Respiratory System Algorithm for the selection of the most

Respiratory System

Algorithm for the selection of the most appropriate inhaler device for patients with chronic stable asthma

Information on Inhaler devices

Devices

ββββ2 agonist bronchodilators

Antimuscarinic bronchodilator

Corticosteroid therapy

Theophylline, leukotriene receptor antagonists, mucolytics

Stop Smoking - 0800 169 1943 Please also see section on Drugs used in substance dependence for patients with

established chemical dependence

Antihistamines

Respiratory tract infections - Please refer to the ‘Treatment of infections in Primary Care’ section

Updated: 27.08.2009

Information on inhaler devices

Throughout this formulary section, for inhaled preparations, unless stated the drug and or devices listed, are licensed in children of all ages. Selected inhaler devices and compatibility with spacer devices Education for Health, incorporating The National Respiratory Training Centre, has produced “Simply Devices: A Practical Pocket Book” which covers the use of all inhaler devices. It is available from Education for Health on 01926 493224 and costs £5.25. (2006) Information available at www.educationforhealth.org.uk

Inhaler device type

Volumatic ® Aerochamber Plus ®

Metered Dose Inhaler

Connection with inhaler is rigid and oval and will not fit inhalers with round mouthpieces: i.e. Airomir®, Qvar®, Atrovent®

Connection with inhaler is flexible and oval. Fits all inhalers including those with round mouthpieces: i.e. Airomir®, Qvar®, Atrovent®

Breath Actuated Inhaler

Autohaler®, Easi-Breathe®

Dry Powder Inhaler Accuhaler®, Airohaler®, Clickhaler®, Diskhaler®, Easyhaler®, Pulvinal®, Turbohaler®

Selected advantages and disadvantages of each type of inhaler device

Device Type Advantages Disadvantages

pMDI NICE 1st line choice Small, portable and discreet Wide range of drugs available

High degree of hand - inhalation co-ordination and some manual dexterity is required (but see Handihaler®) Most pMDIs do not have a dose counter

pMDI + spacer device

NICE 1st line choice Reduced need for hand - inhalation co-ordination Spacer reduces systemic absorption and increases lung deposition

Spacer devices can be bulky Not all pMDIs are compatible with all spacer devices (see table above for information on which spacer device is appropriate for particular pMDIs)

Breath Actuated Inhaler

Minimal need for hand - inhalation co-ordination Small and portable Generally cheaper than dry powder inhalers

Not all drugs available in chosen device Appropiiate level of inspiratory flow is required to activate the device Not suitable for use with spacer Some manual dexterity is required with all breath actuated inhalers

Dry Powder Inhaler

Minimal need for hand - inhalation co-ordination Small, portable and discreet

Not all drugs available in chosen device Dexterity required if device requires loading Appropriate flow rate & acceleration of inspiration required Powder can cause cough Generally more expensive than other devices

pMDI = pressurised metered dose inhaler

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Devices

Spacer devices

Peak flow meters and inhalation aids

Spacer devices

Use: Patients should inhale from the spacer device as soon as possible after actuation because the drug aerosol is very short-lived; single-dose actuation is recommended. Tidal breathing is as effective as single breaths. Cleaning: The device should be cleaned once a month by washing in mild detergent and then allowed to dry in air; the mouthpiece should be wiped clean of detergent before use. More frequent cleaning should be avoided since any electrostatic charge may affect drug delivery. Spacer devices should be replaced every 12 months.

Device Notes

Spacer device – large volume [Volumatic® spacer device]

Available with paediatric mask. Connection with inhaler is rigid and oval and will not fit inhalers with round mouthpieces: i.e. Airomir®, Qvar®, Atrovent®

Spacer device – medium volume [AeroChamber® Plus spacer device: standard device (blue), infant device (orange) & child device (yellow).]

Available as adult device with or without mask, or as a child or infant device with mask. Connection with inhaler is flexible and oval. Fits all inhalers including those with round mouthpieces: i.e. Airomir®, Qvar®, Atrovent®

Peak flow meters and inhalation aids

Peak flow meters: patients must be given clear guidelines as to the action they should take if their peak flow falls below a certain level. Patients can be encouraged to adjust some of their own treatment (within specified limits) according to changes in peak flow rate.

Device Notes

Standard Range Peak Flow Meter [Mini-Wright®]

If used in the practice, must be used with a single use one-way valve. Readings from new peak flow meters are often lower than those obtained from old Wright-scale peak flow meters and the correct recording chart should be used.

