| 3.1.1 Adrenoreceptor agonists | | 3.1.1.1 Selective beta2-agonists | | | | GREEN Salbutamol | |
| metered dose inhaler (MDI) 100micrograms/inhalation |
| breath-actuated inhaler 100 microgram/inhalation (Airomir Autohaler®) |
| breath actuated dry powder inhaler 100mcg/inhalation (Easyhaler® Salbutamol ) |
| breath actuated dry powder inhaler 200mcg/inhalation (Easyhaler® Salbutamol ) |
| dry powder inhaler 200 microgram/blister (Ventolin Accuhaler®) |
| nebuliser solution 2.5mg/2.5ml, 5mg/2.5mL |
| syrup 2mg/5mL |
| |
RED Salbutamol
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| injection 500 microgram/mL |
| solution for intravenous infusion 5mg/5mL |
GREEN Terbutaline
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| dry powder inhaler 500 microgram/inhalation (Bricanyl Turbohaler®) |
| nebules 5mg/2mL |
| |
Longer acting beta 2 - agonists
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Use regularly in addition to inhaled corticosteroids and inhaled bronchodilators for improved control as described in Step 3
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of BTS guidelines. Comparative costs for longer acting beta2 - adrenoceptor stimulants are indicated.
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| |
Formoterol
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Formoterol should only be used in accordance with national and local guidance on the management of asthma or COPD.
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| In asthma it should not be used as monotherapy, but be used alongside inhaled corticosteroids as per MHRA advice. |
Formoterol metered dose inhaler (MDI) presented as the brand Easyhaler® is the first line long acting beta-2 agonist of
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choice within Peninne Lancashire.
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GREEN Formoterol
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| dry powder for inhaler 12 microgram/inhalation (Easyhaler Formoterol ®) |
GREEN Formoterol
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| dry powder inhaler 6 microgram/metered inhalation (Oxis Turbohaler®) |
| dry powder inhaler 12 microgram/metered inhalation (Oxis Turbohaler®) |
| |
Salmeterol
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Second line option
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GREEN Salmeterol
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| metered dose inhaler (MDI) 25 microgram/inhalation (Serevent®) |
| dry powder inhaler 50 microgram/blister (Serevent Accuhaler®) |
| |
Indacaterol
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Third line option for patients with moderate COPD who are having difficulties with either compliance or the inhaler device.
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GREEN Indacaterol
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dry powder hard capsule 150, 300 microgram (Onbrez Breezhaler®)
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| Note minimum inspiratory flow rate required 50L/min |
| |
| Beclomethasone dipropionate/formoterol fumarate dihydrate/glycopyrronium bromide [Trimbow®] |
| For maintenance treatment of asthma, in adults not adequately controlled with a maintenance combination of a |
| long-acting beta-2 agonist plus a medium dose of inhaled corticosteroid, and who had one or more exacerbations |
| (flare-ups) in the past year. |
GREEN restricted use Beclomethasone dipropionate/formoterol fumarate dihydrate/glycopyrronium bromide 87/5/9 pMDI
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| [Trimbow®] |
| 3.1.2 Antimuscarinic bronchdilators |
For relieving bronchoconstriction in COPD as an alternative to beta2 -agonists. Ipratropium is a short acting muscarinic
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antagonist whilst Tiotropium is long acting. Tiotropium is an option at step 2 of the local guidelines in those patients with
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persistent exacebations/breathlesness.
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GREEN Ipratropium bromide
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| metered dose inhaler (MDI) 20micrograms/inhalation |
| nebuliser solution 250micrograms/mL |
GREEN Tiotropium inhaler (Braltus® Zonda inhaler)
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| (Braltus 10 microgram per delivered dose inhalation powder, hard capsule) |
Add on maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary
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| disease (COPD) |
Note: Ipratropium should be discontinued when tiotropium is introduced.
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GREEN Tiotropium Spiriva® Respimat ®▼
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N.B. Braltus is the preferred Tiotropium product.The Tiotropium Respimat is restricted for use in COPD patients to those who
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| have poor manual dexterity and difficulty using the Handihaler® |
| |
Add on maintenance bronchodilator treatment in adult patients with Asthma who meet all of the following criteria:
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| > persistent airflow limitation demonstrated by an FEV¹ <80% predicted and a ratio of FEV¹/FVC <70% and |
| > currently treated with the maintenance combination of inhaled corticosteroids (>800 micrograms budesonide/day or |
| equivalent*) and long acting ß² agonists and |
| > experienced one or more severe exacerbations in the previous year. |
| |
Second line ONLY where Tiotropium is not appropriate, not tolerated or there is difficulty using the device.
