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Area Prescribing Committee Formulary  
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 Formulary Chapter 3: Respiratory system - Full Chapter
Notes:

Choice of inhaler device should be dependent 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.

*Important*


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  Bronchodilators
03.01  Asthma
03.01  Chronic obstructive pulmonary disease
03.01  Croup
03.01.01  Adrenoceptor agonists to top
03.01.01.01  Selective Beta2 agonists
 note 

**North of Tyne, Gateshead and North Cumbria Area Prescribing Committee encourages the use of low carbon inhalers wherever this is clinically appropriate**

03.01.01.01  Short-acting beta2 agonists
Salbutamol
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Formulary
Green
  • 100 mcg/puff CFC-free metered dose inhaler (MDI) & breath actuated CFC-free MDI (Airomir® Autohaler & Salamol® Easi-Breathe).
  • Accuhaler® breath actuated dry powder inhaler (DPI) 200 mcg/puff.
  • Easyhaler® breath actuated DPI 100 mcg/puff: For use in children only, as a second line treatment after the Accuhaler®.
  • 2.5mg in 2.5ml & 5mg in 2.5ml nebules
  • 2mg in 5ml sugar-free oral solution
  • 500 mcg in 1ml & 5mg in 5ml injections Red Traffic Light - parenteral use is rarely indicated
 
   
Terbutaline
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Formulary
Green
  • Turbohaler® 500 mcg/puff
  • 500 mcg in 1ml injection
 
   
03.01.01.01  Long-acting beta2 agonists
Salmeterol
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Formulary
Green
  • MDI 25 mcg/puff
  • Accuhaler® breath actuated DPI 50 mcg/puff
 
   
Formoterol
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Formulary
Green
  • Turbohaler® breath actuated DPI 6 mcg & 12 mcg/puff
 
   
03.01.01.02  Other adrenoceptor agonists
 note 

**North of Tyne, Gateshead and North Cumbria Area Prescribing Committee encourages the use of low carbon inhalers wherever this is clinically appropriate**

Ephedrine Hydrochloride
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Formulary
Green
 
   
03.01.02  Antimuscarinic bronchodilators to top
 note 

**North of Tyne, Gateshead and North Cumbria Area Prescribing Committee encourages the use of low carbon inhalers wherever this is clinically appropriate**

Umeclidinium (Incruse Ellipta®)
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Formulary
Green
 
   
Glycopyrronium (Seebri Breezhaler®)
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Formulary
Green
 
   
Aclidinium (Eklira Genuair®)
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Formulary
Green
 
   
Tiotropium (Handihaler®)
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Formulary
Green

COPD

  • Handihaler® breath actuated DPI 18 mcg capsules.
    • 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.

Asthma

  • Step 4 of BTS/SIGN guidelines. Treatment should be stopped if not effective. 
  • 2.5mg Respimat® inhaler
  • Handihaler® device for patiernts who cannot use the Respimat inhaler (off label use).
 
   
Ipratropium
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Formulary
Green
 
   
03.01.03  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.

Theophylline
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First Choice
Green
 
Aminophylline
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Alternatives
Green
  • 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.
 
   
03.01.04  Compound bronchodilator preparations
 note 

**North of Tyne, Gateshead and North Cumbria Area Prescribing Committee encourages the use of low carbon inhalers wherever this is clinically appropriate**

Glycopyyronium & indacaterol inhaler (Ulitbro Breezhaler®)
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Formulary
Green
  • First Choice LABA/LAMA for COPD.
 
   
Tiotropium & olodaterol® (Spiolto Respimat)
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Formulary
Green
 
   
Umeclidinium & vilanterol (Anoro Ellipta®)
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Formulary
Green
  • Alternative LABA/LAMA for COPD.
 
   
Aclidinium & formoterol inhaler (Duaklir Genuair®)
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Formulary
Green
  • Alternative LABA/LAMA for COPD.
 
   
Ipratropium bromide with salbutamol
(Nebuliser solution)
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Formulary
Green
 
   
03.01.05  Peak flow meters, inhaler devices and nebulisers
03.01.05  Peak flow meters
03.01.05  Drug delivery devices to top
AeroChamber Plus®
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Formulary
Green
 
   
Volumatic®
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Formulary
Green
 
   
03.01.05  Nebulisers
03.01.05  Nebuliser Diluent
03.02  Corticosteroids
 note 

Note: For COPD patients on the LABA/LAMA combinations who require escalating to triple therapy with inhaled corticosteroid (ICS) it is appropriate to leave patients on their existing LABA/LAMA and add in a single agent ICS (off label use).

