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Herefordshire & Worcestershire
Medicines and Prescribing Committee
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 Formulary Chapter 3: Respiratory system - Full Chapter
Notes:
Osmohale as been approved as a standardised BHR challenge test in secondary care in line with the product's marketing authorisation in the Summary of Product Characteristics (SPC)
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03.01  Bronchodilators
03.01.01  Adrenoceptor agonists
03.01.01.01  Selective Beta2 agonists
03.01.01.01  Short-acting beta2 agonists
Salbutamol
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Formulary
Green

Inhaler devices, tablets, solution & nebules

 
 
Terbutaline Sulphate
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Formulary
Green

Inhaler device (Bricanyl Turbohaler®), nebules 

 
 
Salbutamol IV
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Formulary
Red
 
 
03.01.01.01  Long-acting beta2 agonists to top
Formoterol Fumarate
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Formulary
Green

Inhaler devices (Easyhaler®,Oxis® Atimos®)


PRESCRIBE BY BRAND


Not to be used in asthma without an inhaled corticosteroid

 
 
Salmeterol
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Formulary
Green

Inhaler devices


PRESCRIBE BY BRAND - Be aware of differences in excipients among thr different MDI brands


Not be used in asthma without an inhaled corticosteroid.

 
 
03.01.01.02  Other adrenoceptor agonists
03.01.02  Antimuscarinic bronchodilators
Aclidinium (Eklira®Genuair)
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Formulary
Green

Approved for the maintenance treatment of COPD; to be considered as a twice daily option when initiating treatment for a new patient.


PRESCRIBE BY BRAND

 
 
Glycopyrronium
(Seebri® Breezhaler)
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Formulary
Green

Approved for the maintenance treatment of COPD; to be considered as a daily option when initiating treatment for a new patient.


PRESCRIBE BY BRAND

 
 
Tiotropium (Spiriva Respimat®)
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Formulary
Green

For COPD & asthma


COPD:To be considered as a daily option when initiating treatment for a new patient where a dry powder inhaler is not suitable.


Asthma:Recommended as adjunctive treatment at BTS specialist therapies step.  


PRESCRIBE BY BRAND

 
 
Umeclidinium
(Incruse ® Ellipta)
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Formulary
Green

Approved for the maintenance treatment of COPD; to be considered as a daily option when initiating treatment for a new patient.


 PRESCRIBE BY BRAND

 
 
Tiotropium (Braltus Zonda® )
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Restricted Drug Restricted
Green

Braltus Zonda® Inhaler - Preferred alternative for existing Spiriva Handihaler® patients only.


PRESCRIBE BY BRAND

 
Link  Braltus-tiotropium risk of inhalation of capsule if placed in the mouthpiece of the inhaler
 
Tiotropium (Spiriva Handihaler® )
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Restricted Drug Restricted
Green

Restricted for existing patients only


PRESCRIBE BY BRAND

 
 
Ipratropium Bromide
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Formulary
Green

Inhaler devices and nebules

 
 
03.01.02  Short Acting Anti-muscarinic Bronchodilators
03.01.02  Long Acting Anti-muscarinic Bronchodilators
03.01.03  Theophylline to top
Aminophylline
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Formulary
Green

MR tablets


PRESCRIBE BY BRAND


NOTE: Phyllocontin® (aminophylline) Continus 225mg and Phyllocontin® Forte Continus 350mg modified-release tablets are being discontinued in the UK.



  • Remaining supplies of the 225mg strength are expected to be exhausted by 2nd March 2021 and the 350mg strength are expected to be exhausted by 5th April 2021.


Please see the alert here for advice on switching and monitoring.

 
 
Aminophylline
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Formulary
Red

IV Injection

 
 
Theophylline (Uniphyllin Continus® & Nuelin SA®)
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Formulary
Green

Modified-release tablets


PRESCRIBE BY BRAND

 
 
03.01.04  Compound bronchodilator preparations
Aclidinium & formoterol  (Duaklir® Genuair)
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Formulary
Green

Approved for the maintenance treatment of COPD; to be considered as a twice daily LAMA/LABA option when initiating treatment for a new patient.


