| 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... |
 BTS/SIGN British Guideline on the Management of Asthma |
| County Durham and Tees Valley COPD Treatment Guide |
| County Durham and Tees Valley Adult Asthma Inhaler Guide |
| County Durham and Tees Valley Paediatric Asthma Inhaler Guide |
 North of Tyne, Gateshead and North Cumbria - Asthma in Children Summary Guideline |
| North of Tyne, Gateshead and North Cumbria - COPD Management Guide |
| North of Tyne, Gateshead and North Cumbria - Paediatric Asthma Inhaler Guidance (Children under 5 years) |
| South Tyneside and Sunderland - Asthma Guidance (RS1) |
| South Tyneside and Sunderland - Guidance for Choice of Inhalers for Asthma (RS2) |
| South Tyneside and Sunderland - Guideline for the treatment of COPD (RS3) |
| South Tyneside and Sunderland - Guideline for the Choice of Inhalers for COPD (RS4) |
| NICE NG80: Asthma: diagnosis, monitoring and chronic asthma management |
| 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 |
| NENC Regional ‘At A Glance Carbon Footprint Guidance’ |
| NICE TA10: Asthma inhaler devices (children under 5) |
| NICE TA38: Asthma inhaler devices (older children) |
| North Cumbria - Asthma Inhaler Decision Tool |
| North Cumbria - COPD Inhaler Decision Tool |
| North Cumbria - Paediatric doses of inhaled corticosteroids |
| North East and North Cumbria Clinical Network Guide - Supporting Greener Respiratory Care |
| Details... |
| 03.02 |
Corticosteroids |
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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).
**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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Budesonide
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Formulary
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- 100 microgram/dose dry powder inhaler - Easyhaler® (DPI)
- 100 microgram/dose dry powder inhaler - Turbohaler® (DPI)
- 500 microgram/2ml & 1mg/2ml nebuliser liquid
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Beclometasone (Qvar®)
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Formulary
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- QVAR® CFC-free MDI: 50mcg, 100mcg per puff
- QVAR® breath-actuated MDI: 50mcg, 100mcg per puff
- N.B. CFC-free beclometasone must be prescribed by brand name.
- 50mcg QVAR is equivalent to 100mcg for a conventional beclometasone inhaler and 100mcg is equivalent to 250mcg conventional beclometasone.
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Beclometasone dipropionate (Clenil Modulite®)
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Formulary
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- 50 / 100 / 200 / 250 microgram/dose pressurised metered dose inhaler (pMDI) - Clenil Modulite®
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Fluticasone propionate (Flixotide®)
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Formulary
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- 50mcg/inhalation
- Approved for asthma in children only
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Fluticasone propionate and formoterol (Flutiform®)
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Formulary
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- 50/5mcg per puff
- 125/5mcg per puff
- 250/10mcg per puff
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Fluticasone propionate and salmeterol (Combisal®)
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Formulary
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- Fluticasone 50microgram & salmeterol 25 microgram; fluticasone 125microgram & salmeterol 25 microgram; & fluticasone 250microgram & salmeterol 25 microgram (pMDI)
- Approved for asthma in children only
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Fluticasone propionate and salmeterol (Sereflo®)
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Formulary
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Fluticasone propionate and salmeterol (Seretide®)
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Formulary
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Fluticasone propionate and salmeterol (Sirdupla®)
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Formulary
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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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Mometasone, Indacaterol & glycopyrronium (Enerzair Breezhaler®)
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Formulary
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- Mometasone 136 microgram/dose, indacaterol 114 microcram/dose & glycopyrronium 46 microgram/dose inhalation powder capsules (DPI)
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| 03.02.02 |
Low dose |
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| 03.02.02 |
Moderate dose |
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| 03.02.02 |
High dose |
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| 03.02.03 |
Combination products (ICS+LABA) for COPD |
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Budesonide and formoterol (DuoResp Spiromax®)
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Formulary
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- Budesonide 160 microgram/dose & formoterol 4.5 microgram/dose (equivalent to budesonide 200 microgram/dose & formoterol fumarate dihydrate 6 microgram/dose) dry powder inhaler (DPI)
- Budesonide 320 microgram/dose & formoterol 9 microgram/dose (equivalent to budesonide 400 microgram/dose & formoterol fumarate dihydrate 12 microgram/dose) dry powder inhaler (DPI)
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Budesonide and formoterol (Fobumix®)
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Formulary
