Please also see section on Drugs used in substance dependence for patients with established chemical dependence

Transcription

1 Respiratory System Algorithm for the selection of the most appropriate inhaler device for patients with chronic stable asthma Information on Inhaler devices Devices β 2 agonist bronchodilators Antimuscarinic bronchodilator Corticosteroid therapy Theophylline, leukotriene receptor antagonists, mucolytics Stop Smoking Antihistamines Please also see section on Drugs used in substance dependence for patients with established chemical dependence Respiratory tract infections - Please refer to the Treatment of infections in Primary Care section Updated:

2 Information on inhaler devices

3 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 and costs (2006) Information available at Inhaler device type Metered Dose Inhaler Breath Actuated Inhaler Volumatic Aerochamber Plus Connection with inhaler is rigid and oval and will not fit inhalers with round mouthpieces: i.e. Airomir, Qvar, Atrovent Autohaler, Easi-Breathe Connection with inhaler is flexible and oval. Fits all inhalers including those with round mouthpieces: i.e. Airomir, Qvar, Atrovent 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 pmdi + spacer device Breath Actuated Inhaler NICE 1 st line choice Small, portable and discreet Wide range of drugs available NICE 1 st line choice Reduced need for hand - inhalation coordination Spacer reduces systemic absorption and increases lung deposition Minimal need for hand - inhalation coordination Small and portable Generally cheaper than dry powder inhalers High degree of hand - inhalation co-ordination and some manual dexterity is required (but see Handihaler ) Most pmdis do not have a dose counter 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) 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

4 Dry Powder Inhaler Minimal need for hand - inhalation coordination 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

5 Back to main index 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; singledose 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 Spacer device large volume [Volumatic spacer device] Spacer device medium volume [AeroChamber Plus spacer device: standard device (blue), infant device (orange) & child device (yellow).] Notes Available with paediatric mask. Connection with inhaler is rigid and oval and will not fit inhalers with round mouthpieces: i.e. Airomir, Qvar, Atrovent 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

6 Standard Range Peak Flow Meter [Mini-Wright ] Low Range Peak Flow Meter [Mini-Wright ] Inhalation aid Haleraid 120 (for 120-dose pmdis) Haleraid 200 (for 200-dose pmdis) 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. 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. May be useful for patients who have difficulty using a pmdi due to manual dexterity problems. Back to devices index Back to main index β 2 agonist bronchodilators Short acting β 2 agonist bronchodilator Long acting β 2 agonist bronchodilator Short acting β 2 agonist bronchodilators

7 Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from: or Advise patients not to exceed the prescribed dose and to follow manufacturer's directions; if a previously effective dose of inhaled β 2 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 β 2 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. Plasmapotassium 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 β 2 agonist are more effective and have fewer side effects. Formulation and Device Salbutamol Salbutamol CFC-free 100mcg/dose pmdi (200-dose unit metered dose inhaler) Salbutamol breath-actuated inhaler 100mcg/dose (200-dose unit: Easi-Breathe ) Notes 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 ) Terbutaline sulphate nebulisation single dose unit 2.5mg/ml (2ml unit) Not recommended in children under 5 years. Long acting β 2 -agonist bronchodilators

8 Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from: or To ensure safe use, the CSM has advised that for the management of chronic asthma, long-acting β 2 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 β 2 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 β 2 -agonist fails to provide adequate relief, the patient should be advised to contact the surgery urgently. Formulation and device Salmeterol Notes Salmeterol CFC-free pmdi 25mcg/puff (120 dose-unit) Salmeterol 50mcg/blister( 4 blisters/disk, 15 disks/unit i.e. 60 blisters per box with Diskhaler & 15 disk refills) Salmeterol dry powder for inhalation 50mcg/dose (60 dose-unit: Accuhaler ) Formoterol dry powder inhaler 12mcg/actuation (60-dose unit Easyhaler ) Formoterol dry powder inhaler 6mcg & 12mcg/actuation (60-dose unit: Oxis Turbohaler ) Licensed in children over 4 years Licensed in children over 4 years Use the refill pack for continuation of prescribing. Licensed in children over 4 years Licensed for children over 6 yrs 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

9 Back to β 2 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: or 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 Formulation and device Ipratropium Notes 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

10 Refer to the NICE COPD Guidelines for the place of these drugs in therapy. Available from 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 β 2 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 β 2 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 β 2 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. Formulation and device Tiotropium Tiotropium dry powder for inhalation 18mcg/capsule (30 capsule pack with Handihaler & 30 capsule refill pack) Respimat device Notes 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 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 Corticosteroid therapy General Information Inhaled corticosteroid - Beclometasone Inhaled corticosteroid Budesonide

11 Inhaled corticosteroid Fluticasone Combination of Inhaled steroid and long acting beta 2 -agonist Corticosteroids oral Corticosteroid therapy

12 Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from or 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) Budesonide Fluticasone Not licensed in children 800mcg 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 mg of beclometasone (as CFC-containing beclometasone or Clenil Modulite ) or budesonide per day o 0.4 1mg of fluticasone per day

13 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 1 st 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 ( /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).

