netFormulary The Pennine Acute Hospitals NHS
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 Formulary Chapter 3: Respiratory system - Full Chapter
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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
03.01.01.01  Short-acting beta2 agonists
Salbutamol
(100 micrograms/dose CFC free Metered Dose Inhaler (MDI))

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First Choice Brands include Ventolin Evohaler®, Airomir® inhaler.
 
Salbutamol
(100 microgram/dose, 200microgram per dose)

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Formulary Dry powder inhaler (DPI)(Easyhaler®)
Breath-actuated inhaler (Airomir® Autohaler, Salamol Easi-breathe®)
Dry powder inhaler(Ventolin®Accuhaler)
 
Terbutaline
(500 micrograms/dose)

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Formulary Dry powder inhaler (DPI)(Bricanyl® Turbohaler)
 
Salbutamol

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Formulary Inhalers (see separate entries)
Nebuliser solution
Tablets
Oral solution
Injection
Solution for infusion


Restricted Item The use of short-acting adrenoreceptor agonists for tocolyis in premature labour has been restricted to 48 hours maximum parenteral use under specialist supervision, after a European safety review (MHRA 2013 - see Drug Safety Update)

Link  MHRA Drug Safety Update Nov 2013  
Terbutaline

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Formulary Inhaler (see separate entry)
Nebuliser solution 5mg/2ml (Respules®)
 
03.01.01.01  Long-acting beta2 agonists
 note  In the management of asthma, long-acting beta 2 agonists (LABAs) should always be prescribed with concomitant inhaled corticosteroid (ICS) and only when ICS alone is not sufficient to control asthma symptoms. Review LABA therapy regularly, prescribe the lowest effective dose, and stop if there is no benefit.
Formoterol

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First Choice Dry powder inhaler 12 micrograms/dose (Easyhaler®)
Dry powder inhaler 6 micrograms/dose, 12 micrograms/dose (Oxis® Turbohaler)

 
Salmeterol

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Formulary Metered dose inhaler 25 micrograms/dose (Serevent Evohaler®)
Dry powder inhaler (Serevent Accuhaler®)

 
Indacaterol

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Formulary Dry powder inhaler 150 microgram/dose, 300 microgram/dose (Onbrez Breezhaler®)

May be considered as a treatment option for COPD patients in whom another long acting β-adrenoceptor agonist (LABA) would be suitable (GMMMG).

Not licensed for asthma.
 
03.01.01.02  Other adrenoceptor agonists
03.01.02  Antimuscarinic bronchodilators to top
 note  GMMMG: COPD Inhaler Options
Glycopyrronium (Seebri breezhaler®)
(Long acting)

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First Choice Inhalation powder, hard capsule for use with Breezhaler® device

Reserved for COPD patients with intolerance to tiotropium, or those who cannot use tiotropium devices.

Link  GMMMG: COPD Inhaler Options
Link  IPNTS recommendation: Glycopyrronium  
Aclidinium (Eklira Genuair®)
(Long acting)

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Formulary Inhaler 400 micrograms/dose


Link  GMMMG: COPD Inhaler Options
Link  IPNTS recommendation: Aclidinium  
Ipratropium
(Short acting)

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Formulary Metered dose inhaler (MDI) 20 micrograms/dose
Nebuliser solution 250 micrograms/ml, 500 micrograms/ml

 
Umeclidinium (Incruse Ellipta)
(55mcg/dose )

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Formulary

Link  GMMMG: COPD Inhaler Options  
Tiotropium (Spiriva®)
(Long acting)

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Formulary Inhalation powder, hard capsule for use with Handihaler® device, 18 micrograms.
Respimat® inhaler 2.5 micrograms/dose.

The Spiriva Respimat device should be used with caution in patients with known cardiac rhythm disorders - see SPC

Link  GMMMG: COPD Inhaler Options  
03.01.03  Theophylline
Theophylline

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First Choice Modified release tablets (Nuelin SA®, Uniphyllin Continus®)
Modified release capsules (Slo-Phyllin®)

Specify brand when prescribing.
 
Aminophylline

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Formulary Modified release tablets

Red Traffic Light  Injection




Link  Adult Loading Doses Policy  
03.01.04  Compound bronchodilator preparations
Aclidinium / Formoterol (Duaklir® Genuair)

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Formulary Combination LABA/LAMA inhaler

Link  GMMMG: COPD Inhaler Options  
Glycopyrronium / Indacaterol (Ultibro® Breezhaler)

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Formulary Combination LABA/LAMA inhaler

Link  GMMMG: COPD Inhaler Options  
Tiotropium / Olodaterol (Spiolto® Respimat)

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Formulary Metered dose inhaler

Combination LABA/LAMA inhaler

Link  GMMMG: COPD Inhaler Options  
Umeclidinium / Vilanterol (Anoro® Ellipta)

