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 Formulary Chapter 3: Respiratory system - Full Chapter
Notes:

Coronavirus guidance

Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.

The list of resources will be updated as new material becomes available so please check back regularly for updates.

The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.

Respiratory system

Review date: March 2022

Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.

Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol View childrens BNF) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Chapter Links...
 Details...
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
 note  (Although drowsiness is rare, nevertheless, patients should be advised that it can occur and may affect performance of skilled tasks e.g., driving; excess alcohol should be avoided).
Loratadine
View adult BNF View SPC online View childrens BNF
First Choice
Green
Tablets 10 mg;
Syrup 5 mg/5 Ml  
Cetirizine hydrochloride
View adult BNF View SPC online View childrens BNF
First Choice
Green
Tablets 10 mg;
Oral solution 5 mg/5 mL  
Fexofenadine hydrochloride
View adult BNF View SPC online View childrens BNF
Second Choice
Green
Tablets 30 mg, 120 mg, 180 mg  
   
03.04.01  Expand sub section  Sedating antihistamines
 note  Drowsiness may affect performance of skilled tasks e.g., driving; sedating effects enhanced by alcohol.

Drowsiness may affect performance of school tasks and academic achievement in children.
Chlorphenamine maleate
View adult BNF View SPC online View childrens BNF
First Choice
Green
Tablets 4 mg;
Oral solution 2 mg/5 mL 
Promethazine hydrochloride
View adult BNF View SPC online View childrens BNF
First Choice
Green
Tablets 10 mg, 25 mg;
Elixir 5 mg/5 mL

Paediatrics: short term use only. 
Hydroxyzine hydrochloride
View adult BNF View SPC online View childrens BNF
First Choice
Green
Tablets 10 mg, 25 mg

MHRA Advice:
The maximum adult daily dose of hydroxyzine is now 100 mg. Do not prescribe hydroxyzine to people with a prolonged QT interval or risk factors for QT interval prolongation
 
Alimemazine tartrate
View adult BNF View SPC online View childrens BNF
Formulary
Black

Tablets 10 mg;
Syrup 7.5 mg/5 mL, 30 mg/5 mL

Amber Recommended Paediatrics only. 

Expensive: recommended only where all other sedating antihistamines are unsuitable. N.B. when used for insomnia - short-term use only

 
   
Cyproheptadine
View adult BNF View SPC online
Formulary
Red
Tablets 4mg

Antidote for the management of serotonin syndrome.

Paediatrics: no BNFc entry; seek specialist advice. 
   
03.04.02  Expand sub section  Allergen Immunotherapy to top
Bee and wasp allergen extracts (Pharmalgen®)
View adult BNF View SPC online View childrens BNF
Formulary
Red
Bee venom injections
Wasp venom injections 
Link  NICE TA246, Pharmalgen for the treatment of bee and wasp venom allergy
   
Grass pollen extract (Grazax®)
View adult BNF View SPC online View childrens BNF
Formulary
Red
SPECIALIST SERVICE
Tablets, grass pollen extract 75 000 units 
   
03.04.02  Expand sub section  Mepolizumab & Omalizumab
Benralizumab Black Triangle
View adult BNF View SPC online View childrens BNF
Formulary
Red
NHS England

30 mg solution for injection in pre filled syringe

NHSE NHSE commissioned drug - see Specialised Commissioning: Key documents and NICE TA565, for treating severe oesinophilic asthma

 
Link  NICE TA565: Benralizumab for treating severe eosinophilic asthma
   
Dupilumab
View adult BNF View SPC online View childrens BNF
Formulary
Red

Pre-filled syringe 200mg, 300mg

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents for allergic asthma

 
   
Mepolizumab
View adult BNF View SPC online
Formulary
Red

100mg powder for solution for injection
(As per NICE TA431)

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents

 
Link  NICE TA671 (2021): Mepolizumab for treating severe eosinophilic asthma
   
Omalizumab
View adult BNF View SPC online View childrens BNF
Formulary
Red
Pre-filled syringe 75mg in 0.5mL, 150 mg in 1mL
(As per NICE guidance TA278 & TA339)

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents
for allergic asthma

CCG Commissioned for chronic urticaria 
Link  NICE TA339: Omalizumab for previously treated chronic spontaneous urticaria
Link  NICE TA278: Omalizumab for the treatment of severe persistent allergic asthma in children aged 6 and over and adults (review of TA133 and TA201) National Institute for Health and Clinical Excellence Technology Appraisal
Link  Omalizumab for severe asthma in adults NHS England specialised commissioning resources: the clinical reference group responsible for respiratory disease has published a commissioning policy that defines access to a particular service for a cohort of patie
   
Reslizumab
View adult BNF View SPC online
Formulary
Red

10 mg/mL concentrate for solution for infusion

(As per NICE TA479)

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents

 
Link  NICE TA479: Reslizumab for treating severe eosinophilic asthma
   
03.04.03  Expand sub section  Allergic emergencies
Adrenaline
View adult BNF View SPC online View childrens BNF
Formulary
Green
Self administration
150 micrograms, 300 micrograms; Epipen®, Jext®, Emerade®
300 micrograms; Epipen®, Jext®, Emerade®
500 micrograms; Emerade®
These auto-injectors are administered by intramuscular injection. Individuals at considerable risk of anaphylaxis must carry adrenaline at all times. Patients need to be prescribed two devices and carry both at all times. 
Link  MHRA (2019). Adrenaline auto-injectors: recent action taken to support safety
Link  Pan Mersey APC (2019). ADRENALINE auto-injectors
   
Adrenaline
View adult BNF View SPC online View childrens BNF
Formulary
Red
Intravenous injection, intramuscular injection; 1 in 1000, 1 in 10,000

Green administered in emergency 
   
03.04.03  Expand sub section  Anaphylaxis
03.04.03  Expand sub section  Angioedema
 note 

C1-Esterase Inhibitor, Conestat Alfa, and Icatibant

NHSE NHSE commissioned service- see Clinical Commissioning Policy: Treatment of Acute Attacks in Hereditary Angioedema, April 2013 for further information.

 ....
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

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection.  Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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