Low Range Peak Flow Meter [Mini-Wright®]

Appropriate for severely restricted airflow in adults and children. If used in the practice, must be used with a single use one-way valve. Readings from new peak flow meters may be lower than those obtained from old Wright-scale peak flow meters and the correct recording chart should be used.

Inhalation aid Haleraid® 120 (for 120-dose pMDIs) Haleraid® 200 (for 200-dose pMDIs)

May be useful for patients who have difficulty using a pMDI due to manual dexterity problems.

Back to devices index Back to main index

ββββ2 agonist bronchodilators

Short acting ββββ2 agonist bronchodilator

Long acting ββββ2 agonist bronchodilator

Short acting ββββ2 agonist bronchodilators

Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from: http://www.brit-thoracic.org.uk or http://www.nice.org.uk

Advise patients not to exceed the prescribed dose and to follow manufacturer's directions; if a previously effective dose of inhaled β2 agonist fails to provide at least 3 hours relief, the patient should be advised to contact the surgery urgently.

CSM: Potentially serious hypokalaemia may result from β2 agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, diuretics, and by hypoxia. Plasma-potassium concentration should therefore be monitored in severe asthma.

Oral preparations of salbutamol are available and may be used by patients who cannot manage the inhaled route, but inhaled β2 agonist are more effective and have fewer side effects.

Formulation and Device Notes

Salbutamol

Salbutamol CFC-free 100mcg/dose pMDI (200-dose unit metered dose inhaler)

Salbutamol breath-actuated inhaler 100mcg/dose (200-dose unit: Easi-Breathe®)

Salbutamol dry powder breath-actuated inhaler 200mcg/dose (100-dose unit: Easyhaler®, Pulvinal ®) Licensed in children over 6 yrs

Salbutamol dry powder breath-actuated inhaler 95mcg/dose (200-dose unit: Clickhaler®)

Salbutamol breath-actuated inhaler 100mcg/dose (200-dose unit: Autohaler®)

Salbutamol dry powder for inhalation 200mcg/dose (60-dose unit: Accuhaler®)

Salbutamol nebuliser solution 2.5mg/2.5ml & 5mg/2.5ml

Terbutaline

Terbutaline sulphate breath-actuated dry powder inhaler 500mcg/dose (100 dose-unit: Turbohaler®) Not recommended in children under 5 years.

Terbutaline sulphate nebulisation single dose unit 2.5mg/ml (2ml unit)

Long acting ββββ2-agonist bronchodilators


To ensure safe use, the CSM has advised that for the management of chronic asthma, long-acting β2 agonist should:

• be added only if regular use of standard-dose inhaled corticosteroids has failed to control asthma adequately;

• not be initiated in patients with rapidly deteriorating asthma;

• be introduced at a low dose and effectiveness properly monitored before considering any dose increase;

• be discontinued in the absence of benefit;

• be reviewed as clinically appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved;

• patients should be advised to report any deterioration in symptoms following initiation of treatment with a long-acting β2 agonist Existing corticosteroid therapy should NOT be reduced or withdrawn. Advise patients that salmeterol should not be used for relief of acute attacks, not to exceed prescribed dose, and to follow manufacturer's

directions. If a previously effective dose of inhaled long acting β2-agonist fails to provide adequate relief, the patient should be advised to contact the surgery urgently.

Formulation and device Notes

Salmeterol

Salmeterol CFC-free pMDI 25mcg/puff (120 dose-unit) Licensed in children over 4 years

Salmeterol 50mcg/blister( 4 blisters/disk, 15 disks/unit i.e. 60 blisters per box with Diskhaler® & 15 disk refills)

Licensed in children over 4 years Use the refill pack for continuation of prescribing.

Salmeterol dry powder for inhalation 50mcg/dose (60 dose-unit: Accuhaler®) Licensed in children over 4 years

Formoterol dry powder inhaler 12mcg/actuation (60-dose unit Easyhaler®) Licensed for children over 6 yrs

Formoterol dry powder inhaler 6mcg & 12mcg/actuation (60-dose unit: Oxis Turbohaler®)

Licensed for children over 6 yrs Each metered inhalation of Oxis 6 Turbohaler® delivers 4.5 micrograms formoterol fumarate. Each metered inhalation of Oxis 12 Turbohaler® delivers 9 micrograms formoterol fumarate

Back to β2 agonist bronchodilators index Back to main index

Antimuscarinic bronchodilator

Ipratropium

Tiotropium

Antimuscarinic bronchodilator - Ipratropium

Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from: http://www.brit-thoracic.org.uk or http://www.nice.org.uk Antimuscarinic side effects can occur due to systemic absorption; dry mouth is a common side effect. The combined aerosol inhalation preparation of salbutamol and ipratropium (Combivent Metered Aerosol®) will be discontinued during 2008.