 

**North of Tyne, Gateshead and North Cumbria Area Prescribing Committee encourages the use of low carbon inhalers wherever this is clinically appropriate**

Beclometasone
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Formulary
Green
  • QVAR® MDI, QVAR® Easibreathe, QVAR® Autohaler
  • Clenil Modulite®
  • Easyhaler®

Note: CFC-Free beclometasone must be prescribed by brand name. 50 mcg QVAR is equivalent to 100 mcg for a conventional inhaler & 100 mcg is equivalent to 250 mcg conventional beclometasone. 

 
   
Budesonide
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Formulary
Green
  • Turbohaler® 
  • Easyhaler®
  • Nebules
 
   
Budesonide and formoterol
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Formulary
Green
  • First Choice ICS/LABA combination
    • Duroresp Spiromax®: First choice budesonide/formoterol preparation.
    • Symbicort Turbohaler®: Second choice budesonide/formoterol preparation.

 
   
Fluticasone furoate & vilanterol (Relvar Ellipta®)
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Formulary
Green
  • Second Choice ICS/LABA combination
    • 22 mcg/92 mcg: Licensed for COPD and asthma.
    • 22 mcg/184 mcg: Licensed for asthma only.

 
   
Fluticasone propionate and formoterol (Flutiform®)
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Formulary
Green
  • Second Choice ICS/LABA combination
    • For patients preferring MDIs.
    • Approved the use for maintenance treatment of asthma.

 
   
Beclometasone and formoterol (Fostair®)
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Formulary
Green
  • Third Choice ICS/LABA combination
    • CFC-free MDI (Fostiar®)
    • DPI (Fostair NEXThaler®)

      Note:
      100 mcg of beclometasone in Fostair® is equivalent to a 250 mcg dose in a conventional beclometasone metered dose inhaler (e.g. Becloforte, Beclazone and Clenil Modulite).

 
   
Trelegy Ellipta®
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Formulary
Green
  • First choice triple therapy ICS/LABA/LAMA inhaler
  • Fluticasone furoate 92 microgram/umeclidinium bromide 65 microgram/vilanterol (as Vilanterol trifenatate) 22 microgram per dose

  • Patients on other triple therapy combinations should be given the opportunity to change to a triple therapy preparation to potentially improve compliance and realise savings. This must be done following a face to face review.
 
   
Trimbow®
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Formulary
Green
  • Second choice triple therapy ICS/LAMA/LABA inhaler
  • Beclometasone dipropionate 87 microgram/formoterol fumarate dihydrate 5 microgram/glycopyrronium (as glycopyrronium bromide) 9 microgram per dose.

  • A spacer should be used

  • Patients on other triple therapy combinations should be given the opportunity to change to a triple therapy preparation to potentially improve compliance and realise savings. This must be done following a face to face review.
 
   
03.03  Cromoglicate, related therapy and leukotriene receptor antagonists
03.03.01  Cromoglicate and related therapy to top
03.03.01  Related therapy
03.03.02  Leukotriene receptor antagonists
Montelukast
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Formulary
Green
  • Review treatment after 6 weeks of initiation and discontinue if no evidence of improvement. Should typically only be initiated by hospital specialist.
  • Montelukast is 2nd line after an inhaled corticosteroid for asthmatic children < 5 years old.
 
   
03.03.03  Phosphodiesterase type-4 inhibitors
Roflumilast (Daxas®)
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Formulary
Green plus
  • 500microgram film-coated tablets
  • Approved for the treatment of chronic obstructive pulmonary disease in line with NICE
 
Link  NICE TA461: Roflumilast for treating chronic obstructive pulmonary disease
   
03.04  Antihistamines, hyposensitisation, and allergic emergencies
03.04.01  Antihistamines to top
03.04.01  Non-sedating antihistamines
Cetirizine
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First Choice
Green
 
Loratadine
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First Choice
Green
 
Desloratadine
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Alternatives
Green
 
   
Fexofenadine
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Alternatives
Green
 
   
03.04.01  Sedating antihistamines
Chlorphenamine
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First Choice
Green
 
Hydroxyzine
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Alternatives
Green
 
   
Promethazine
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Alternatives
Green
 
   
Alimemazine
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Alternatives
Red
  • 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  
 
   
03.04.02  Allergen Immunotherapy
Bee and Wasp Allergen Extracts (Pharmalgen®)
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Formulary
Red
  • For use in adults and children by adult and paediatric immunologists only. Only approved for use in accordance with NICE guidance. 
 
