Allergies Formulary

Self-care should be encouraged as. Self Care The self care forum states: Empowering people with the confidence information to look after themselves when they can, visit the GP when they need to, gives people greater control of their own health encourages healthy behaviours that help prevent ill health in the long-term. People can often take care of themselves when they have common symptoms such as sore throats, coughs etc, for example by using over-the-counter medicines. In addition, this will potentially help to reduce pressure on the NHS resources allowing re-direction to areas of greatest need. NOTE: Caution should be exercised when encouraging self-care for patients to ensure that patinet needs can be encompassed within the over the counter sales licensing of the medicine required. For further information resources see the self care forum website. For a list of suggested self care medications to treat hayfever symptoms please see Appendix Two Formulary Key BNF Statement: Although drowsiness is rare, nevertheless patients should be advised that it can occur may affect performance of skilled tasks (eg driving); excess alcohol should be avoided. Drug Formulations Dose Notes First Line CETIRIZINE T: 10mg 10mg daily. Available to purchase over the counter - self care should be encouraged LORATADINE CHLORPHENAMINE L: 5mg/5ml Child 6-12 5mg twice daily. Child 2-6 2.5mg twice daily. T: 10mg Adult & children over 12 10mg daily L: 5mg/5ml Child: 2-12 Body weight under 30kg 5mg once daily Child: 2-12 Body weight over 30kg 10mg once daily T: 4mg Allergies Formulary - 2016-2017 Formulary prepared based on information found in the BNF (current version at time of formulary issue) individual drug Summary of Product Characteristics. This formulary should be used in conjunction with national guidelines. Management of Allergic Rhinitis - see CKS Guidelines Management of Allergic Conjunctivitis - Seasonal or Perennial - see CKS Guidelines British Society for Allergy & Clinical Immunology (BSACI) primary Care Guidelines- see for further information. One of the BSACI's main activities is the formulation of National Guidelines for use by allergy specialists. NICE has accredited the process used by the BSACI to produce its patient management guidelines. Accreditation is valid from 2010 until 2018. 1st line formulary choice Alternative formulary choice 2nd line formulary choice Shared Care (TAG Amber) 3.4.1 Antihistamines Non - sedating Antihistamines Sedating Antihistamine Children aged 6-12 : ½ tablet 4 to 6 hourly. Maximum daily dose: 3 tablets (12mg) in any 24 hours SPC caution: reduce dose in renal impairment Available to purchase over the counter - self care should be encouraged Available to purchase over the counter - self care should be encouraged Allergies Formulary NEL CSU 1 Version: 4.0 Issued: May 2016 Review: May 2017

ADRENALINE (EPINEPHRINE) Emerade First Choice - Mast SODIUM Cell Stabiliser CROMOGLICATE Second Choice - OLOPATADINE (Opatanol ) L: 2mg/5ml Adult children over 12 4mg 4-6 hrly (max: 24mg/24hrs) Elderly : maximum 12mg / 24 hours. Not recommended under 1yr Child: 1-2 1mg twice daily 2-6 1mg every 4-6 hours - (max 6mg daily) 6-12 2mg every 4-6 hours - (max 12mg daily) IM Inj 150 microgram Patients 15-30kg in weight One injection when anaphylaxis symptoms present. Another dose 5-15 minutes later if deterioration or no clinical improvement. IM Inj 300 microgram Patients greater than 30kg One injection when anaphylaxis symptoms present. Another dose 5-15 minutes later if deterioration or no clinical improvement. IM Inj Drops: Drops: 500 microgram 3.4.3 Allergic Emergencies ADULT CHILD over 12 at risk of severe anaphylaxis, 500 micrograms repeated after 5 15 minutes as necessary. 1mg/ml Adult Child over 3 : Apply twice daily. Adult: one spray each nostril twice daily The elderly are more likely to experience neurological anticholinergic effects. Contraindicated with MAOIs Emergency use for anaphylaxis - Emerade is currently recommended as the cost effective choice for new patients. It has approximately double the use by date compared to other brs. Existing patients should be prescribed the br they have been trained to use. MHRA 2014 See link below. Adrenaline Autoinjector Advice for healthcare professionals: Ensure that people with allergies their carers have been trained to use the particular auto-injector that they have been prescribed. Injection technique varies between injectors. Encourage people with allergies their carers to obtain practise using a trainer device (available for free from the manufacturers websites). Advice to give to people with allergies their carers: Carry TWO adrenaline auto-injectors at all times. This is particularly important for people who also have allergic asthma as they are at increased risk of a severe anaphylactic reaction. MHRA Drug Safety Update : Adrenaline Autoinjectors - Advice for Patients Healthcare Professionals. Available to purchase over the counter - self care should be encouraged Ensure generic prescribing of 13.5ml pack size as much cheaper Contains Benzalkonium chloride, soft contact lenses should not be worn during treatment period. Seasonal allergic conjunctivitis Max duration of treatment 4 months. Side effects are uncommon. Has dual action as both a mast cell stabiliser antihistamine. Contains Benzalkonium chloride, soft contact lenses should not be worn during treatment period. Otrivine-Antistin Rapid acting intermittent use antihistamine eye drop for use in patients over 12 can be purchased over the counter. 12.2.1 Drugs used in Nasal Allergies Antihistamines AZELASTINE (Rhinolast ) Spray: 11.4.2 Other Anti-inflammatory preparations for the Eye 2% 140micrograms/ spray Apply one or two drops in each eye 4 times daily. Perennial seasonal allergic rhinitis. Useful for controlling breakthrough symptoms in allergic rhinitis Child: 6 over - one spray each nostril twice daily Not recommended for children under 6 Allergies Formulary NEL CSU 2 Version: 4.0 Issued: May 2016 Review: May 2017

