BNF Chapter 3

1. Gastro-Intestinal System | 2. Cardiovascular System | 3. Respiratory System | 4. Central Nervous System | 5. Antimicrobials | 6. Endocrine System | 7. Obstetrics, Gynaecology & Urology | 8. Malignant Disease & Immunosuppression | 9. Nutrition & Blood | 10. Musculoskelatal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics |  GP Centre Home


Respiratory System

1 Airways disease, obstruction
AsthmaBTS Asthma Guideline
Global Initiative for Asthma Guideline
Asthma Management Guidelines
APC Asthma ICS/LABA Inhaler Choices
COPDNICE Guideline 101: Management of COPD
COPD Medicines Management Primary Care Guidelines
COPD Inhaler Device Summary
Prescribing notepMDI should be considered 1st line device of choice. Other devices may be considered if patients have been unable to use an MDI

Prescribe combination inhalers by BRAND

ANTIMUSCARINIC BRONCHODILATORS – Long-acting agents (LAMA)
ACLIDINIUM BROMIDE[DPI] Eklira Genuair 322micrograms/dose Licensed for COPD only

APC traffic light status: GREEN

GLYCOPYRRONIUM[DPI] Seebri Breezhaler 44micrograms/doseAPC traffic light status: GREEN
TIOTROPIUM[DPI] Spiriva Handihaler 18micrograms/dose

 

 

Handihaler not recommended for initiation. Licensed for COPD only

APC traffic light status: GREEN

 

Spiriva Respimat 2.5micrograms / doseAPC traffic light status: GREEN
Braltus 10mcg dry powder inhalerLicensed for COPD only (not 1st line)

APC traffic light status: GREEN

Short-acting agents
IPRATROPIUM BROMIDEMDI 20micrograms/dose, 40micrograms/dose
Nebules 250micrograms in 1ml, 500micrograms in 2mlAPC traffic light status: BLUE
BETA-ADRENOCEPTOR AGONISTS
Short-acting agents (SABA)
SALBUTAMOLMDI (Salamol) 100micrograms, Autohaler 100micrograms, Accuhaler (DPI)

Nebuliser solution 2.5mg in 2.5ml, 5mg in 2.5ml

 

Salbutamol Accuhaler not recommended

APC traffic light status: GREEN

Injection 500micrograms/ml, 5mg in 5ml

Tablets 2mg, 4mg

Syrup 2mg/5ml

TERBUTALINE

 

Turbohaler 250micrograms, 500micrograms/DOSE

Respules 5mg in 2ml

Injection 500micrograms/ml, 2.5mg in 5ml

Syrup 1.5mg in 5ml

Terbutaline Inhalers not recommended for initiation
Long-acting agents (LABA)
FORMOTEROLAtimos Modulite (MDI) 12micrograms/dose

Turbohaler 4.5micrograms, 9 micrograms/dose

Easyhaler

 

Formoterol Turbohalers not recommended for initiation

Formoterol Easyhaler can be used as an alternative to Atimos Modulite

APC traffic light status: GREEN

SALMETEROLMDI 25micrograms/dose

Accuhaler (DPI) 50micrograms/dose

Accuhaler not recommended for initiation

MDI can be used in combination with Volumatic spacer or Aerochamber plus

APC traffic light status: GREEN

ONBREZ BREEZHALER

(Indaterol)

 150 micrograms, 300 micrograms/doseOnly for those patients on a social care package requiring ONCE daily administration

Licensed for COPD

APC traffic light status: GREEN

OLODATEROLStriverdi Respimat (DPI) 2.5 micrograms/doseAlternative to Atimos Modulite

APC traffic light status: GREEN

Combination preparations (LAMA/LABA)
DUAKLIR GENUAIR (aclidinium/formoterol)[DPI] 340/12 microgramsAPC traffic light status: GREEN
ULITBRO BREEZHALER (indacaterol/glycopyrronium)Inhalation powder, hard capsule 85/43 microgramsAPC traffic light status: GREEN
SPIOLTO RESPIMAT (Tiotropium/oladaterol)Solution for inhalation, 2.5/2.5microgramsAPC traffic light status: GREEN
CORTICOSTEROIDSNOTES
Must be prescribed by BRANDMHRA Statement on CFC-free Beclometasone Prescribing
CLENIL