Link  NICE TA246: Pharmalgen for the treatment of bee and wasp venom allergy
   
Grass and Tree Pollen Extract (Pollinex®)
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Formulary
Red
  • For use in adults and children by adult and paediatric immunologists only.
 
   
Grass pollen extract (Grazax®)
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Formulary
Red
 
   
Grass and Tree Pollen Extract (Pollinex Quattro®)
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Formulary
Red
  • For use in adults and children by adult and paediatric immunologists only.
  • Less injections than with conventional Pollinex®
 
   
03.04.02  Mepolizumab & Omalizumab
Benralizumab (Fasenra®)
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Formulary
Red
High Cost Medicine
NHS England
  • Approved for treating severe eosinophilic asthma in adults in line with NICE
 
Link  NICE TA565: Benralizumab for treating severe eosinophilic asthma
   
Mepolizumab (Nucala®)
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Formulary
Red
High Cost Medicine
NHS England
BlueTeq
  • Approved for the treatment of severe refractory eosinophilic asthma in line with NICE and NHS England Commissioning Policy.
 
Link  NICE TA431: Mepolizumab for treating severe refractory eosinophilic asthma
   
Omalizumab
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Formulary
Red
High Cost Medicine
NHS England
BlueTeq
  • Only approved for use in accordance with NICE guidance. 
 
Link  NICE TA278: Omalizumab for treating allergic asthma
Link  NICE TA339: Omalizumab for previously treated chronic spontaneous urticaria
   
Reslizumab (Cinquil®)
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Formulary
Red
NHS England
  • 10 mg/mL concentrate for solution for infusion
  • Approved for the treatment of severe eosinophilic asthma in line with NICE and NHS England Commissioning Policy as of 2 January 2018
 
Link  NICE TA479 Reslizumab for treating severe eosinophilic asthma
   
03.04.03  Allergic emergencies to top
03.04.03  Anaphylaxis
Adrenaline / Epinephrine (Emerade®)
(500 microgram)
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Formulary
Green plus
  • Approved for use in the emergency treatment of anaphylaxis for patients with a BMI of >40 or who have required more than one auto-injector previously to control symptoms. Specialist immunologist initiation only Green Traffic Light.
  • Approved for use by NUTH Community Dental Team in anaphylaxis boxes Red Traffic Light.
 
   
Adrenaline / Epinephrine (Jext® & Jext Junior®)
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Formulary
Green plus
 
   
03.04.03  Angioedema
C1 Esterase Inhibitor
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Formulary
Red
High Cost Medicine
NHS England
  • Approvded for the treatment and pre-procedure prevention of angioedema attacks in patients with hereditary angioedema (HAE).
  • Approvded for the routine prevention of angioedema attacks in adults and adolescents years old with severe and recurrent attacks of HAE.

 

 

 
Link  Clinical Commissioning Policy: Plasmaderived C1-esterase inhibitor for prophylactic treatment of hereditary angioedema (HAE) types I and II
   
Icatibant (Firazyr®)
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Formulary
Red
High Cost Medicine
NHS England
  • For use on the advice of immunologist in the treatment hereditary angioedema associated with C1-esterase inhibitor.
 
   
Lanadelumab (Takhzyro®)
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Formulary
Red
NHS England
  • 300mg/2mL solution for injection
    • Approved for preventing recurrent attacks of hereditary angioedema in line with NICE
 
Link  NICE TA606: Lanadelumab for preventing recurrent attacks of hereditary angioedema
   
Danazol
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Unlicensed Drug Unlicensed
Red
  • For use on the advice of an immunologist in the prophylaxis, treatment hereditary angioedema associated with C1-esterase inhibitor deficiency.
     
 
   
Oxandrolone 2.5mg and 10mg capsules
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Unlicensed Drug Unlicensed
Red
  • For use on the advice of an immunologist in the prophylaxis treatment hereditary angioedema associated with C1-esterase inhibitor deficiency when danzol and stanozolol are not available.
 
   
Stanozolol 50mg tablets
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Unlicensed Drug Unlicensed
Red
  • For use on the advice of an immunologist in the prophylaxis treatment hereditary angioedema associated with C1-esterase inhibitor deficiency.