PRESCRIBE BY BRAND 

 
 
Glycopyrronium & indacaterol
(Ultibro® Breezhaler.)
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Formulary
Green

Approved for  the maintenance treatment of COPD; to be considered as a once daily LAMA/LABA option when initiating treatment for a new patient


PRESCRIBE BY BRAND

 
 
Tiotropium & olodaterol (Spiolto® Respimat)
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Formulary
Green

 LAMA/LABA option for COPD  patients unable to use dry powder inhalers


 PRESCRIBE BY BRAND

 
 
Umeclidinium & vilanterol  (Anoro® Ellipta.)
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Formulary
Green

Approved for the maintenance treatment of COPD; to be considered as a once daily LAMA/LABA option when initiating treatment for a new patient.


PRESCRIBE BY BRAND

 
 
Ipratropium bromide & salbutamol (Combivent® Nebules)
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Formulary
Green
 
 
03.01.05  Peak flow meters, inhaler devices and nebulisers
Oscillating positive expiratory pressure device
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Restricted Drug Restricted
Red

The prescribing committee supported the addition of the Flutter® valve device (Clement Clarke) to the formulary, when required as an adjunct to Active Cycle of Breathing Techniques (ACBT) in patients with bronchiectasis, COPD bronchiectasis and Cystic Fibrosis and as an addition to ACBT in patients who need extra techniques to clear effectively or who are having repeated infections; ONLY following recommendation, training and supply by competent, qualified NHS respiratory physiotherapists as part of the MDT process; i.e. GP prescribing is NOT supported.


Acapella® device also supported in line with provider site preference with same restrictions.

 
 
03.01.05  Peak flow meters
Low range peak flow meter
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Formulary
Green
 
 
Standard range peak flow meter
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Formulary
Green
 
 
03.01.05  Drug delivery devices
Drug Delivery Device(Spacer)
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Formulary
Green

  • AeroChamber Plus®

  • Volumatic®

 
 
03.01.05  Nebulisers to top
03.01.05  Nebuliser Diluent
Nebuliser diluent (Sodium chloride 0.9%)
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Formulary
Green
 
 
03.02  Corticosteroids
03.02.01  Inhaled Corticosteroids
Beclometasone inhalers
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Formulary
Green

QVAR® & Clenil® MDI 


Easyhaler® Beclometasone (DPI) 


All are only licensed for asthma 


PRESCRIBE BY BRAND - devices are not bioequivalent

 
 
Budesonide
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Formulary
Green

Dry powder inhaler (Pulmicort® Turbohaler)


Nebulised solution

 
 
Fluticasone inhalers
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Formulary
Green

Inhaler devices (MDI, Accuhaler)

 
 
Beclometasone & formoterol  (Fostair® )
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Formulary
Green

Fostair® MDI is a preferred option for asthma (100/6 & 200/6) & COPD (100/6 only)

Fostair Nexthaler® is a preferred fixed dose DPI ICS/LABA option (100/6 & 200/6) for asthma.


DPI and MDI can also be used in asthma MART regime (100/6 only)


PRESCRIBE BY BRAND

 
 
Fluticasone furoate & vilanterol  (Relvar® Ellipta)
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Formulary
Green

Relvar® Ellipta 92/22  a preferred device for asthma (medium dose) and COPD 


Relvar® Ellipta 184/22  a preferred device for asthma only (high dose) 


PRESCRIBE BY BRAND

 
 
Budesonide & formoterol (Duoresp® Spiromax )
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Formulary
Green

Duoresp® Spiromax Available in 160/4.5 & 320/9 strengths 


Maintenance treatment of COPD and asthma; to be considered as a twice daily preferred DPI ICS/LABA option.


For asthma, can also be used in MART regime  (160/4.5 strength only)

PRESCRIBE BY BRAND

 
 
Budesonide & formoterol  (Fobumix® Easyhaler)
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Formulary
Green

Fobumix® Easyhaler available in 80/4.5 160/4.5 & 320/9 strengths 


A preferred  fixed dose DPI ICS/LABA option for asthma. 