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Glycopyrronium bromide inhaler is available in a new device which requires lower inspiratory rate and enables visual
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| compliance. |
GREEN Glycopyrronium bromide, inhaler (Seebri Breezhaler®)
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| |
3rd line ONLY where Tiotropium is not tolerated or there is difficulty using the device.
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GREEN Aclidinium bromide, inhalation powder (Eklira Genuair®▼)
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| 3rd line option when Tiotropium is not tolerated or the device cannot be used effectively |
| |
Long acting Antimuscarinic bronchodilators in combination with Long-Acting Beta² agonists (LAMA/LABA)
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GREEN Tiotropium and olodaterol
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| (Spiolto® Respimat 2.5 microgram/2.5 microgram, inhalation solution) |
| |
Spiolto® Respimat is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with
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chronic obstructive pulmonary disease (COPD).
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GREEN Glycopyrronium bromide 85mcg/Indacterol maleate 43mcg inhalation powder
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| capsule device. (Ultibro®Breezhaler dry powder inhaler) |
GREEN Aclidinium and fomoterol
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| (Duaklir® Genuair 340 micrograms /12 micrograms inhalation powder) |
GREEN Glycopyrronium bromide 9 µg equivalent to 7.2 µg of glycopyrronium, and 5 µg of formoterol fumarate
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| dihydrate mdi |
| (Bevespi Aerosphere mdi) |
| |
Duaklir Genuair is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic
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obstructive pulmonary disease (COPD)
|
| |
| Bevespi Aerosphere is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with |
| chronic obstructive pulmonary disease (COPD). |
| |
| |
| Triple combination inhaler [ICS + LAMA + LABA] |
Trimbow® inhaler - link to guideline
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First line use in Patient Group D, where patient requires Triple Therapy (LAMA+LABA+ICS) (single combination inhaler,
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dose 2puffs bd).
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(Use reserved for patients who have failed to achieve or maintain an adequate response to an appropriate course of dual
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GREEN [restricted use]
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| Beclomethasone 87mcg, formoterol fumarate 5mcg, glycopyrronium bromide 9mcg |
| (Trimbow®pMDI) (dose = 2 puffs twice daily) |
| GREEN [restricted use] |
| Beclomethasone 87mcg, formoterol fumarate 5mcg, glycopyrronium bromide 9mcg |
| (Trimbow® NEXThaler) (dose = 2 puffs twice daily) |
| |
| Trixeo Aerosphere 5mcg/7.2mcg/160mcg pressurised inhalation, suspension |
| Maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) who are |
| not adequately treated by a combination of an inhaled corticosteroid and a long-acting beta2-agonist or combination of a |
| long-acting beta2-agonist and a long-acting muscarinic antagonist. |
| The intended place in therapy for the Trixeo Aeropshere is in line with the 2019 NICE Guidelines for the treatment of |
| patients with moderate to severe COPD for whom a MDI is considered clinically appropriate and who experience a severe |
| exacerbation (requiring hospitalisation) or two moderate exacerbations within a year whilst receiving ICS/LABA or |
LAMA/LABA.
|
| |
| GREEN RESTRICTED 5μg formoterol fumarate dihydrate, glycopyrronium bromide 9μg, equivalent to 7.2μg of |
| glycopyrronium, and budesonide 160μg |
| Trixeo Aerosphere (dose = 2 puffs twice daily) |
| |
| 3.1.3 Theophylline |
Used for reversible airways obstruction. Narrow margin between therapeutic and toxic dose.
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| Prescribe oral preparations by brand name. |
|
GREEN Theophylline (Uniphyllin®) tablets m/r 200mg, 300mg, 400 mg
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| |
Other preparations
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| AMBER Aminophylline tablets 225mg, 350mg |
RED Aminophylline injection 25mg/ml, 10mL ampoule
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RED Caffeine citrate oral solution 50mg/5mL (unlicensed)
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RED Caffeine citrate intravenous injection 10mg/2mL (NICU only) (unlicensed)
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Note: caffeine 10mg = caffeine citrate 20mg.
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To avoid confusion these preparations must always be prescribed as CAFFEINE CITRATE.
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