Ipratropium

Ipratropium bromide CFC-free pMDI 20mcg/dose (200 dose unit)

Ipratropium bromide nebuliser solution 250mcg/ml (1ml vials & 2ml vials) A mouthpiece should be used to administer nebulised ipratropium to reduce the risk of acute closed angle glaucoma, particularly when given with salbutamol.

Antimuscarinic bronchodilator - Tiotropium

Refer to the NICE COPD Guidelines for the place of these drugs in therapy. Available from www.nice.org.uk TNDG: Tiotropium has been approved for the management of COPD as follows:

• A course of tiotropium inhaler should be considered where the patient's symptoms are not controlled with ipratropium inhaler and

o The use of a long acting β2 agonist has also failed to control the symptoms, is contra-indicated or has not been tolerated and o The patient's inhaler technique has been checked and is satisfactory

In the situations described above the ipratropium and long acting ββββ2 agonist inhalers should be stopped before commencing tiotropium inhaler. There may be some exceptional circumstances where a patient cannot be controlled on either tiotropium or a long acting

β2 agonist. In these situations it may be appropriate to use the two inhalers in combination if symptom control is improved.

• All patients should undergo full lung function tests before commencing on tiotropium.

• Where tiotropium inhaler is commenced a 4 to 6 week course should be prescribed and the patient reassessed. Where no improvement is demonstrated the tiotropium inhaler should be stopped.

• Patients must be educated on the use of tiopropium and the Handihaler® device.


Tiotropium

Tiotropium dry powder for inhalation 18mcg/capsule (30 capsule pack with Handihaler® & 30 capsule refill pack)

Licensed for adults for COPD ONLY, not licensed for asthma. Use the refill pack for continuation of prescribing. Please ensure the patient is aware that tiotropium should be inhaled once a day only

Respimat®▼ device TNDG: Approved only for patients who fit NICE criteria for tiotropium, but experience difficulty in using the Handihaler® device

Back to Antimuscarinic bronchodilator index Back to main index


General Information

Inhaled corticosteroid - Beclometasone

Inhaled corticosteroid – Budesonide

Inhaled corticosteroid – Fluticasone

Combination of Inhaled steroid and long acting beta2-agonist

Corticosteroids – oral


Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from http://www.brit-thoracic.org.uk or http://www.nice.org.uk MHRA: Inhaled corticosteroids and adrenal suppression in children

• Adrenal suppression can occur with all inhaled corticosteroids and is dose related. Symptoms of adrenal suppression and crisis are non-specific and include anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, decreased consciousness, hypoglycaemia and seizures.

• Acute crisis can be triggered by a variety of factors. Adrenal crisis is more frequently seen with fluticasone however, higher than licensed doses of fluticasone are prescribed more widely than other inhaled corticosteroids.

• Fluticasone should normally be used at HALF the dose of Clenil Modulite®� because fluticasone has double the potency.

• The paediatric licensed dosages of all inhaled corticosteroids should not be exceeded – see table below

Maximum licensed daily doses of inhaled corticosteroids in children CFC-free preparation Maximum DAILY dose

Clenil Modulite®▼ (CFC-free beclometasone) 400 mcg (200mcg BD)

Qvar ® (CFC-free beclometasone) Not licensed in children

Budesonide 800mcg

Fluticasone 400mcg (200mcg BD)

• Review therapy regularly and titrate down to lowest dose at which effective control of asthma is maintained

• If a child’s asthma is not controlled on the maximum licensed dose of inhaled corticosteroids despite the addition of other therapies, the child should be referred to a specialist in the management of paediatric asthma

• Use the lowest strength of inhaler appropriate to the child’s dose; high strength inhalers should NOT be used for children

CSM: the height of children receiving prolonged treatment of inhaled corticosteroid should be monitored; if growth is slowed, referral to a paediatrician should be considered. High dose inhaled corticosteroids used for prolonged periods can induce adrenal suppression and patients receiving this treatment or a high dose inhaler should be given a steroid card. High dose inhaled corticosteroid treatment is defined as:

• For an adult: o 0.8-2 mg of beclometasone (as CFC-containing beclometasone or Clenil Modulite®▼) or budesonide per day o 0.4 – 1mg of fluticasone per day

• For a child aged 0-2 years (via a large volume spacer): o 0.4mg beclometasone (as CFC-containing beclometasone or Clenil Modulite®▼) or budesonide per day o Fluticasone not recommended

• For a child aged 2-12 years (via a large volume spacer):

o 0.8mg beclometasone (as CFC-containing beclometasone or Clenil Modulite®▼) or budesonide per day o 0.4mg of fluticasone per day (aged 4 – 12 years – not recommended for child aged below 4 years)

• High strength corticosteroid inhalers (indicated beside the relevant drug) are not indicated for children

• The dose of inhaled corticosteroid should be no higher than is necessary to keep the patients’ asthma under control

• A spacer device should be used with a pMDi as 1st line in all children under 15 years to minimise systemic absorption of corticosteroid and is useful in children over 15 years and adults. The spacer should be replaced at least yearly.

• To prevent oral candidiasis advise patient to rinse mouth with water (or clean teeth) after a dose and spit the water out. Use of a spacer device also reduces the risk.

Steroid treatment over 3 weeks (oral or high dose inhaled)

• Gradual withdrawal is required;

• Patient requires a steroid card (available from NHS Customer Services (0161 683 2376/2382).

• Advise patient about adrenal suppression, immunosuppression (particularly susceptibility to chickenpox and measles), mood and behaviour changes, abrupt withdrawal and serious musculoskeletal, gastrointestinal and ophthalmic side effects. See current BNF.

Patients who have had a short course (<10 days) of oral corticosteroid for a mild exacerbation of asthma can usually stop oral treatment abruptly however it should be reduced more gradually in patients with poor asthma control to reduce the possibility of serious relapse. CSM: Corticosteroid treatment, especially with high doses, can alter mood and behaviour early in treatment—the patient can become confused, irritable and suffer from delusion and suicidal thoughts. These effects can also occur when corticosteroid treatment is being withdrawn. Patients with history/family history should be treated with particular care although no firm evidence exists they are at increased risk. Paradoxical bronchospasm The potential for paradoxical bronchospasm (calling for discontinuation and alternative therapy) should be borne in mind—mild bronchospasm

may be prevented by inhalation of a short-acting β2 agonist (or by transfer from an aerosol inhalation to a dry powder inhalation).

Back to Corticosteroid therapy index

Inhaled corticosteroid - Beclometasone

Medicines Monthly June 2007. Switching to CFC-free inhaled steroids: Guidance from Tower Hamlets PCT. CFC-containing beclometasone inhalers are being phased out, manufacturing ceased in July 2007. Doses of Clenil® and Qvar® are NOT equivalent and the MHRA has advised that these preparations should be prescribed by brand name. All other inhalers should be prescribed generically.


Clenil Modulite®�� CFC-free pMDI 50mcg, 100mcg, 200mcg & 250mcg (200 dose unit)

MHRA: CFC-free beclometasone inhalers should be prescribed by brand. No dose change is necessary when changing from CFC-containing beclometasone. High Strength: 200 mcg & 250mcg – not for use in children

Beclomethasone dry powder breath-actuated inhaler100mcg, 200mcg & 400mcg/dose (100-dose unit: Easyhaler®, Pulvinal ®)

Licensed for children over 6 years High Strength: 400mcg - not for use in children

Beclomethasone dry powder inhaler 50mcg,100mcg & 200mcg/dose (100-dose unit: Clickhaler®)

High Strength: 250mcg - not for use in children

Beclometasone 100mcg,200mcg or 400mcg / blister( 4 blisters/disk, 15 disks/unit i.e. 60 blisters per box with Diskhaler® & 15 disk refills)

Use the refill pack for continuation of prescribing. High Strength: 400mcg - not for use in children

Qvar® Autohaler CFC-free breath-actuated inhaler 50mcg & 100 mcg/dose (200-dose unit)

MHRA: CFC-free beclometasone inhalers should be prescribed by brand. The dose of Qvar® should be roughly half that of a CFC-containing beclometasone. Licensed for children over 12 years. High Strength: 100mcg - not for use in children

