available OTC, can be purchased as part of self-care for self-limiting conditions as per NHSE policy guidance |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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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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