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BNSSG Adult Joint Formulary

3.3 Conditions affecting sputum viscosity

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Last edited: 24-10-2024

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Mucolytics

Mucolytics should be consider in all patients with a diagnosis of COPD experiencing chronic productive cough, particularly if excessive viscous mucus is produced, and continued if symptoms improve. Treatment should be reviewed 4 weeks after initiation and stopped if no benefit.
If continued then ensure regularly review to assess if on-going benefit and/or potential for dose reduction.
Mucolytics should be used with caution, or avoided, in those with a history of peptic ulceration or risk factors for peptic ulceration because they may disrupt the gastric mucosal barrier. Consider gastroprotection in at risk patients.

Guidelines

Acetylcisteine (Acepiro^®) 600mg effervescent tablets (TLS Green)

Carbocisteine (TLS Green)

Hypertonic Sodium chloride 3% or 6% or 7% (TLS Amber Specialist Initiated)

To be started by respiratory specialist only - first dose to be given under medical supervision by specialist team.

3.3.1 Cystic Fibrosis

NHS England - Service specifications

Dornase alfa (TLS Red)

To improve pulmonary function in cystic fibrosis patients with a FVC of greater than 40% predicted
Use on specialist respiratory advice only
Requirement for dornase alfa should be reviewed every 3 days
In accordance with the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/P/b)
Also commissioned for intrapleural administration with alteplase to facilitate draining of infected pleural collections
Not routinely commissioned for primary ciliary dyskinesia see NHS England Policy 16029/P

Ivacaftor (TLS Red)

Commissioned by NHS England Specialised Services Commissioning
See NHS England Clinical Commissioning Policy: Ivacaftor for Cystic Fibrosis (A01/P/b)

Mannitol dry powder for inhalation (TLS Red)

NICE TA266 as an option for treating cystic fibrosis in adults:

Who cannot use rhDNase because of ineligibility, intolerance or inadequate response to rhDNase
and
Whose lung function is rapidly declining (forced expiratory volume in 1 second [FEV₁] decline greater than 2% annually)
and
For whom other osmotic agents are not considered appropriate

Acetylcysteine (unlicensed) (TLS Red)

Use on specialist respiratory advice only

Ivacaftor (TLS Red)

As per NHSE policy statement Clinical Commissioning Urgent Policy Statement Cystic Fibrosis Modulator Therapies Access Agreement for licensed mutations
As per NHSE policy statement Clinical Commissioning Urgent Policy Statement: Ivacaftor and tezacaftor/ivacaftor for cystic fibrosis: “off-label” use in patients with named mutations

Lumacaftor / Ivacaftor (TLS Red)

As per NHSE policy statement Clinical Commissioning Urgent Policy Statement Cystic Fibrosis Modulator Therapies
NHSE SSC 2538 Age group licence extension for lumacaftor/ivacaftor (Orkambi) for patients aged 1-2 years with cystic fibrosis
As per NICE TA988 Ivacaftor–tezacaftor–elexacaftor, tezacaftor–ivacaftor and lumacaftor–ivacaftor for treating cystic fibrosis

Ivacaftor / Tezacaftor (TLS Red)

As per NHSE policy statement Clinical Commissioning Urgent Policy Statement Cystic Fibrosis Modulator Therapies
As per NHS England Policy Clinical Commissioning Urgent Policy Statement: Ivacaftor and tezacaftor/ivacaftor for cystic fibrosis: “off-label” use in patients with named rarer mutations
As per NICE TA988 Ivacaftor–tezacaftor–elexacaftor, tezacaftor–ivacaftor and lumacaftor–ivacaftor for treating cystic fibrosis

Elexacaftor / Tezacaftor / Ivacaftor (TLS Red)

As per Specialised Services Circular (SSC 2328)
As per NICE TA988 Ivacaftor–tezacaftor–elexacaftor, tezacaftor–ivacaftor and lumacaftor–ivacaftor for treating cystic fibrosis

3.3.2 Other

Dornase alfa (TLS Red)

Also commissioned for non-CF patients for intrapleural administration with alteplase to facilitate draining of infected pleural collections

Aerobika^® oscillating positive expiratory pressure device (TLS Amber Specialist Recommended)

for chest airways mucus clearance for adult patients following assessment/recommendation by a chest clearance competent respiratory practitioner. It is expected that patients will have been provided training on how to use the device by the practitioner recommending the device.
These devices are expected to have a 12 month replacement life.

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3.3 Conditions affecting sputum viscosity

Mucolytics

Guidelines

Acetylcisteine (Acepiro®) 600mg effervescent tablets (TLS Green)

Carbocisteine (TLS Green)

Hypertonic Sodium chloride 3% or 6% or 7% (TLS Amber Specialist Initiated)

3.3.1 Cystic Fibrosis

Dornase alfa (TLS Red)

Ivacaftor (TLS Red)

Mannitol dry powder for inhalation (TLS Red)

Acetylcysteine (unlicensed) (TLS Red)

Ivacaftor (TLS Red)

Lumacaftor / Ivacaftor (TLS Red)

Ivacaftor / Tezacaftor (TLS Red)

Elexacaftor / Tezacaftor / Ivacaftor (TLS Red)

3.3.2 Other

Dornase alfa (TLS Red)

Aerobika® oscillating positive expiratory pressure device (TLS Amber Specialist Recommended)

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Acetylcisteine (Acepiro^®) 600mg effervescent tablets (TLS Green)

Aerobika^® oscillating positive expiratory pressure device (TLS Amber Specialist Recommended)