14 Back to Corticosteroid therapy index Inhaled corticosteroid - Beclometasone Medicines Monthly June Switching to CFC-free inhaled steroids: Guidance from Tower Hamlets PCT. CFC-containing beclometasone inhalers are being phased out, manufacturing ceased in July 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. Formulation and device Clenil Modulite CFC-free pmdi 50mcg, 100mcg, 200mcg & 250mcg (200 dose unit) Beclomethasone dry powder breath-actuated inhaler100mcg, 200mcg & 400mcg/dose (100-dose unit: Easyhaler, Pulvinal ) Beclomethasone dry powder inhaler 50mcg,100mcg & 200mcg/dose (100-dose unit: Clickhaler ) Beclometasone 100mcg,200mcg or 400mcg / blister( 4 blisters/disk, 15 disks/unit i.e. 60 blisters per box with Diskhaler & 15 disk refills) Qvar Autohaler CFC-free breath-actuated inhaler 50mcg & 100 mcg/dose (200-dose unit) Notes 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 Licensed for children over 6 years High Strength: 400mcg - not for use in children High Strength: 250mcg - not for use in children Use the refill pack for continuation of prescribing. High Strength: 400mcg - not for use in children 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 Formulation and device Budesonide dry powder inhaler 100mcg, 200mcg & 400mcg/actuation (Easyhaler ) Budesonide dry powder inhaler 100mcg, 200mcg & 400mcg/dose (Turbohaler ) Notes Licensed for children over 6 years Licensed for children over 12 years

15 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. Formulation and device Fluticasone Fluticasone propionate CFC-free pmdi inhaler 50mcg, 125mcg & 250mcg/puff (120-dose unit) 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 β 2 -agonist Notes Licensed in children over 4 years High Strength: 125mcg & 250mcg - not for use in children Licensed in children over 4 years High Strength: 250mcg & 500mcg - not for use in children Licensed in children over 4 years High Strength: 250mcg & 500mcg - not for use in children Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from: or Asthma: there is no difference in efficacy in giving inhaled steroid and long acting β 2 -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 β 2 -agonist. An increase in dose of steroid without review of the inhaler strength will therefore also result in an increased dose of long acting β 2 -agonist. High doses of β 2 -agonist are associated with hypokalaemia. Formulation and device Notes

16 Budesonide & formoterol dry powder inhaler 100/6, 200/6 & 400/12 mcg/actuation, (Symbicort 100/6, 200/6 & 400/12 Turbohaler ) Fluticasone and salmeterol CFC-free inhaler 50/25, 125/25 & 250/25mcg/actuation (120-dose unit) (Seretide 50, 125 & 250 Evohaler ) Fluticasone and salmeterol dry powder inhaler 100/50, 250/50 & 500/50 ( 60 blisters) (Seretide 100, 250 & 500 Accuhaler ) 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 Seretide 50 licensed for children over 4 years and adults. Seretide 125 & 250 licensed for children over 12 years and adults 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 ( /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.

17 Theophylline, leukotriene receptor antagonists, mucolytics Oral theophylline bronchodilators Leukotriene receptor antagonist Mucolytic therapy Oral theophylline bronchodilators Please refer to the British Thoracic Society Asthma Guidelines or NICE COPD Guidelines for the place of these drugs in therapy. Available from: or Drug Formulation Notes 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 Uniphyllin Continus M/R tablets, Nuelin SA SA tablets, Slo-Phyllin MR capsules 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

18 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: 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 β 2 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: or CSM: prescribers should be alerts to the development of eosinophilia, vasculitic rash, worsening of pulmonary symptoms, cardiac complications or peripheral neuropathy. Drug Formulation Notes 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: 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 Stop if no improvement after 4 Carbocisteine Reduction of sputum viscosity Capsules, oral liquid weeks.

19 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: Stop Smoking Please refer the patient to the following number if help is required for smoking cessation: 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 Drug Indication Formulation Notes Chlorphenamine Symptomatic relief of allergy Tablets Licensed for adults and children over 6 years. such as hayfever, urticaria Oral solution Licensed for adults and children over 1 year.

20 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. Drug Indication Formulation Notes Cetirizine Symptomatic relief of allergy Tablets Licensed for children over 6 years. such as hayfever, urticaria. Oral solution Licensed for children aged 2-6 years. Loratadine Symptomatic relief of allergy Tablets Licensed for children over 6 years. 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 Levocetirizine Not recommended for prescribing Not recommended for prescribing Back to antihistamines index Back to main index

21 References Joint Formulary Committee. British National Formulary. 54 th Ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2007 Joint Paediatric Formulary Committee. British National Formulary for Children 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 β 2 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 Available from: Accessed 10/03/08 National Institute for Clinical Excellence. Asthma (children under 5) inhaler devices. Technology appraisal 10. August Available from: Accessed 10/03/08 National Institute for Clinical Excellence. Asthma (older children) inhaler devices. Technology appraisal 38. March Available from: Accessed 10/03/08 National Institute for Clinical Excellence. Asthma (in children) corticosteroids. Technology appraisal 131. November Available from: 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 Available from: 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 Available from: Accessed 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 Available from: Accessed British Thoracic Society, Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised Edition. July Available from: Accessed Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Guidelines Available from: Accessed MHRA. Inhaled corticosteroids and adrenal suppression in children. Current Problems in Pharmacovigilance. Volume 28. October Available from: Accessed Summary of Product Characteristics. Clenil Modulite. Available from: Accessed 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: Accessed 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. 1 st edition. Back to main index

22