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3.4 Antihistamines, hyposensitisation and allergic emergencies

3.4 Antihistamines, hyposensitisation and allergic emergencies

 3.4.1 Antihistamines
 Of some value in treatment of nasal allergies, urticarial rashes, pruritus, insect bites and drug allergies.  Non-sedating 
 preparations are usually longer acting. 
 Non-sedating antihistamines                    
 Although drowsiness is rare, nevertheless patients should be advised that it can occur and may affect performance of skilled tas
 (e.g. driving); excess alcohol should be avoided. 
 Non-sedating antihistamines should be offered first line to all patients, especially children and adolescents.
 GREEN       Cetirizine tablets 10mg [Consider OTC/Self care] 
                     Cetirizine oral solution 5mg/5mL [Consider OTC/Self care] 
 GREEN       Fexofenadine tablets 120mg, 180mg 
 GREEN       Fexofenadine tablets 30mg 
 GREEN       Loratadine tablets 10mg, syrup 5mg/5mL [Consider OTC/Self care] 
 Sedating antihistamines
GREEN        Chlorphenamine (chlorpheniramine) tablets 4mg,  syrup 2mg/5mL [Consider OTC/Self care] 
                    Chlorphenamine (chlorpheniramine) injection 10mg/mL
 GREEN       Hydroxyzine tablets 10mg, 25mg
 GREEN       Promethazine tablets 10mg, 25mg   [Consider OTC/Self-care]    
                     Promethazine liquid 5mg/5mL
                     Promethazine is RED traffic light for use in insomnia/sleep disorders see section 4.1
AMBER       Alimemazine 7.5mg/5mL SF oral solution [Second line use after promethazine when initiated by tertiary centre for 
                    indications that include insomnia/sedation]. Use restricted to paediatrics only.
 3.4.2 Allergen Immunotherapy
Treatment of severe persistent allergic asthma (NICE TAG278)  
 (recommended as an option by NICE in people aged 6 years and older)
RED           Omalizumab injection 150mg/mL 
For previously treated chronic spontaneous urticaria - recommended as an option by NICE TAG 339
RED           Omalizumab injection 150mg/mL
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3.4.3 Allergic emergencies
In anaphylactic shock adrenaline 1 in 1000 should be give by intramuscular injection at the doses below.
NOTE:   1. When administering adrenaline in an emergency the Health Care Professional should base the dose on age.
By intramuscular injection
Child under 6 years     150 micrograms (0.15 mL), repeated every 5 minutes if necessary
Child 6–12 years           300 micrograms (0.3 mL), repeated every 5 minutes if necessary
Child 12–18 years          500 micrograms (0.5 mL), repeated every 5 minutes if necessary      
Adult                               500 micrograms (0.5 mL), repeated every 5 minutes if necessary

GREEN       Adrenaline injection 1 in 1000, 1mL    

 Hereditary Angioedema
 RED     Lanadelumab [Takhzyro]                                                                                                               NHS England Commissioned
 NICE TA606  Lanadelumab is recommended as an option for preventing recurrent attacks of hereditary angioedema in people 
                        aged 12 and older, only if:
                            >  they are eligible for preventive C1-esterase inhibitor (C1-INH) treatment in line with NHS England's                 
                                commissioning  policy, that is, they are having 2 or more clinically significant attacks (as defined in the 
                                policy) per week over 8 weeks despite oral preventive therapy, or oral therapy is contraindicated or not tolerated
                            >  the lowest dosing frequency of lanadelumab is used in line with the summary of product characteristics, that is, 
                                when the condition is in a stable, attack-free phase (see section 2) and
                            >  the company provides lanadelumab according to the commercial arrangement.
 RED     Berotralstat [Orladeyo]                                                                                                                    NHS England Commissioned
 NICE TA738  Berotralstat is recommended as an option for preventing recurrent attacks of hereditary angioedema in people 
                        12 years and older, only if:  
                              >  they have at least 2 attacks per month, and
                              >  it is stopped if the number of attacks per month does not reduce by at least 50% after 3 months.
                        It is only recommended if the company provides berotralstat according to the commercial arrangement.

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Adrenaline pre-filled syringes

When prescribing for a patient 'just in case' then the prescription should be based on weight.
 Any child over 30kg should be prescribed  the 300mcg strength pen
For information:  Managing patients at risk of anaphylactic reactions
                                Infographic showing The Correct use of your Adrenaline Auto-Injector (AAI)
                                Video - How to correctly use your Adrenaline Auto-Injector (AAI)
Jext® - [Note 18 month expiry]
GREEN       Adrenaline (epinephrine) (Jext®) single dose pre-loaded syringe   

                     150micrograms (body weight up to 15 Kg for self administration)                                                                                                       300micrograms (body weight 30Kg and above for self administration)                                                         

                   Jext Website - information for Patients includes the 'How to use' videos
                   Jext Patient Information Leaflet view here
                   The following link provide training materials for the Jext devices:
                   Jext® devices
                   Jext® 150 Training Video
                   Jext® 300 Training Video
GREEN       Adrenaline (epinephrine) (Emerade®) single dose pre-loaded syringe  
                   500micrograms (for issue to patients at risk of severe anaphylaxis)  
                   300micrograms (body weight 30Kg and above for self administration) 
                   150micrograms (body weight up to 15 Kg for self administration)  
                   See latest MHRA Emerade® recall information here 
Adrenaline (epinephrine) (EpiPen Auto-injector®) single dose pre-loaded syringe [for issue to patients at risk of anaphylaxis]
GREEN      Epipen150micrograms, [19 month expiry see SPC]
                    Epipen  300micrograms [24 month expiry - see SPC]


                   EpiPen Website - information for Patients
                   EpiPen Patient information Leaflet - view here
                  The following links provide training materials for the Epipen devices: 
                  EpiPen® devices
                  EpiPen® 0.15mg
                  EpiPen® 0.3mg
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 All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the 
 public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service.
 Email: info.elmmb@nhs.net
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