Can also be used in a MART regime (80/4.5 & 160/4.5 strengths only


PRESCRIBE BY BRAND

 
 
Fluticasone & formoterol (Flutiform® )
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Formulary
Green

Flutiform® MDI, available in 50/5, 125/5 & 250/10 strengths


A preferred MDI option for asthma


PRESCRIBE BY BRAND

 
 
Budesonide & formoterol  (Symbicort® Turbohaler )
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Formulary
Green

Symbicort® Turbohaler Available in 100/6 200/6 400/12 strengths


Fixed dose option for asthma


SMART option for asthma (100/6 & 200/6 only)


Also preferred option for COPD 


PRESCRIBE BY BRAND 

 
 
Fluticasone & salmeterol  (Sirdupla® , Airfusal® )
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Formulary
Green

MDIs available in 125/25 & 250/25 strengths only 


Formulary options for asthma 

PRESCRIBE BY BRAND

 
 
Fluticasone & salmeterol  (Airflusal® Forspiro)
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Restricted Drug Restricted
Green

Airflusal® Forspiro 500 device for existing COPD patients only


PRESCRIBE BY BRAND

 
 
Fluticasone & salmeterol  (Seretide®)
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Restricted Drug Restricted
Green

Seretide®Accuhaler and MDI inhalers available for existing asthma patients only. 

Seretide®500 Accuhaler also available for existing COPD patients only 


PRESCRIBE BY BRAND

 
 
03.02.02  Combination products (ICS+LABA) for asthma
03.02.02  Low dose to top
03.02.02  Moderate dose
03.02.02  High dose
03.02.03  Combination products (ICS+LABA) for COPD
03.02.03  Triple Therapy products for COPD
Fluticasone furoate/umeclidinium/vilanterol  (Trelegy® Ellipta)
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Formulary
Green

Trelegy® Ellipta (DPI) 92/5/22


Patients currently on triple therapy should not automatically be optimised to this device without an assessment to confirm the need for triple therapy to continue


PRESCRIBE BY BRAND 

 
 
Beclometasone/formoterol/glycopyrronium
(Trimbow® )
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Formulary
Green

 Trimbow® MDI 87/5/9 


Patients currently on triple therapy should not automatically be optimised to this device without an assessment to confirm the need for triple therapy to continue.


PRESCRIBE BY BRAND

 
 
03.03  Cromoglicate, related therapy and leukotriene receptor antagonists to top
03.03.01  Cromoglicate and related therapy
Sodium Cromoglicate Inhaler Devices
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Formulary
Green
 
 
03.03.01  Related therapy
03.03.02  Leukotriene receptor antagonists
Montelukast
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Formulary
Green

Adjunctive therapy in asthma, to be added if required after introduction of inhaled LABA in a combination inhaler.

 
Link  MHRA Drug Safety Update (Oct 19); Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions
 
03.03.03  Phosphodiesterase type-4 inhibitors
Roflumilast (Daxas®)
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Formulary
Amber

In line with NICE TA 461.

 
Link  NICE TA461 Roflumilast for treating Chronic Obstructive Pulmonary Disease
 
03.04  Antihistamines, hyposensitisation, and allergic emergencies to top
03.04.01  Antihistamines
03.04.01  Non-sedating antihistamines
Cetirizine Hydrochloride
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Formulary
Green

Patients with conditions appropriate for self-care should be advised to buy over the counter, in line with NHSE guidance

 
Link  NHSE Conditions for which over the counter items should not routinely be prescribed in primary care
 
Loratadine
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Formulary
Green

Patients with conditions appropriate for self-care should be advised to buy over the counter, in line with NHSE guidance

 
Link  NHSE Conditions for which over the counter items should not routinely be prescribed in primary care
 
Fexofenadine Hydrochloride
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Formulary
Green

Prescribing to be considered only when alternative, more readily available OTC antihistamines have failed.

