3.1 Airways disease, obstructive

Guidelines

• Refer to Global Initiative for Asthma (GINA) Reference guide (2021)
• Refer to Global Initiative for COPD (GOLD) Reference Guide (2021)
• Refer to the BNSSG Adult Asthma Guidelines and COPD Guidelines
• Choice of inhaler device should be based on patient preference and assessment of use
• Inhalers should be prescribed by brand to ensure that patients receive the correct drugs in the most appropriate device
• Inhalers should only be prescribed after patients have received training in the use of the device and have demonstrated satisfactory technique
• Nebulised therapy may be appropriate in the treatment of acute asthma and COPD. This should be reviewed when the patient is stable
• Consider consistency of device for patients
• Caution note: Prescribers should be aware that new inhaler devices entering the market are moving away from the traditional blue for reliever and brown for preventer colours. It is important that any changes made to a patient's inhaler treatment considers the patient's understanding of the use of that inhaler and are aware of these changes before a new inhaler is prescribed. Caution should be exercised in patients where understanding is not assured.
• Refer to the Inhaler Identification Chart

Asthma

Refer to BNSSG Adult Asthma Guidelines

Patients with asthma on long-acting reliever inhalers (long-acting beta agonists (LABA) and/or long-acting muscarinic receptor antagonists (LAMA) with no inhaled corticosteroid (ICS) are at greater risk of severe asthma attacks.

COPD

Refer to BNSSG COPD Guidelines

BNSSG COPD Step down guidelines

Antimuscarinics

• Caution in patients with; cardiac arrhythmia (excluding chronic atrial fibrillation), symptomatic prostatic hyperplasia or bladder-neck obstruction or narrow-angle glaucoma. If Ipratropium nebules are needed acutely LAMA inhalers should be withheld for the duration of the course
• Glycopyrronium bromide should be used with caution in patient with an eGFR <30mL/min
• Tiotropium should be used with caution in patients with an eGFR <50mL/min

Aclidinium (Eklira Genuair^®) (TLS Blue)

• For COPD

Glycopyrronium (Seebri Breezhaler^®) (TLS Blue)

• For COPD

Ipratropium (TLS Green)

• For COPD

Tiotropium (Spiriva Respimat^®) (TLS Blue)

• For COPD
• In accordance with NICE NG115

Tiotropium (Respimat^®) (TLS Amber Specialist Recommended)

• For Asthma

Umeclidinium (Incruse Ellipta^®) (TLS Blue)

• For COPD

Beta₂ Agonists (Long acting)

Selective beta₂ agonists

• Single agent LABA generally only indicated if LAMA not tolerated
• Consider concomitant asthma in patients with COPD. Do not give a LABA without an inhaled corticosteroid (ICS) in patients where concomitant asthma is a possibility

Salmeterol (TLS Green)

• For asthma

Formoterol (Atimos Modulite^® Formoterol Easyhaler^®) (TLS Green)

• For asthma/COPD

Indacaterol (Onbrez Breezhaler^®) (TLS Blue)

• For maintenance of chronic obstructive pulmonary disease

Olodaterol (Striverdi Respimat^®) (TLS Blue)

• For maintenance of chronic obstructive pulmonary disease

Beta₂ Agonists (short acting)

Salbutamol (inhaled & nebulised) (TLS Green)

• For asthma and COPD

Alternative:

Terbutaline (inhaled & nebulised) (TLS Blue)

Salbutamol (parenteral) (TLS Blue)

• According to BTS/SIGN Guidelines

Combined Long Acting Beta₂ Agonist and Long Acting Muscarinic Antagonist (LABA/LAMA)

Formoterol / Aclidinium (Duaklir Genuair^®) (TLS Blue)

• For COPD

Indacaterol / Glycopyrronium (UltiBro Breezhaler^®) (TLS Blue)

• For COPD 

Vilanterol / Umeclidinium (Anoro Ellipta^®) (TLS Blue)

• For COPD

Olodaterol / Tiotropium (inhaled) (Spiolto Respimat^®) (TLS Blue)

• Maintenance treatment of COPD

Formoterol / Glycopyrronium (Bevespi Aerosphere^®) (TLS Blue)

• For COPD for patients who prefer to use a pMDI device and are unable to use other inhaler devices due to the nature of their lung function, breathing technique, or dexterity concerns.