Corticosteroids First Choice- Adults BECLOMETASONE DIPROPIONATE First Choice- Children MOMETASONE FUROATE Spray: Spray: Aqueous nasal spray 50 micrograms/spray 50 microgram per dose pump nasal spray, 140-dose unit Adult & Child over 6 100 micrograms (2 sprays) each nostril twice daily. Max total 400 micrograms (8 sprays) daily. When symptoms controlled, dose reduced to (1 spray) into each nostril twice daily. Beconase currently cheaper than generic Not recommended for children under 6 Available to purchase as over the counter (OTC) but DO NOT prescribe as OTC Beconase Hay fever as this is expensive on FP10. Please prescribe 200 dose pack - currently cheaper than 180 dose. Minimum dose should be used at which effective control of symptoms is maintained. Rhinitis, Not recommended for children under 3. Child 3 11, 1 spray in each nostril once daily. The patient should continue regular use to achieve full Adults & Adolescent 12 therapeutic benefit. over: 2 sprays in each nostril once daily, increasing to 4 sprays in each nostril once daily if necessary. Reduce to 1 spray in each nostril once daily when controlled. Second Choice BUDESONIDE (Rhinocort Aqua ) Spray: Aqueous nasal spray 64 micrograms/spray Adults & Adolescent 12 over: spray 2 sprays into each nostril once daily in the morning. Alternatively - one spray in each nostril morning evening. When control achieved 1 spray each nostril daily. Available OTC for 18 over. Not recommended for children under 12. Maximum duration of use - 3 months. Minimum dose should be used at which effective control of symptoms is maintained MOMETASONE FUROATE Spray: Nasal spray 50 micrograms / spray Adults & Adolescent 12 over: spray 2 sprays into each nostril once daily, increased if necessary to max 200 micrograms (4 sprays) into each nostril once daily. When control is achieved reduce to 50 micrograms (1 spray) into each nostril once daily. Child 6 to 11 : 50 micrograms (1 spray) into each nostril once daily. Not recommended for children under 6. It may take several days of treatment to achieve maximum benefit. Duration of treatment should be restricted to the period that corresponds to allergenic exposure. Intermittent mild symptoms Intermittent or regular oral antihistamines are a good first choice. Intranasal antihistamines have a faster onset of action. Intermittent moderate to severe symptoms Intermittent or regular oral or nasal antihistamines. Treatment Options for Hay Fever Intranasal corticosteroids or decongestants ease nasal congestion. Intranasal decongestants can be used short-term to relieve congestion allow penetration of an intranasal corticosteroid. Available OTC Persistent moderate to severe symptoms Intranasal corticosteroids are the first-choice treatment. Intranasal decongestants can be used short-term to relieve congestion allow penetration of an intranasal corticosteroid. If symptoms remain uncontrolled, increase the corticosteroid dose or use a different one. If itching sneezing are troublesome, an antihistamine can be used. If non- allergic watery rhinorrhoea is the predominant symptom, try intranasal ipratropium Rinatec. If symptoms continue to be poorly controlled, consider a short course of oral corticosteroids. Allergies Formulary NEL CSU 3 Version: 4.0 Issued: May 2016 Review: May 2017