 
   
03.04.03  Intramuscular adrenaline (epinephrine)
03.04.03  Intravenous adrenaline (epinephrine)
03.04.03  Self-administration of adrenaline (epinephrine) to top
03.05  Respiratory stimulants and pulmonary surfactants
03.05.01  Respiratory stimulants
Doxapram
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Formulary
Red
 
   
Caffeine Citrate
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Unlicensed Drug Unlicensed
Red
  • 50mg in 5ml injection (equivalent to 25mg caffeine base in 5ml).
  • 50mg in 5ml oral solution.
 
   
Caffeine Citrate
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Unlicensed Drug Unlicensed
Red

50mg in 5ml injection (equivalent to 25mg caffeine base
in 5ml)
50mg in 5ml oral solution

 
   
03.05.02  Pulmonary surfactants
Poractant Alfa
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Formulary
Red
High Cost Medicine
 
   
03.06  Oxygen
03.06  Long-term oxygen therapy to top
03.06  Short burst oxygen therpary
03.06  Ambulatory oxygen therapy
03.06  Oxygen therapy equipment
03.06  Arrangements for supplying oxygen
03.07  Mucolytics to top
Acetylcysteine
(Mucolytic)
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Formulary
Green plus
  • 600mg plain and effervescent tablets.
  • For use on specialist advice in the treatment of idiopathic pulmonary fibrosis.
  • For the prevention of x-ray contrast media induced renal damage Red Traffic Light.
 
   
Carbocisteine
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Formulary
Green
  • 375mg capsules.
  • 750mg/10ml oral solution in sachets: first choice liquid preparation for adult patients.
  • 250mg in 5ml syrup.
 
   
Ivacaftor
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Formulary
Red
High Cost Medicine
  • Approved for the treatment of cystic fibrosis in patients who have a faulty mutation in the CFTR gene in line with NHS England Clinical Commissioning Policy. 
 
Link  Clinical Commissioning Policy: Ivacaftor for children aged 2-5 years with cystic fibrosis (named mutations)
Link  Clinical Commissioning Policy: Ivacaftor for Cystic Fibrosis
   
03.07  Dornase alfa
Dornase Alfa
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Formulary
Red
High Cost Medicine
 
   
03.07  Hypertonic Sodium Chloride
Hypertonic sodium chloride 7% (Nebusal®)
(For nebulisation)
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Formulary
Green plus
 
   
03.07  Mannitol
Mannitol inhalation (Bronchitol ®)
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Formulary
Red
High Cost Medicine
  • Only approved for use in accordance with NICE guidance. 
 
Link  NICE TA266: Cystic fibrosis - mannitol dry powder for inhalation
   
Mannitol inhalation
(0mg, 5mg, 10mg, 20mg, 40mg capsules for inhalation)
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Formulary
Red
  • Approved for bronchial provocation testing in patients unable to tolerate the taste of methacholine.
 
   
03.08  Aromatic inhalations
03.09  Cough preparations to top
03.09.01  Cough suppressants
Codeine Phosphate
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Formulary
Green
  • 15mg in 5ml linctus.
 
   
Pholcodine
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Formulary
Green
  • 5mg in 5ml sugar-free linctus.
 
   
03.09.01  Palliative care
03.09.02  Expectorant and demulcent cough preparations
Simple Linctus
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Formulary
Green
  • Simple linctus and Paediatric simple linctus.
 
   
03.10  Systemic nasal decongestants
Pseudoephedrine Hydrochloride
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Formulary
Green
 
   
03.11  Antifibrotics to top
Nintedanib (Ofev®)
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Formulary
Red
High Cost Medicine
  • Only approved for use in accordance with NICE guidance. 
 
Link  NICE TA379:Nintedanib for treating idiopathic pulmonary fibrosis
   
Pirfenidone (Esbriet®)
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Formulary
Red
High Cost Medicine
  • Approved for the treatment of idiopathic pulmonary fibrosis in line with NICE and NHS England Commissioning Policy
 
Link  NICE TA504: Idiopathic pulmonary fibrosis - pirfenidone
   
 ....
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
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
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.   

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 hospital specialist, but where the provision of an information leaflet may be appropriate to facilitate continuing treatment by GPs. Many of these information sheets are in the process of development.  

Green

Drugs where prescribing by GPs is appropriate. Drugs not classified as Red, Amber or Green Plus (formerly blue in North of Tyne) are generally classified as ‘Green’ by default. The Green drugs listed here include those products normally initiated by hospital specialists where there was a need for discussion and debate as to the category in which they should be placed.  

netFormulary