 
 
03.04.01  Sedating antihistamines
Chlorphenamine Maleate
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Formulary
Green

Patients with conditions appropriate for self-care should be advised to buy the preparation over the counter, in line with NHSE&I guidance

 
Link  NHSE/I: Items which should not routinely be prescribed in primary care: Guidance for CCGs
 
Hydroxyzine Hydrochloride
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Formulary
Green
 
 
Ketotifen Tablets and Syrup
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Formulary
Green

Zaditen® -  Paediatrics only

 
 
Promethazine Hydrochloride
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Formulary
Green
 
 
03.04.02  Allergen Immunotherapy
Bee and Wasp Allergen Extracts (Pharmalgen®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

In line with NICE TA 246 

 
Link  NICE TA 246 Pharmalgen for the treatment of bee and wasp venom allergy
 
Benralizumab (Fasenra®)
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Formulary
Red

Commissioned  by NHS England in line with NICE TA565 for the treatment of severe eosinophilic asthma

 
Link  NICE TA565 Benralizumab for treating severe eosinophilic asthma
 
Mepolizumab (Nucala®)
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Formulary
Red

Commissioned  by NHS England in line with NICE TA431 for the treatment of severe eosinophilic asthma

 
Link  NICE TA431 Mepolizumab for treating severe refractory eosinophilic asthma
 
Reslizumab (Cinqaero®)
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Formulary
Red

Commissioned by NHS England in line with NICE TA479 for the treatment of severe eosinophilic asthma

 
Link  NICE TA479 Reslizumab for treating severe eosinophilic asthma
 
Sublingual Allergen Immunotherapy (SLIT)
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Formulary

The availability of the SLIT armoury is supported as deemed appropriate both clinically and financially by the Specialist Division within WAHT; with consultant initiation and prescribing retained in secondary care. 


An annual update in relation to SLIT and noted outcomes will be received.

 
 
03.04.02  Omalizumab to top
Omalizumab (Xolair®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

Commissioned  by NHS England in line with NICE TA278 (Updates of TA133 and 201) via designated specialist centres.

CCG commissioned in line with NICE TA339: Recommended as an option as add-on therapy for treating severe chronic spontaneous urticaria in adults and young people aged 12 years and over.

 
Link  NICE TA278 Omalizumab for treating severe persistent allergic asthma (updates and replaces 133 and 201)
Link  NICE TA339 Omalizumab for previously treated chronic spontaneous urticaria
Link  Omalizumab, Chronic Spontaneous Urticaria – Cytokine Modulator Pathway
 
03.04.03  Allergic emergencies
C1 Esterase Inhibitor
View adult BNF View SPC online View childrens BNF
Formulary
Red

Berinert® (As of Jan 20, very limited stock available)


Cynrize® 


Commissioned by NHS England

 
 
Icatibant
View adult BNF View SPC online View childrens BNF
Formulary
Red

Firazyr®


Commissioned by NHS England

 
 
03.04.03  Anaphylaxis
03.04.03  Angioedema
03.04.03  Intramuscular adrenaline (epinephrine)
03.04.03  Self-administration of adrenaline (epinephrine) to top
Adrenaline / Epinephrine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Epipen® & Jext® auto-injectors


There are shelf life, device and administration differences for the devices, therefore related education and training is required for patients and their carers.


PRESCRIBE BY BRAND


Note that as of 18/5/20 all strengths of Emerade® are unavailable following class 2 MHRA patient level recalls - see MHRA website below:  

 
Link  MHRA Drug-device alerts
 
Adrenaline / Epinephrine (Adrenaline / Epinephrine 1 in 1000)
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Formulary
Green
 
 
03.05  Respiratory stimulants and pulmonary surfactants
03.05.01  Respiratory stimulants
Caffeine (base) Injection
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

  • Unlicensed.

  • Specialist use for neonates only

  • Prescribe as caffeine citrate as per BNF advice

 
 
Doxapram Hydrochloride
View adult BNF View SPC online View childrens BNF
Formulary
Red

Consultant use only

 
 
03.05.02  Pulmonary surfactants
Poractant Alfa (Curosurf®)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

  • For Neonates only

  • Approved for use for Respiratory distress syndrome 

 
 
03.06  Oxygen
03.06  Long-term oxygen therapy to top
03.06  Short burst oxygen therpary
03.06  Abulatory oxygen therapy
03.06  Oxygen therapy equipment
03.06  Arrangements for supplying oxygen
03.07  Mucolytics to top
Carbocisteine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Capsules, liquid & SF sachets.


Note: BNF recommendation that mucolytic therapy should be reviewed & stopped if there is no benefit after a 4 week trial.

 
 
Acetylcysteine
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

  • For interstitial lung disease/idiopathic pulmonary fibrosis but no longer routinely recommended.

  • Any prescribing for new patients to be retained by secondary care.