Inhaled corticosteroid – Budesonide


Budesonide dry powder inhaler 100mcg, 200mcg & 400mcg/actuation (Easyhaler®)

Licensed for children over 6 years

Budesonide dry powder inhaler 100mcg, 200mcg & 400mcg/dose (Turbohaler®)

Licensed for children over 12 years

Inhaled corticosteroid – Fluticasone

MHRA: Adrenal crisis is more frequently seen with fluticasone however, higher than licensed doses of fluticasone are prescribed more widely than other inhaled corticosteroids. Fluticasone provides equal clinical activity to beclometasone and budesonide but at half the dose, there is limited evidence that it causes fewer side effects at an equal clinical dose. Fluticasone should normally be used at HALF the dose of Clenil Modulite®� because fluticasone has double the potency.


Fluticasone

Fluticasone propionate CFC-free pMDI inhaler 50mcg, 125mcg & 250mcg/puff (120-dose unit)

Licensed in children over 4 years High Strength: 125mcg & 250mcg - not for use in children

Fluticasone dry powder for inhalation 50mcg, 100mcg, 250mcg & 500mcg (60 dose unit: Accuhaler®)


Fluticasone 50mcg, 100mcg, 250mcg & 500mcg /blister (4 blisters/disk, 15 disks/unit i.e. 60 blisters per box with Diskhaler® & 15 disk refills)


Back to Corticosteroid therapy index

Combination of Inhaled steroid and long acting ββββ2-agonist


Asthma: there is no difference in efficacy in giving inhaled steroid and long acting β2-agonist in combination or in separate inhalers. COPD: A Cochrane review concluded that combined inhalers were effective and reduced the frequency of exacerbations compared with their

long-acting β-agonist component, but there was an increased risk of pneumonia with combined inhalers. The clinical effectiveness of combined treatments can be assessed by improvements in symptoms, activities of daily living, exercise capacity and lung function. Combination treatment should be discontinued if there is no benefit after 4 weeks.

Combination inhalers have fixed combination of corticosteroid and long acting β2-agonist. An increase in dose of steroid without review of the

inhaler strength will therefore also result in an increased dose of long acting β2-agonist. High doses of β2-agonist are associated with hypokalaemia.


Budesonide & formoterol dry powder inhaler 100/6, 200/6 & 400/12 mcg/actuation, (Symbicort® 100/6, 200/6 & 400/12 Turbohaler®)

Symbicort® 100/6 is licensed for children over 6 years and adults. Symbicort® 200/6 & 400/12 is licensed for children over 12 years and adults

Fluticasone and salmeterol CFC-free inhaler 50/25, 125/25 & 250/25mcg/actuation (120-dose unit) (Seretide® 50, 125 & 250 Evohaler®)

Seretide® 50 licensed for children over 4 years and adults. Seretide® 125 & 250 licensed for children over 12 years and adults

Fluticasone and salmeterol dry powder inhaler 100/50, 250/50 & 500/50 ( 60 blisters) (Seretide® 100, 250 & 500 Accuhaler®)

Seretide® 100 Accuhaler® licensed for children over 4 years and adults, Seretide® 250 & 500 Accuhale® licensed for children over 12 years and adults.

Corticosteroids – oral

Steroid treatment over 3 weeks

• Gradual withdrawal is required;

• Patient requires a steroid card (available from NHS Customer Services (0161 683 2376/2382).

• Advise patient about adrenal suppression, immunosuppression (particularly susceptibility to chickenpox and measles), mood and behaviour changes, abrupt withdrawal and serious musculoskeletal, gastrointestinal and ophthalmic side effects. See current BNF.

Patients who have had a short course (<10 days) of oral corticosteroid for a mild exacerbation of asthma can usually stop oral treatment abruptly however it should be reduced more gradually in patients with poor asthma control to reduce the possibility of serious relapse. CSM: Corticosteroid treatment, especially with high doses, can alter mood and behaviour early in treatment—the patient can become confused, irritable and suffer from delusion and suicidal thoughts. These effects can also occur when corticosteroid treatment is being withdrawn. Patients with history/family history should be treated with particular care although no firm evidence exists they are at increased risk.

Drug Formulation Notes

Prednisolone Tablets, soluble tablets, e/c tablets

The potential advantage of soluble or enteric-coated preparations in reducing the risk of GI side effects is speculative only.

Dexamethasone Tablets, oral solution If indicated for croup in children, given as a single dose of 150micrograms/kg.