(beclometasone dipropionate)

MDI  50 micrograms, 100micrograms, 200micrograms, 250micrograms/doseCLENIL MODULITE 1st Line Beclometasone Inhaler of Choice  (Joint PCT/Acute Trust Prescribing Guidelines)

APC traffic light status: GREEN

QVAR

(beclometasone dipropionate)

MDI  50micrograms, 100micrograms/dose, 

Autohaler 50micrograms, 100micrograms/dose, 

Easi-breathe 50micrograms, 100micrograms/dose

QVAR 2nd line choice

APC traffic light status: GREEN

PULMICORT

(Budesonide)

[DPI]  Turbohaler 100micrograms, 200micrograms, 400micrograms/dose

PULMICORT Respules 500micrograms in 2ml, 1mg in 2ml

APC traffic light status: GREEN
EASYHALER

(Budesonide)

dose dry powder inhaler 100micrograms, 200 micrograms, 400 microgramsAPC traffic light status: GREEN
FLIXOTIDE

(Fluticasone)

Evohaler 50micrograms, 125micrograms, 250micrograms/dose

Accuhaler 50micrograms, 100micrograms, 250micrograms, 500micrograms/dose

APC traffic light status: GREEN
COMPOUND PREPARATIONS (ICS + LABA)
Must be prescribed by BRAND
DUORESP SPIROMAX (Budesonide/formoterol)160/4.5 micrograms, 320/9 microgramsCost effective inhaler combination of budesonide and formoterol

APC traffic light status: GREEN

FLUTIFORM (fluticasone/formoterol)50/5, 125/5, 250/10 microgramsAPC traffic light status: GREEN
FOSTAIR (Beclomethasone/formoterol)MDI 100/6 micrograms

NEXThaler [DPI] 100/6 micrograms

APC traffic light status: GREEN
RELVAR ELLIPTA (Fluticasone/vilanterol)92/22micrograms

184 / 22 micrograms

 

 

 

 

 

 

 

COPD and Asthma

Asthma only

Prescribing in asthma is restricted to patients where:

  • A medium or high dose ICS/LABA is indicated
  • The patient has already trialled one or more twice daily ICS/LABA devices and  is unable to comply due to the dosing regimen
  • The patient requires a once daily social package of care
PCN Policy statement – Relvar Ellipta in Asthma

APC traffic light status: GREEN

SYMBICORT (Budesonide/

formoterol)

 100/6, 200/6, 400/12APC traffic light status: GREEN
SERETIDE (Fluticasone/Salmeterol) Evohaler (MDI) 50, 125

Accuhaler (DPI) 100, 250, 500

 Not recommended for COPD

APC traffic light status: GREEN

SIRDUPLA (Fluticasone/salmeterol)Inhaler (MDI) 125, 250Cost-effective option, clinically equivalent to Seretide (Evohaler)

Not licensed in children

APC traffic light status: GREEN

COMPOUND PREPARATIONS (ICS + LABA + LAMA)
Must be prescribed by BRAND
TRELEGY ELIPTA (Fluticasone / umeclidium / vilanterolEllipta 92micrograms/dose / 55micrograms/dose / 22micrograms/dose dry powder inhalerCOPD

APC Policy statement: Trelegy for COPD

APC traffic light status: GREEN

TRIMBOW (Beclometasone / formoterol / glycopyrronium87micrograms/dose / 5micrograms/dose / 9micrograms/dose inhalerCOPD

APC Policy statement: Trimbow for COPD

APC traffic light status: GREEN

IMMUNOSUPPRESSANTS – MONOCLONAL ANTIBODIES
BENZALIZUMAB30mg / ml pre-fill injectionPrescribing should be by a specialist only, in line with NICE and/or local pathways. Commissioning through NHSE.

NICE TA 565: Benralizumab for treating severe eosinophilic asthma

APC traffic light status: RED

OMALIZUMABInjection 75mg in 0.5ml, 150mg in 1mlPrescribing should be by a specialist only, in line with NICE and/or local pathways. Commissioning through NHSE.

NICE TA278: Omalizumab for treating severe persistent allergic asthma

APC traffic light status: RED

RESLIZUMAB10mg / ml vial Prescribing should be by a specialist only, in line with NICE and/or local pathways. Commissioning through NHSE.