  • Primary care prescribing supported for existing patients only, where 600mg effervescent tablets  (NACSYS®)  should be used.

 
 
Hypertonic sodium chloride solution 3% 6% 7%
View adult BNF View SPC online View childrens BNF
Formulary
Amber

For nebulisation

 
 
Mannitol dry powder for inhalation
View adult BNF View SPC online View childrens BNF
Formulary
Red

In line with NICE TA266. Dry powder inhalation for treating cystic fibrosis 


Commissioned by NHSE

 
Link  NICE TA266 Mannitol dry powder for inhalation for treating cystic fibrosis
 
03.07  Dornase alfa
Dornase Alfa
View adult BNF View SPC online View childrens BNF
Formulary

Red New patients to receive from Acute Trust Provider. Commissioned by NHS England for Cystic Fibrosis only.


Amber GPs can continue to prescribe for existing patients & will be commissioned  by the CCG (when delivered via nebulisation/inhalation).


 GPs should not take on any new prescribing of this drug.


 


 

 
 
03.08  Aromatic inhalations
03.09  Cough preparations
03.09.01  Cough suppressants
Codeine Linctus BP
View adult BNF View SPC online View childrens BNF
Formulary
Green

Patients with conditions appropriate for self-care should be advised to buy the preparation over the counter, in line with NHSE guidance

 
Link  NHSE Conditions for which over the counter items should not routinely be prescribed in primary care
 
Pholcodine Linctus, BP
View adult BNF View SPC online View childrens BNF
Formulary
Green

Patients with conditions appropriate for self-care should be advised to buy the preparation over the counter, in line with NHSE&I guidance

 
Link  NHSE Conditions for which over the counter items should not routinely be prescribed in primary care
 
03.09.01  Palliative care to top
03.09.02  Expectorant and demulcent cough preparations
Simple Linctus, BP
View adult BNF View SPC online View childrens BNF
Formulary
Green

Patients with conditions appropriate for self-care should be advised to buy the preparation over the counter

 
Link   NHSE/I: Items which should not routinely be prescribed in primary care: Guidance for CCGs
 
Simple Linctus, Paediatric BP
View adult BNF View SPC online View childrens BNF
Formulary
Green

Patients with conditions appropriate for self-care should be advised to buy the preparation over the counter

 
Link  NHSE/I: Items which should not routinely be prescribed in primary care: Guidance for CCGs
 
03.10  Systemic nasal decongestants
03.11  Antifibrotics
Nintedanib (Ofev®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

  • Commissioned  by NHS England.

  • In line with NICE TA379 for the use in idiopathic pulmonary fibrosis

 
Link  NICE TA379 Nintedanib for treating idiopathic pulmonary fibrosis
 
Pirfenidone (Esbriet®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

  • Commissioned by NHS England.

  • In line with NICE TA504 for use in idiopathic pulmonary fibrosis

 
Link  NICE TA504:Pirfenidone for treating idiopathic pulmonary fibrosis
 
 ....
 Non Formulary Items
Alimemazine Tartrate  (Vallergan®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Ciclesonide  (Alvesco®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Desloratadine  (Neoclarityn®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Indacaterol  (Onbrez Breezhaler®)

View adult BNF View SPC online View childrens BNF
Non Formulary

Prescribing not supported by prescribing committee  on 3/7/12

Levocetirizine Hydrochloride  (Xyzal®)

View adult BNF View SPC online View childrens BNF
Non Formulary
  
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
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Red

Secondary care only, not to be prescribed in primary care.   

Amber 2

Specialist initiation with shared care guidance Medicines which should be initiated in secondary care by the specialist with follow-on prescription and monitoring according to a specific Shared Care (SC) Guideline. Prescribing may be continued in primary care in line with a shared care guideline   

Amber with Shared Care

Specialist initiation with shared care guidance Medicines which should be initiated in secondary care by the specialist with follow-on prescription and monitoring according to a specific Shared Care (SC) Guideline. Prescribing may be continued in primary care in line with a shared care guideline   

Amber

Considered suitable for primary care prescribing following specialist initiation/recommendation.  

Green

Considered appropriate for prescribing in both secondary and primary care. Suitable for initiation in primary care.   

netFormulary