Back to Corticosteroid therapy index Back to main index .

Theophylline, leukotriene receptor antagonists, mucolytics

Oral theophylline bronchodilators

Leukotriene receptor antagonist

Mucolytic therapy

Oral theophylline bronchodilators



Theophylline

Uniphyllin Continus® M/R tablets, Nuelin SA® SA tablets, Slo-Phyllin® MR capsules

The rate of absorption from modified-release preparation can vary between brands. These drugs should therefore be prescribed by brand name and patients discharged from hospital must be maintained on the brand which they were stabilised on as an inpatient. Theophylline has a narrow therapeutic index. Toxicity can occur within therapeutic range. Signs of toxicity include nausea, gastric irritation, headache, CNS stimulation, tachycardia, palpitations, arrhythmias and convulsions. Serious features of toxicity may develop as long as 12 hours after overdosage with modified release formulations. Routine monitoring is not necessary however it is required after dose change, introducing or withdrawing interacting drugs and may be useful to assess compliance or toxicity. Phyllocontin Continus® Forte M/R tablets may be useful for smokers and other patients who

Aminophylline (a mixture of theophlline and ethylenediamine)

Phyllocontin Continus® M/R tablets, Phyllocontin Continus® Forte M/R tablets Norphyllin SR® tablets (Dosing is based on bodyweight, use ideal bodyweight in obese patients to avoid excessive dosage)

metabolise theophylline more quickly. TDM: Level measured is theophylline Target serum concentration: 10-20 mg/L Sample time: 4-6 hours post dose Notes: Wait at least 5 days after starting treatment or changing dose before taking a theophylline level. Many factors affect theophylline metabolism, see current BNF or SPC for details.

CSM: Potentially serious hypokalaemia may result from β2 agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, and diuretics, and by hypoxia. Plasma-potassium concentration should therefore be monitored in severe asthma.

Leukotriene receptor antagonist

Please refer to the British Thoracic Society Asthma Guidelines for the place of these drugs in therapy. Available from: http://www.brit-thoracic.org.uk or http://www.nice.org.uk CSM: prescribers should be alerts to the development of eosinophilia, vasculitic rash, worsening of pulmonary symptoms, cardiac complications or peripheral neuropathy.


Montelukast Tablet, chewable tablets, granules Licensed for children aged over 6 months. Not for use in COPD.

Mucolytic therapy

Please refer to the NICE COPD Guidelines for the place of these drugs in therapy. Available from: http://www.nice.org.uk NICE: Mucolytic drug therapy should be considered in patients with COPD who have a chronic cough productive of sputum. The mucolytic should be stopped if there is no symptomatic improvement (for example, reduction in frequency of cough and sputum production) after a 4 week trial.

Drug Indication Formulation Notes

Carbocisteine Reduction of sputum viscosity Capsules, oral liquid Stop if no improvement after 4 weeks.

Back to Theophylline, leukotriene receptor antagonists, mucolytics index

Back to main index

Asthma UK Asthma UK is a source of independent advice and information on asthma for patients and health professionals and has a range of useful resources including point of diagnosis booklets, self management materials, and an interactive guide to using inhalers and translated information that can be downloaded and the Asthma UK's Adviceline. This can be found at: http://www.asthma.org.uk/ Stop Smoking

Please refer the patient to the following number if help is required for smoking cessation: 0800 169 1943.

GP surgeries and community pharmacies can also provide advice and support to stop smoking. Please also see section on Drugs used in substance dependence for patients with established chemical dependence Back to main index

Antihistamines

Sedating antihistamines

Non-sedating antihistamines

Sedating antihistamines


Tablets Licensed for adults and children over 6 years. Chlorphenamine

Symptomatic relief of allergy such as hayfever, urticaria Oral solution Licensed for adults and children over 1 year.

Promethazine

Symptomatic relief of allergy such as hayfever, urticaria

Tablets Elixir

Elixir licensed for children over 2 years.

Hydroxyzine Pruritis Tablets Syrup

Syrup licensed for children over 6 months.

Non-sedating antihistamines

Driving: Although drowsiness is rare, nevertheless patients should be advised that it can occur and may affect performance of skilled tasks (e.g. driving); excess alcohol should be avoided.


Tablets Licensed for children over 6 years. Cetirizine

Symptomatic relief of allergy such as hayfever, urticaria. Oral solution Licensed for children aged 2-6 years.