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- Budesonide 80 microgram/dose & formoterol 4.5 microgram/dose (equivalent to budesonide 100 microgram/dose & formoterol fumarate dihydrate 6 microgram/dose) dry powder inhaler - Easyhaler (DPI)
- Budesonide 160 microgram/dose & formoterol 4.5 microgram/dose (equivalent to budesonide 200 microgram/dose & formoterol fumarate dihydrate 6 microgram/dose) dry powder inhaler - Easyhaler (DPI)
- Budesonide 320 microgram/dose & formoterol 9 microgram/dose (equivalent to budesonide 400 microgram/dose & formoterol fumarate dihydrate 12 microgram/dose) dry powder inhaler - Easyhaler (DPI)
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Budesonide and formoterol (Symbicort Turbohaler®)
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Formulary
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- Budesonide 200 microgram/dose & formoterol 6 microgram/dose inhalation powder (DPI)
- Budesonide 400 microgram/dose & formoterol 12 microgram/dose inhalation powder (DPI)
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Mometasone and indacaterol (Atectura®)
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Formulary
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- Mometasone furoate 127.5 microgram/dose & indacaterol 125 microcram/dose inhalation powder capsules (DPI)
- Mometasone furoate 260 microgram/dose & indacaterol 125 microcram/dose inhalation powder capsules (DPI)
- Both strengths approved for asthma only
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Beclometasone and formoterol (Fostair NEXThaler®)
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Formulary
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- Beclomethasone 100 microgram/dose & formoterol 6 microgram/dose dry powder inhaler (DPI)
- Beclomethasone 200 microgram/dose & formoterol 6 microgram/dose dry powder inhaler (DPI)
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Beclometasone and formoterol (Fostair®)
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Formulary
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- Beclomethasone dipropionate 100 microgram/dose & formoterol 6 microgram/dose pressurised metered dose inhaler (pMDI)
- Beclomethasone dipropionate 200 microgram/dose & formoterol 6 microgram/dose pressurised metered dose inhaler (pMDI)
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Beclometasone and formoterol (Luforbec®)
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Formulary
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- Beclomethasone dipropionate 100 microgram/dose & formoterol 6 microgram/dose pressurised metered dose inhaler (pMDI)
- Additional treatment option
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Fluticasone furoate & vilanterol (Relvar Ellipta®)
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Formulary
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- Fluticasone 22 microgram/dose & vilanterol 92 microgram/dose dry powder inhaler (DPI): Licensed for COPD and asthma.
- Fluticasone 22 microgram/dose & vilanterol 184 microgram/dose dry powder inhaler (DPI): Licensed for asthma only.
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| 03.02.03 |
Triple Therapy products |
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Beclometasone, formoterol & glycopyrronium (Trimbow®)
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Formulary
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- Beclometasone 87 microgram/dose, formoterol 5 microgram/dose & glycopyrronium 9 microgram/dose pressurised metered dose inhaler (pMDI)
- Beclometasone 172 microgram/dose, formoterol 5 microgram/dose & glycopyrronium 9 microgram/dose pressurised metered dose inhaler (pMDI)
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Beclomethasone, formoterol & glycopyrronium (Trimbow NEXThaler®)
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Formulary
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- Beclomethasone 88 microgram/dose, formoterol 5 microgram/dose & glycopyrronium 9 microgram/dose dry powder inhaler (DPI)
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Fluticasone, umeclidinium & vilanterol (Trelegy Ellipta®)
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Formulary
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- Fluticasone 92 microgram/dose, umeclinidium 65 microgram/dose & vilanterol 22 microgram/dose dry powder inhaler (DPI)
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Budesonide, formoterol & glycopyrronium (Trixeo Aerosphere® )
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Formulary
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- Formoterol 5 microgram/dose, glycopyrronium 7.2 microgram/dose & budesonide 160 microgram/dose pressurised metered dose inhaler (pMDI)
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Key |
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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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CCG |
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Traffic Light Status Information
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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.
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. |
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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. |
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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. |
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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. |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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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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