Combined Long Acting Beta₂ Agonist, Long Acting Muscarinic Antagonist and Inhaled Corticosteroid (LABA/LAMA/ICS) Triple Inhaler

Beclometasone / Formoterol / Glycopyrronium (Trimbow^® Nexthaler DPI 88/5/9) (TLS Green)

• Maintenance treatment of COPD

Beclometasone / Formoterol / Glycopyrronium (Trimbow^® pMDI 87/5/9) (TLS Green)

• Maintenance treatment of COPD

Beclometasone / Formoterol / Glycopyrronium (Trimbow^® pMDI)  (TLS Blue)

• For maintenance treatment of asthma 

Fluticasone / Umeclidinium / Vilanterol (Trelegy Ellipta^®) (TLS Green)

• Maintenance treatment of COPD

Formoterol / Budesonide / Glycopyrronium (Trixeo^®) pressurised inhaler (TLS Green)

• As an option for moderate to severe COPD

Airways Disease, Use of Corticosteroids

• Patients should be started at a dose of inhaled steroids appropriate to the severity of disease. The dose should be titrated to the lowest dose at which effective control of the disease is maintained
• See NICE TA138 Asthma - inhaled corticosteroids for the treatment of chronic asthma in adults and children aged 12 years and over

Beclometasone (inhaled) (TLS Green)

• Includes Clenil Modulite^® and Qvar^® Please prescribe by brand name as they are not bioequivalent

Alternatives:

Budesonide (inhaled & nebulised) (TLS Blue)

Fluticasone (inhaled & nebulised) (TLS Blue)

Ciclesonide (inhaled) (TLS Blue)

Combined Inhaled Corticosteroids Plus Long Acting Beta₂ Agonist (ICS/LABA)

• Inhaled corticosteroids in COPD confer a small, but significant, increased risk of pneumonia. The main risk factors for pneumonia in patients with COPD receiving an ICS are; current smoking, prior pneumonia, BMI <25 and severe airflow limitation

Beclometasone / Formoterol (Luforbec^® pMDI) (TLS Green)

• For asthma

Beclometasone / Formoterol (Fostair^® pMDI) (TLS Green)

• For asthma/COPD

Beclometasone / Formoterol (Fostair NEXThaler^®) (TLS Green)

• For asthma/COPD

Budesonide / Formoterol (Fobumix Easyhaler^®) (TLS Green)

• For asthma/COPD

Budesonide / Formoterol (Symbicort^®) (TLS Green)

• For asthma/COPD

Budesonide / Formoterol (DuoResp Spiromax^®) (TLS Green)

• Joint Formulary decision on April 2018 to make DuoResp^® non-formulary. This recommendation is not intended to affect treatment with Duoresp^® that was started prior to this date. People having treatment with Duoresp^® may continue without change until they and their NHS clinician consider it appropriate to stop
• For asthma/COPD

Fluticasone furoate / Vilanterol (Relvar Ellipta^®) (TLS Green)

• Relvar^® 92/22 for asthma/COPD
• Relvar^® 184/22 for asthma. Consider 184/22 micrograms and 92/22 micrograms inhaler at Step 4 of BNSSG Asthma guidance for Adults over 18 years

Fluticasone propionate / Salmeterol (Combisal^®, Seretide^® and Sirdupla^®) (TLS Green)

• For asthma
• Please prescribe by brand

Fluticasone propionate / Formoterol (Flutiform^® inhaler, Flutiform^® k-haler) (TLS Green)

• For asthma

Leukotriene Receptor Antagonists

• Not to be used to relieve an attack of severe acute asthma.
• Leukotriene receptor antagonists should be withdrawn if no significant response after 6 weeks

Montelukast (TLS Green)

Alternative:

Zafirlukast (TLS Blue)

Mast Cell Stabilisers

Cromoglicate and related therapy

Sodium cromoglicate pMDI (TLS Green)

PDE-4 inhibitors

Roflumilast (TLS Amber Specialist Initiated)

• NICE TA461 - Roflumilast for treating COPD in adults with chronic bronchitis

Monoclonal Antibodies

Omalizumab (TLS Red)

• Commissioned by NHS England Specialised Services Commissioning; NHS England funded via Prior Approval Scheme on Blueteq
• NICE TA278 Omalizumab for treating severe persistent allergic asthma (review of technology appraisal guidance 133 and 201)
• NICE TA339 Omalizumab for previously treated chronic spontaneous urticaria

Reslizumab (TLS Red)

• NICE TA479 Reslizumab for treating severe eosinophilic asthma

Benralizumab (TLS Red)

• NICE TA565 Benralizumab for treating severe eosinophilic asthma

Mepolizumab (TLS Red)