Tablets Licensed for children over 6 years. Loratadine

Symptomatic relief of allergy such as hayfever, urticaria.

Syrup Licensed for children aged 2-6 years.

Fexofenadine

120mg tablets: Seasonal allergic rhinitis 180mg tablets: Chronic idiopathic urticaria

Tablets

Metabolite of terfenadine. Seasonal allergic rhinitis: licensed in children over 6 years and adults. Chronic idiopathic urticaria: licensed in children aged 12 years and adults.

Desloratadine Not recommended for prescribing

Levocetirizine Not recommended for prescribing

Back to antihistamines index Back to main index

References

• Joint Formulary Committee. British National Formulary. 54th Ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2007

• Joint Paediatric Formulary Committee. British National Formulary for Children 2007. British Medical Association, the Royal Pharmaceutical Society of Great Britain, the Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group ; 2007

• Thomas M, Chrystyn H, Leyshon J et al. Consensus guideline on the use of inhaler devices in asthma. Berkhamsted: Medendium Group Publishing, 2008

• MHRA. Long-acting β2 agonists for asthma: review Drug Safety Update: Volume 1, Issue 6, January 2008

• National Institute for Clinical Excellence. Chronic obstructive pulmonary disease – Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical guideline 12. February 2008. Available from: www.nice.org.uk. Accessed 10/03/08

• National Institute for Clinical Excellence. Asthma (children under 5) – inhaler devices. Technology appraisal 10. August 2000. Available from: www.nice.org.uk. Accessed 10/03/08

• National Institute for Clinical Excellence. Asthma (older children) – inhaler devices. Technology appraisal 38. March 2002. Available from: www.nice.org.uk. Accessed 10/03/08

• National Institute for Clinical Excellence. Asthma (in children) – corticosteroids. Technology appraisal 131. November 2007. Available from: www.nice.org.uk. Accessed 10/03/08

• National Institute for Clinical Excellence. Inhaled corticosteroids for the treatment of chronic asthma in adults and children aged 12 years and over. Technology appraisal 138. March 2008. Available from: www.nice.org.uk. Accessed 27/03.08

• Barts and The London & Queen Mary’s School of Medicine and Dentistry. Clinical Effectiveness Group Fast Track Summary Guidelines: Chronic Obstructive Disease. June 2003. Available from: http://www.ihse.qmul.ac.uk/chs/nhs/ceg/guidelines/. Accessed 10.03.08

• Barts and The London & Queen Mary’s School of Medicine and Dentistry. Clinical Effectiveness Group Fast Track Summary Guidelines: Asthma with a focus on adults and children over 5. June 2003. Available from: http://www.ihse.qmul.ac.uk/chs/nhs/ceg/guidelines/. Accessed 10.03.08

• British Thoracic Society, Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised Edition. July 2007. Available from: http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/asthma_fullguideline2007.pdf . Accessed 14.03.08

• Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Guidelines. 2007. Available from: www.goldcopd.org. Accessed 14.03.08

• MHRA. Inhaled corticosteroids and adrenal suppression in children. Current Problems in Pharmacovigilance. Volume 28. October 2002. Available from: http://www.mhra.gov.uk/Publications/Safetyguidance/CurrentProblemsinPharmacovigilance/index.htm. Accessed 14.03.08

• Summary of Product Characteristics. Clenil Modulite®. Available from: http://www.trinity-chiesi.co.uk/files/SmPC%20Clenil%20comb_50-100-200-250mcg.pdf. Accessed 14.03.08

• Summary of Product Characteristics. Ventolin®, Serevent®, Qvar®, Pulmicort®, Oxis®, Flixotide®, Seretide®, Symbicort®, Spiriva®, Bricanyl®, Phyllocontin Continus® , Phyllocontin Continus® Forte, Norphyllin SR®, Uniphyllin Continus® , Nuelin SA® , Slo-Phyllin® Volumatic®, Aerochamber®Plus. Available from: http://emc.medicines.org.uk . Accessed 14.03.08

• Nannini LJ, Cates CJ, Lasserson TJ, Poole P. Combined corticosteroid and long-acting beta-agonist in one inhaler versus long-acting beta-agonists for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4.

• Education for Health. National Respiratory Training Centre. Simply Devices, A Practical Pocket Book. 1st edition. www.educationforhealth.org.uk

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Respiratory System Algorithm for the selection of the most