If eye symptoms predominate Oral antihistamines can be taken intermittently or regularly. Intraocular antihistamines are an alternative act more rapidly; they may be preferable for intermittent use. Otrivine- Antisitin can be bought over the counter. Intraocular sodium cromoglicate can also be used for prophylaxis or persistent eye symptoms. CKS Classification of allergic rhinitis: - Intermittent symptoms occur less than 4 days a week for less then 4 weeks. Persistent symptoms occur more than 4 days per week for mote then 4 weeks. Mild symptoms are not troublesome normal activities, such as sleep, sport, leisure, work school, are unaffected. Moderate symptoms are troublesome one or more of the following occur: impairment of normal activities, such as sport, leisure, work school; disturbed sleep. Allergies Formulary NEL CSU 4 Version: 4.0 Issued: May 2016 Review: May 2017

Appendix ONE

Intended as a reference for healthcare professionals only Not to be given to patients Information Key 1st line choice Alternative choice Not on formulary General Sale List Pharmacy Only Medicine Encouraged On Formulary Non-Formulary [GSL] GSL P-Med! Range price is up to date as per 04-02-2016! Dose age restrictions may apply for OTC formulations 10mg tablet 1mg/1ml liquid 10mg tablet 1mg/1ml liquid Antihistamines Non-sedating Antihistamines BNF Statement: Although drowsiness is rare, nevertheless patients should be advised that it can occur may affect performance of skilled tasks (eg driving); excess alcohol should be avoided. Cetirizine (generic) Loratadine (generic) Over The Counter Hayfever Drugs 10mg daily Child 6-12 5mg (half tab) twice daily 10mg daily Child 6-12 5mg twice daily Child 2-6 2.5mg twice Adults & children over 2 with body weight > 30kg 10mg daily Adults & children over 2 with body weight > 30kg 10mg daily Child 2-12 with body weight < 30kg 5mg once daily. 7, 14, 30, tabs [GSL] 100m [GSL] SPC caution: 60 tabs reduce dose in renal impairment 7, 14, 30, tabs [GSL] 70ml [GSL] 60 tabs 7 tablets: 1.00 14 tablets 1.50 30 tablets 2.50 60 tablets 11.49 100ml pack 5.52 7 tablets: 1.00 14 tablets 1.50 30 tablets 2.50 60 tablets 11.49 70ml pack 4.49 Acrivastine 8mg capsule 8mg up to three times daily 12 Cap [GSL] 24 Cap pharmacies SPC caution: not recommended for use in the elderly in significant renal impairment 12 capsules 4.99 24 capsules 8.49 Benadryl ) Issue date; March-2016 For further information please contact WN Prescribing Medicine Management Team Review date: March-2017

Antihistamines Sedating Antihistamines Chlorphenamine 4mg tablet 2mg/5ml liquid 4mg every 4-6 hours (max 24mg/24hrs) Child 6-12 2mg (½ tablet) every 4 to 6 hours. (max 12mg daily) Elderly: maximum 12mg / 24 hours. Not recommended <1yr Child: 1-2 1mg twice daily Child: 2-6 1mg every 4-6 hours - (max 6mg daily) Child: 6-12 2mg every 4-6 hours - (max 12mg daily) only The elderly are more likely to experience neurological anticholinergic effects. Contraindicated with MAOIs 30 tablets 3.19 60 tablets 6.39 Piriton ) 150ml pack 3.36 Piriton ) Mast cell stabiliser Sodium Cromoglycate 2% eye drops Antihistamine / decongestant Anti-inflammatory preparations for the Eye Apply one or two drops in each eye 4 times daily [GSL] Contains Benzalkonium chloride, avoid with soft contact lenses 5ml pack 3.99 10ml pack 5.74 Opticrom allergy ) (Preservative Free preparation also available 20 Unit dose 7.99) Contraindicated with MAOIs Antazoline 0.5% ylometazoline 0.05% (Otrivine- Antistin ) eye drops Adult & Child over 12 1-2 drops two to three times daily (Rapid acting, for intermittent use) pharmacies only Not to be used in narrow angle glaucoma Contains Benzalkonium chloride, avoid with soft contact lenses 10ml pack 4.48 Issue date; March-2016 For further information please contact WN Prescribing Medicine Management Team Review date: March-2017