NICE TA 479: Reslizumab for treating severe eosinophilic asthma

APC traffic light status: RED

LEUKOTRIENE RECEPTOR ANTAGONISTS
MONTELUKASTTablets Chewable 4mg, 5mg

Granules 4mg

Tablets 10mg

APC traffic light status: GREEN
CROMOGLYCATE AND RELATED THERAPY
SODIUM CROMOGLICATE Inhaler 5mgINHALERS
PHOSPHODIESTERASE TYPE 4 INHIBITORS
RoflumilastTablets, 500microgramsNICE TA461: Roflumilast for treating chronic obstructive pulmonary disease

Roflumilast for COPD PCN Policy Statement

APC traffic light status: BLUE

XANTHINESNOTES
UKMI Medicines Q&A: How is an intravenous aminophylline dose converted to an oral aminophylline or theophylline dose?

How is an intravenous aminophylline dose converted to an oral aminophylline or theophylline dose?

SASH GuidelineSASH Aminophylline guideline
Prescribing GuidanceTherapeutic Drug Monitoring Required (Aminophylline blood levels)
Blood sample to be taken prior to oral dose (pre-dose level)
Target 56-111 micromoles/litre (10-20mg/L)
Aminophylline Toxicity Signs
Nausea & Vomiting, Agitation, Tachycardia, Arrhythmias & ConvulsionsNOTE: Always prescribe by Brand, differing brands may have differing bioequivalence
THEOPHYLLINETablets [Nuelin] 125mg, [Nuelin SA] MR 125mg, 250mg,

Capsules MR [Slo-Phyllin] 60mg, 125mg, 250mg

Tablets MR [Uniphyllin Continus] 200mg, 300mg, 400mg

Prescribe MR preparations by brand.

Therapeutic Drug Monitoring Required

APC traffic light status: GREEN

AMINOPHYLLINE Tablets MR 225mg, 350mg

Injection 250mg in 10ml

Therapeutic Drug Monitoring Required

For injection blood sample to be taken 18hr after start infusion

CAFFEINE CITRATE Injection 10mg in 1ml

Oral solution 20mg in 1ml

For use in neonates only

Caffeine Citrate 20mg/ml provides 10mg caffeine per ml

Unlicensed product

PEAK FLOW METERS, SPACERS, INHALER AIDS & NEBULISER DEVICES
AEROCHAMBER PLUS (Orange)
with Mask (Infant)
Masks cannot be detached from Aerochamber
Prescribe Aerochamber Plus (Standard + Mouthpiece) if mask is not requiredAerochamber Plus
Medium Volume DeviceCompatible with Salbutamol, Ventolin, Qvar, Beclazone, Fluticasone, Serevent, Seretide.NICE Guidance on Inhaler Devices (under 5yr)NICE Guidance on Inhaler Devices (older children)
AEROCHAMBER PLUS (Yellow)
with Mask (Child)
AEROCHAMBER PLUS (Blue) ( STANDARD + MOUTHPIECE)
(4yr+ to Adult)
BABYHALER
HALERAID 120 Dose
HALERAID 200 Dose
NEBUHALER
NEBUHALER WITH MASK
PEAK FLOW METER (LOW RANGE)
PEAK FLOW METER (STANDARD)
VOLUMATIC INHALATION DEVICEVOLUMATIC PAEDIATRIC INHALATION DEVICEVolumatic
Large Volume DeviceVolumatic products have been re-instated and are now availableCompatible with Salbutamol, Ventolin, Qvar, Becloforte, Becotide, Fluticasone, Serevent, Seretide.NICE Guidance on Inhaler Devices (under 5yr)NICE Guidance on Inhaler Devices (older children)
2 ALLERGIC CONDITIONS
EPINEPHRINE / ADRENALINE Auto-Injector 300micrograms (1 in 1000), 150micrograms (1 in 2000)JEXT 1st Line Agent of ChoiceJEXT Patient Information SASH[in case of product shortage or product recall, other brands may be used]
[ie EPIPEN / ANAPEN]APC traffic light status: GREEN
 ANTIHISTAMINES (non-sedating)
CETIRIZINETablets 10mg