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Formulary Combination LABA/LAMA inhaler

Link  GMMMG: COPD Inhaler Options  
03.01.05  Peak flow meters, inhaler devices and nebulisers
 note  Spacers should not be regarded as interchangeable: patients who use a spacer with their inhaler should use the spacer dervice named in the Summary of Product Characteristics (where specified by name).
03.01.05  Drug delivery devices
Drug Delivery Device (Volumatic®)

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First Choice
 
Drug Delivery Device (AeroChamber Plus®)

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Formulary
 
03.01.05  Nebuliser Diluent to top
Sodium Chloride 0.9%

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Formulary Nebuliser solution
 
03.02  Corticosteroids
 note 

Prescribe beclomethasone diproprionate by brand.
The MHRA has advised that beclomethasone diproprionate CFC-free inhalers should be prescribed by brand name. Clenil Modulite® and Qvar® are not interchangeable. Qvar® has extra fine particles and is approximately twice as potent as Clenil Modulite®.
 
Single component corticosteroid inhalers are only licensed for ASTHMA. COPD patients should be prescribed combination inhalers.

Beclometasone (Clenil Modulite®)

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First Choice Metered Dose Inhaler (MDI)
 
Beclometasone (Qvar®)

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First Choice Metered Dose Inhaler (MDI)
Easi-breathe®
Autohaler®

note Not licensed for use in paediatrics.
 
Budesonide

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Formulary Dry powder inhaler (Easyhaler®, Pulmicort® Turbohaler)
Respules
 
Fluticasone

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Formulary Metered dose inhaler (Flixotide® Evohaler)
Dry powder inhaler (Flixotide® Accuhaler)
Nebules
 
Beclometasone and formoterol (Fostair®)

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Formulary Metered dose inhaler (MDI)

Combination ICS/LABA inhaler

Fostair® contains an extra-fine formulation of beclomethasone and is more potent than traditional CFC-containing beclomethasone inhalers - check dose.

note  First-line MDI for patients with COPD who cannot use dry powder inhalers or would prefer a metered-dose inhaler.

Link  GMMMG: COPD Inhaler Options  
Budesonide and formoterol (DuoResp® Spiromax)

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Formulary Dry powder inhaler

Combination ICS/LABA inhaler
 
Fluticasone and formoterol (Flutiform®)

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Formulary Metered dose inhaler

Combination ICS/LABA inhaler

note Licensed for ASTHMA only.
 
Fluticasone furoate & vilanterol (Relvar Ellipta®)

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Formulary Dry powder inhaler

Combination ICS/LABA inhaler

note184/22 strength licensed for ASTHMA only

Link  GMMMG: COPD Inhaler Options  
Budesonide and formoterol (Symbicort® Turbohaler)

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Restricted Drug Restricted Dry powder inhaler

Combination ICS/LABA inhaler

Restricted Item Not to be initiated, but can be continued in established patients
 
Fluticasone and salmeterol (Seretide®)

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Restricted Drug Restricted Metered dose inhaler (Seretide® Evohaler)
Dry powder inhaler (Seretide® Accuhaler)

Combination ICS/LABA inhaler

note Only the Seretide 500 Accuhaler is licensed for use in COPD. Seretide 250 Evohaler is very expensive - please consider alternatives where possible.

Restricted Item Not to be initiated, but can be continued in established patients.
 
03.03  Cromoglicate, related therapy and leukotriene receptor antagonists
03.03.01  Cromoglicate and related therapy
03.03.01  Related therapy
03.03.02  Leukotriene receptor antagonists to top
Montelukast (Singulair®)

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Formulary Tablets
Restricted Item Chewable Tablets
Restricted Item Granules

Restricted Item The Scottish Medicines Compendium has advised (June 2007) that montelukast chewable tablet and granules are restricted for use as an alternative treatment option to low-dose inhaled corticosteroids for children 2 to 14 years of age with mild persistent asthma who do not have a recent history of serious asthma attacks that required oral corticosteroid use, and who have demonstrated that they are not capable of using inhaled corticosteroids.

The chewable tablets and granules should be initiated by specialists in paediatric asthma care.

 
03.03.03  Phosphodiesterase type-4 inhibitors
Roflumilast (Daxas®)

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Formulary Tablets

Link  NICE TA461: Roflumilast for treating chronic obstructive pulmonary disease  
03.04  Antihistamines, hyposensitisation, and allergic emergencies
03.04.01  Antihistamines
03.04.01  Non-sedating antihistamines
Cetirizine

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First Choice Tablets
Oral solution
 
Loratadine

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Second Choice Tablets
Oral Solution
 
Fexofenadine

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Formulary Tablets

Restricted Item  For established patients only
 
03.04.01  Sedating antihistamines to top
Chlorphenamine

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First Choice Tablets
Oral Solution
 
Hydroxyzine

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Second Choice Tablets
Oral Solution

Hydroxyzine is favoured by dermatologists for its anti-itch and sedating effects.


