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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...
 Details...
03.01  Expand sub section  Bronchodilators
Magnesium Sulphate
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Formulary
Red
 
Link  MHRA Drug Safety Update (May 2019): Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy
 
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
Salbutamol
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Formulary
Green
  • 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)
    • Airomir® Autohaler  
      • Salamol® Easi-Breathe - alternative for patients hypersensitive to lactose or milk protein
  • 2.5mg in 2.5ml & 5mg in 2.5ml nebules (Medicine Supply Notification 028 - Supply issue with salbutamol 2.5mg/2.5ml nebuliser liquid unit dose vials)
  • 2mg in 5ml sugar-free oral solution

 

 
Link  National Patient Safety Alert - Shortage of salbutamol 2.5mg/2.5ml and 5mg/2.5ml nebuliser liquid unit dose vials (26 February 2024)
Link  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
 
Salbutamol Injection
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Formulary
Red
  • 500 mcg in 1ml & 5mg in 5ml injections  

 

 
 
Terbutaline
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Formulary
Green
  • Turbohaler® 500 mcg/puff (DPI)

 

 
 
Terbutaline Injection
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Formulary
Red
  • 500 mcg in 1ml injection

 

 
 
Terbutaline Nebules
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Formulary
Red
  • 2.5mg/ml nebuliser solution



 

 
Link  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
 
03.01.01.01  Expand sub section  Long-acting beta2 agonists
Formoterol
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Formulary
Green

 

    • 6 mcg & 12 mcg/puff breath actuated dry powder inhaler (DPI) - Turbohaler®



 

 
 
Salmeterol
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Green
  • 50 mcg/puff breath actuated dry powdered inhaler (DPI) - Accuhaler® 
  • 25 mcg/puff metered dose inhaler (pMDI)

 

 
 
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**

Ephedrine Hydrochloride
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Formulary
Red
 
 
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**

Tiotropium (Respimat®)
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Formulary
Green
  • 2.5mg Respimat® inhaler
    • Step 4 of the BTS/SIGN Asthma guidelines. Treatment should be stopped if not effective.


 
Link  MHRA Drug Safety Update (Feb 2015): Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial
 
Umeclidinium (Incruse Ellipta®)
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Formulary
Green

 

    • 55 microgram/dose (equivalent to umeclidinium bromide 65m microgram/dose) dry powder inhaler (DPI)



 

 
 
Tiotropium (Handihaler®)
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Formulary
Green
  • 18 mcg inhalation powder capsule (Handihaler®) (DPI) 
    • For existing COPD patients only and those unable to use the other LAMA devices. Consideration should be given to switching at next review, providing adequate training / counselling is provided in device use.
 
Link  MHRA Drug Safety Update (Feb 2015): Tiotropium delivered via Respimat compared with Handihaler: no significant difference in mortality in TIOSPIR trial
 
Glycopyrronium (Seebri Breezhaler®)
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Formulary
Green

 

    • 44microgram (equivalent to 55 micrograms of glycopyrronium bromide) powder capsule with device (DPI)



 

 
 
Aclidinium (Eklira Genuair®)
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Formulary
Green

 

    • 322 microgram/dose (equivalent to aclidinium bromide 375 microgram/dose) inhalation powder (DPI)



 

 
 
Ipratropium Nebules
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Formulary
Green plus
  • 250 microgram/1ml & 500 microgram/1ml nebuliser liquid



 

 
Link  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
 
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. 

Asthma: consider for patients not controlled on LABA plus inhaled corticosteroid (ICS) discontinue if no benefit see national guidelines.

Aminophylline Injection
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Formulary
Red
  • 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.
 
 
Theophylline (Uniphyllin ®)
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Formulary
Green
  • 200mg, 300mg and 400mg MR tablet 
  • Green plus Green plus50 mg/5 mL oral solution - unlicensed unlicensed
 
Link  MHRA Drug Safety Update (Dec 2014): Smoking and smoking cessation: clinically significant interactions with commonly used medicines
 
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**

Glycopyrronium & formoterol (Bevespi Aerosphere®)
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Formulary
Green

 

    • 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)



 

 
 
Glycopyyronium & indacaterol  (Ultibro Breezhaler®)
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Formulary
Green

 

    • Glycopyrronium 43 microgram/dose & indacaterol 85 microgram/dose (equivalent to glycopyrronium bromide 54 microgram/dose & indacaterol maleate 85 microgram/dose) inhalation powder capsules (DPI)



 

 
 
Tiotropium & olodaterol (Spiolto Respimat®)
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Formulary
Green

 

    • Tiotropium 2.5 microgram/dose & olodaterol 2.5 microgram/dose pressurised metered dose inhaler - (pMDI)



 

 
 
Umeclidinium & vilanterol (Anoro Ellipta®)
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Formulary
Green

 

    • 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)

 

 
 
Aclidinium & formoterol  (Duaklir Genuair®)
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Formulary
Green

 

    • 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)



 

 
 
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
AeroChamber Plus®
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Formulary
Green
 
 
AeroChamber® Flow-Vu
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Formulary
Green
 
 
Space Chamber Plus®
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Formulary  
 
Volumatic®
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Formulary
Green
 
 
03.01.05  Expand sub section  Nebulisers
03.01.05  Expand sub section  Nebuliser Diluent
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
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
CCG

Traffic Light Status Information

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. The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber. If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care.  

Green plus

Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs.  

Green

Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care.  

Black

NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria.   

Brown

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

Not Recomended

NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status.  

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