Liquid 5mg in 5ml

1st  line agent – paeds/ENT & dermatology

APC traffic light status: GREEN

LORATADINETablets 10mg

Syrup 5mg in 5ml

 2nd  line agent – paeds/ENT & dermatology

APC traffic light status: GREEN

ANTIHISTAMINES (sedating)
CHLORPHENAMINETablets 4mg

Syrup 2mg in 5ml

Injection 10mg/ml

HYDROXYZINETablets 10mg, 25mg

Syrup 10mg in 5ml

Main use by dermatology / associated conditions
KETOTIFENElixir 1mg/5mlAntihistamine with little proven benefit in asthma
Occasional  use in paediatrics
PROMETHAZINE HYDROCHLORIDETablets 10mg, 25mg

Elixir 5mg in 5ml

Injection 25mg in 1ml

2.1. ANGIODEMA 
Complement Regulatory Proteins
C1 ESTERASE INHIBITOR Injection 500unitsNAMED PATIENT use only For hereditary angioedema
(also consider tranexamic acid / danazol for long term management)
Monoclonal antibodies
Lanadelumab150 mg per 1 mlPrescribing should be by a specialist only, in line with NICE and/or local pathways. Commissioning through NHSE.

NAMED PATIENT use only For hereditary angioedema

 3 CONDITIONS AFFECT SPUTUM VISCOSITY
MUCOLYTICS
CARBOCISTEINECapsules 375mg

Liquid sachets 750mg/10ml

Liquid 250mg in 5ml

RESTRICTED Use. Respiratory Team only

There is no evidence of improved efficacy with liquid carbocisteine compared to capsule formulation therefore wherever possible capsules should be prescribed.

Swallowing Difficulties

•750mg/10ml sachets 1st line for all patients on 750mg dosing with swallowing difficulties.

• Oral liquid 250mg/5ml should be reserved for patients requiring a dose of 375mg with swallowing difficulties.

APC traffic light status: GREEN

3.1 CYSTIC FIBROSIS
MUCOLYTICS
DORNASE ALFA1000 units (1mg) / ml  NEBULES

2500unit vial (PULMOZYME)

RESTRICTED Use. Respiratory Team only, for treatment in CF patients to improve pulmonary function (patients should have FVC > 40%)
Use undiluted in Jet Nebulisers Only
4 COUGH AND CONGESTION
COUGH SUPPRESSANTS
CODEINE 15 mg in 5ml Linctus
PHOLCODINE(Sugar Free) 5 mg in 5ml Linctus
SYSTEMIC NASAL DECONGESTANTS
PSEUDOEPHEDRINETablets 60mg
COUGH AND COLD PREPARATIONS – Other
CITRIC ACIDSIMPLE (Sugar-free) Linctus 25mg/ml
RESINS
BENZOIN COMPOUND Tincture16.5mg/mlfor inhalation
6 RESPIRATORY DEPRESSION, RESPIRATORY DISTRESS SYNDROME AND APNOEA
RESPIRATORY STIMULANTS
DOXAPRAMInjection 20mg/ml, 5ml ampUsed for post operative respiratory depression and acute respiratory failure.
Administer concurrent oxygen. Monitor ABG
PULMONARY SURFACTANTS
PORACTANT ALFA (80mg/ml) (Curosurf)
Vial 120mg (1.5ml), 240mg (3ml) Administered via Endotracheal Tube
ADDITIONAL PRODCUTS
DEEP HEAT SPRAY150ml sprayRestricted for use in capillary blood gas assessments only.
 Talc (PLEURODESIS)SASH Talc for PleurodesisHow should talc be administered for chemical pleurodesis
SASH Oxygen Therapy in Hospitalised Adult PatientsOxygen Policy SASH
STREPTOKINASEInjection 250000 unitsStreptokinase for intrapleural use (unlicensed indication)

 

1. Gastro-Intestinal System | 2. Cardiovascular System | 3. Respiratory System | 4. Central Nervous System | 5. Antimicrobials | 6. Endocrine System | 7. Obstetrics, Gynaecology & Urology | 8. Malignant Disease & Immunosuppression | 9. Nutrition & Blood | 10. Musculoskelatal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics |  GP Centre Home