• NICE TA671 Mepolizumab for treating severe eosinophilic asthma

Dupilumab (TLS Red)

• NICE TA751 Dupilumab for treating severe asthma with type 2 inflammation

Tezepelumab (TLS Red)

• NICE TA880 Tezepelumab for treating severe asthma

Xanthines

Aminophylline (parenteral) (TLS Red)

Alternative:

Theophylline modified-release (oral) (TLS Blue)

• Prescribe by brand

Inhaled Antibiotics

Colistimethate sodium (injection to be used via nebuliser) (TLS Amber 3 months)

• TLS Amber for chronic infections in non-CF bronchiectasis only. Click here for the SCP for nebulised Colistimethate sodium. Generally a trial of eradication or maintenance of Colistimethate sodium would be considered first line in these patients. Progression between antibiotics would be dictated by tolerance or treatment failure (defined by decline in lung function or no change / increase in rate of exacerbations)
• Colomycin^® injection can be used for nebulisation
• Nebulisation of colistimethate should take place in a well ventilated room. The output from the nebuliser may be vented to the open air or a filter may be fitted. Usually jet or ultrasonic nebulisers are preferred for colistimethate inhalation to ensure the particles are of a suitable diameter

Colobreathe^® 1,662,500unit inhalation powder capsules (inhaled) (TLS red)

• For non-CF bronchiectasis patients who require treatment with colistimethate sodium but are unable to tolerate or comply with nebulisers

Colistimethate sodium (injection to be used via nebuliser) (TLS red)

• TLS Red for management of acute infections
• TLS Red for the management of chronic CF infections in accordance with the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/P/b)

Colistimethate sodium Dry Powder Inhaler (inhaled) (TLS Red)

• NICE TA276 Colistimethate sodium and tobramycin dry powders for inhalation for treating pseudomonas lung infection in cystic fibrosis and
• The NHS England Clinical Commissioning Policy Statement: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/PS/a)
• And also for use in patients with non-Cystic Fibrosis bronchiectasis when colistimethate sodium is indicated, but the patient does not tolerate it in its nebulised form, or are unable to comply with the process of reconstitution and nebulisation of colistimethate despite appropriate training and support

Tobramycin (parenteral) (TLS Red)

• Secondary Care Restricted, see local guidelines

Tobramycin (nebulised) (TLS Red)

• Restricted, see local guidelines
• TLS Red for the management of acute infections
• TLS Red for the management of chronic CF infections in accordance with the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/P/b)

Tobramycin (nebulised) (TLS Amber 3 months)

• Restricted, see local guidelines
• TLS Amber for chronic infections in non-CF bronchiectasis only. Click here for the SCP for nebulised Tobramycin
• Generally a trial of eradication or maintenance of Colistimethate sodium would be considered first line in these patients. Progression between antibiotics would be dictated by tolerance or treatment failure (defined by decline in lung function or no change / increase in rate of exacerbations)

Tobramycin (inhaled) (TLS Red)

• Secondary Care Restricted, see local guidelines
• Tobi Podhaler^®
• NICE TA276 Colistimethate sodium and tobramycin dry powders for inhalation for treating pseudomonas lung infection in cystic fibrosis and the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/P/b)

Peak Flow Meters, Inhaler Devices and Nebulisers

Peak Flow Meters

Peak Flow Meter (standard range) (TLS Green)

Drug Delivery Devices/ Spacer Devices

• Clinicians should select the most appropriate, cost-effective device for the patient.
• Spacers should be replaced every 6 to 12 months according to manufacturer’s recommendations.

Nebulisers

Only to be initiated by a specialist for patients who need acute treatment or are unable to use inhaled devices effectively.

Sodium chloride 0.9% used as diluent (TLS Green)

• Patient information for nebulisers:

University Hospitals Bristol  North Bristol Healthcare Trust

Ipratropium nebs should not be weaned, as patients then get sub-therapeutic dose

Choice of Inhaler Device

Standard inhaler (pMDI) and spacer (TLS Green)

Alternative:

Other Inhaler (TLS Blue)

• Choice of inhaler device should be based on patient preference and assessment of use

Systemic Corticosteroids

Recommended:

Prednisolone (oral) (TLS Green)

Hydrocortisone (parenteral) (TLS Green)

• Systemic steroids should only be used for patients with asthma whose disease cannot be controlled with appropriate doses of inhaled therapies according to BTS/SIGN Guidelines

Contact Us

Got a question or comment about the Joint Formulary? 

Please use the email address below to contact us and we will endeavour to respond within 2 working days.