Link  MHRA alert: risk of QT prolongation and Torsade de Pointes  
Alimemazine

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Formulary Tablets
Oral Solution

Restricted Item On formulary for paediatric use only

 
Promethazine

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Formulary Tablets
Elixir
Injection

 
03.04.02  Allergen Immunotherapy
Bee and Wasp Allergen Extracts (Pharmalgen®)

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Formulary Subcutaneous injection

Restricted Item Specialist Use Only

Link  NICE TA246: Pharmalgen for the treatment of bee and wasp venom allergy  
03.04.02  Omalizumab
Omalizumab (Xolair®)

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Restricted Drug Restricted
Red
Subcutaneous injection

Link  NICE TA278: asthma (severe, persistent, patients aged 6+, adults) - omalizumab  
03.04.03  Allergic emergencies
03.04.03  Anaphylaxis
Adrenaline / epinephrine

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Formulary DotInjection (IM/SC)
DotInjection (IV) Extreme caution
Restricted Item Intravenous adrenaline should only be given by those experienced in its use, in a setting where patients can be carefully monitored. See BNF for more information. DotIntramuscular injection for self-administration (auto-injector) (EpiPen®, Jext®)
It is advisable to prescribe adrenaline auto-injector by brand to avoid confusion.




Link  PAHT Resuscitation Policy  
03.05  Respiratory stimulants and pulmonary surfactants to top
03.05.01  Respiratory stimulants
Doxapram

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Formulary Intravenous injection

May also be given by intravenous infusion (unlicensed)
 
03.05.02  Pulmonary surfactants
Poractant Alfa (Curosurf®)

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Formulary Suspension

Restricted Item Specialist neonatal use only
 
03.06  Oxygen
03.06  Long-term oxygen therapy
03.06  Short burst oxygen therpary to top
03.06  Ambulatory oxygen therapy
03.06  Oxygen therapy equipment
03.06  Arrangements for supplying oxygen
03.07  Mucolytics
Carbocisteine

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Formulary Capsules
Liquid

 
03.07  Dornase alfa to top
Dornase Alfa (Pulmozyme®)

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Formulary
Amber
nebuliser solution

Restricted Item Must only be initiated within hospital for the treatment of cystic fibrosis.
 
03.07  Hypertonic Sodium Chloride
Hypertonic sodium chloride

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Formulary Nebuliser solution
 
03.08  Aromatic inhalations
03.09  Cough preparations
03.09.01  Cough suppressants
Codeine Linctus BP

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Formulary Oral solution

 
Pholcodine

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Formulary Oral solution
 
03.09.01  Palliative care to top
Controlled Drug  Methadone Hydrochloride (Methadone® Linctus)

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Formulary Oral solution

Methadone has been used to control distressing cough in terminal lung cancer, although morphine is now preferred. In other circumstances, it is contraindicated because it induces sputum retention and ventilatory failure. Also causes opioid dependence, has a long duration of action, and tends to accumulate. (BNF 67)

 
03.09.02  Expectorant and demulcent cough preparations
Simple Linctus, BP

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Formulary Oral solution
 
Simple Linctus, Paediatric BP

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Formulary Oral solution
 
03.10  Systemic nasal decongestants
Pseudoephedrine Hydrochloride

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Formulary Tablets
Elixir
 
03.11  Antifibrotics
 ....
 Non Formulary Items
ACETYLCYSTEINE


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Non Formulary
 
Acrivastine


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Non Formulary
 
Adrenaline / Epinephrine (Anapen®)


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Non Formulary
 
Ammonia and Ipecacuanha Mixture BP


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Non Formulary
 
Bambuterol (Bambec®)


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Non Formulary
 
Beractant (Survanta®)


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Non Formulary
 
Bilastine (Ilaxten®)


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Non Formulary
 
Ciclesonide (Alvesco®)


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Non Formulary
 
Clemastine (Tevegil®)


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Non Formulary
 
Codeine Linctus, Paediatric BP


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Non Formulary
 
Controlled Drug  Codeine Phosphate


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Non Formulary
 
Cyproheptadine (Periactin®)


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Non Formulary
 
Desloratadine (Neoclarityn®)


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Non Formulary
 
Dextromethorphan / quinidine (Nuedexta®)


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Non Formulary
 
Drug Delivery Device (Able Spacer®)


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Non Formulary
 
Drug Delivery Device (Babyhaler®)


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Non Formulary
 
Drug Delivery Device (E-Z Spacer®)


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Non Formulary
 
Drug Delivery Device (E-Z Spacer®)


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Non Formulary
 
Drug Delivery Device (Haleraid®)


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Non Formulary
 
Drug Delivery Device (Nebuchamber®)


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Non Formulary
 
Drug Delivery Device (Nebuhaler®)


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Non Formulary
 
Drug Delivery Device (PARI Vortex® Spacer)


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Non Formulary
 
Drug Delivery Device (Pocket Chamber®)


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Non Formulary
 
Drug Delivery Device (Spinhaler®)


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Non Formulary
 
Duovent


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Non Formulary
 
Erdosteine (Erdotin®)


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Non Formulary
 
Fenoterol


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Non Formulary
 
Flo-Tone MDI


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Non Formulary
 
Formoterol Fumarate (Atimos® Modulite)


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Non Formulary
 
Formoterol Fumarate (Foradil®)


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Non Formulary
 
Grass and Tree Pollen Extract (Pollinex®)


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Non Formulary
 
Grass pollen extract (Grazax®)


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Non Formulary
Black
Not recommended for the treatment of grass pollen induced hayfever in adult patients with clinically relevant symptoms and a positive skin-prick test or specific IgE test to grass pollen. It was not deemed to be cost effective and was a low priority for funding.
 
Ipratropium bromide with salbutamol (Combivent®)


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Non Formulary
 
Ivacaftor


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Non Formulary
 
Karvol


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Non Formulary
 
Ketotifen (Zaditen®)


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Non Formulary
 
Levocetirizine (Xyzal®)


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Non Formulary
Black
No reason for benefit over cetirizine which is now generic.
 
Mecysteine Hydrochloride (Visclair®)


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Non Formulary
 
Menthol and Eucalyptus Inhalation BP 1980


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Non Formulary
 
Mizolastine (Mizollen®)


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Non Formulary
 
Mometasone Furoate (Asmanex®)


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Non Formulary
 
Nedocromil (Tilade® CFC-free inhaler)


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Non Formulary
 
Orciprenaline Sulphate (Alupent®)


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Non Formulary
 
Pholcodine Linctus, BP


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Non Formulary
 
Pholcodine Linctus, Strong, BP


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Non Formulary
 
pirfenidone (Esbriet®)


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Non Formulary

Link  NICE TA282: Idiopathic pulmonary fibrosis - pirfenidone (TA282)  
Rupatadine


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Non Formulary
 
Sodium Cromoglicate


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Non Formulary
 
Sodium Cromoglicate (Comogen Easi-Breathe®)


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Non Formulary
 
Sodium Cromoglicate (Intal®)


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Non Formulary
 
Zafirlukast (Accolate®)


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Non Formulary
 
  
Key
note Notes First Choice Item First Choice item
Section Title Section Title (top level) Non Formulary Item Non Formulary section
Section Title Section Title (sub level)
Cytotoxic Drug
Cytotoxic Drug
Restricted Drug
Restricted Drug
CD
Controlled Drug
Unlicensed Drug
Unlicensed
High Cost Medicine
High Cost Medicine
click to search medicines.org.uk
Link to SPCs
click to search medicines.org.uk
Link to adult BNF
Track Changes
Display tracking information
click to search medicines.org.uk
Link to children's BNF
Cancer Drugs Fund
Cancer Drugs Fund
   

 

Traffic Light Status Information

Status Description
  Amber   Drugs designated amber are suitable for shared care arrangements under a shared care protocol. Prescribing may be transferred from secondary to primary care once the patient is stabilised and agreed shared care arrangements have been established. Alternatively primary care may initiate under the supervision of secondary care if this option is given in the shared care document. It is recommended that shared care arrangements should be drawn up following local discussion and agreement by prescribing parties.   
  Black   These products have been reviewed by the GM Joint Formulary Group and have been deemed not suitable for prescribing for adults in primary or secondary care within Greater Manchester. These decisions have been made on the basis of safety, efficacy and cost-effectiveness of the products.  
  Green   Not used   
  Green 1   Drugs designated green1 are suitable for initiation and ongoing prescribing within primary care.   
  Green 2   Drugs designated green2 can be initiated by primary care following written or verbal advice from a specialist and then be subsequently safely prescribed in primary care with little or no monitoring required.  
  Green 3   Drugs designated green3 are suitable for on-going prescribing within primary care after specialist initiation and an initial review (unless specified) in secondary care. Little or no monitoring is required.  
  Grey   Not suitable for routine prescribing but may be suitable for a defined patient population. Whilst prescribers should think very carefully before prescribing or recommending any of the products on the grey list, there may be exceptional instances when the use of one of these products is necessary for a particular patient.   
  Red   Drugs designated red are considered to be specialist medicines and prescribing responsibility for these medicines should normally remain with the consultant or specialist clinician. These drugs should not be initiated or prescribed in primary care. It is recommended that the supply of these specialist medicines should be organised via the hospital pharmacy, this may include arranging for supply via a home care company.   

netFormulary