Corticosteroids Beclometasone Fluticasone Triamcino-lone Topical decongestant 50mcg/spray aqueous nasal spray 50mcg/spray nasal spray 55mcg/spray nasal spray Adult over 18 100 mcg (2 sprays) each nostril twice daily. Max total 400 mcg (8 sprays) daily Maintenance dose: (1 spray) into each nostril twice daily Adult over 18 100 mcg (2 sprays) each nostril daily. Max total 200 mcg daily (2 sprays twice daily) Maintenance dose: (1 spray) into each nostril once a day Adult over 18 110 mcg (2 sprays) each nostril daily. Maintenance dose: (1 spray) into each nostril once a day 100 spray [GSL] 180 spray pharmacies pharmacies only some pharmacies only Minimum dose should be used at which effective control of symptoms is maintained. Minimum dose should be used at which effective control of symptoms is maintained. Minimum dose should be used at which effective control of symptoms is maintained. 100 sprays 4.89 180 sprays 8.49 Beconase hayfever ) 60 sprays 7.89 Pirinase Hayfever ) 30 sprays 5.17 Nasacort ) 0.1% spray nasal spray spray once in each nostril 1- [GSL] MA USE: 7 ylometazoline 0.1% drop nasal drops 0.05% drop child nasal drops Drugs used in Nasal Allergies Max use 7 days, preferably for controlling nightime nasal congestion 3 times daily Use 2-3 drops in each nostril 2-3 times daily Children 6-12 Use 1-2 drops in each nostril 1-2 times daily (Max 2 doses in 24 h) pharmacies only consecutive days (risk of rebound congestion) CHILD DROPS: MA USE: 5 consecutive days 10ml spray 2.30 Otrivine ) 10ml drops 3.36 Otrivine ) 10ml drops 3.05 Otrivine child ) Oxymetazoline 0.05% spray nasal spray 1-2 sprays into each nostril, 6-8 hourly [GSL] MA USE: 7 consecutive days (risk of rebound congestion) 10ml spray 1.00 Vicks ) Normal saline solution Saline solution 0.9% sodium chloride sprays/drops Most preparations suitable from birth (but [GSL] check product specifications) Apply several times per day as required Various preparations 2.00-7.29 Issue date; March-2016 For further information please contact WN Prescribing Medicine Management Team Review date: March-2017

Intended for short-term use only Systemic Decongestant 60mg tablet ONE every 4-6 hours up to 4 times a day 12 tablets 3.00 Sudafed ) Pseudoephredine 30mg tablet 30mg/5ml liquid ONE to TWO every 4-6 hours (Please refer to product for MA daily dose) 10ml every 4-6 hours (Max 4 doses in 24 h) Children 6-12 5ml every 4-6 hours (Max 4 doses in 24 h) pharmacies only Product or combination of products sold must no contain more than 720mg of pseudoephedrine (usually 1 pack) 15 tablets 4.35 18 tablets 4.35 24 tablets 5.99 Brs include: Sinutab (contains paracetamol) Sudafed sinus (contains ibuprofen) 100ml pack 3.28 Sudafed ) Title Over The Counter Hayfever Drugs References Allergies Formulary - 2015-2016 Autumn/Winter 2015 Guide to OTC Boots website URL: http://www.boots.com/en/pharmacy-health/health-shop/allergy-hayfever (accessed on 09-02-2016) Tesco direct website URL: http://www.tesco.com/groceries/product/browse/default.aspx?n=4293437816&ne=4294793660 (accessed on 09-02-2016) Issue date; March-2016 For further information please contact WN Prescribing Medicine Management Team Review date: March-2017

Title Allergies Formulary Persons/Bodies consulted during preparation. Other relevant resources Consultation on Documents Training Implications Monitoring Audit Dissemination Approved by Authorised by Review date by whom Date of Issue Senior Medicines Management Team, NEL Norfolk Waveney Prescribing Reference Group, NICE Guidance, British Society for Allergy & Clinical Immunology (BSACI) CKS Guidelines - Management of Allergic Conjunctivitis - Seasonal or Perennial Management of Allergic Rhinitis Norfolk Waveney Prescribing Reference Group NEL CSU Medicine Management Team Relevant NHS Anglia Programme Commissioning Boards Formulary Pharmacists at Norfolk & Norwich University Hospitals Trust, Queen Elizabeth Hospital Kings Lynn NHS Trust, James Paget University Hospital Trust Norfolk & Waveney Mental Health Care Partnership Trust. Promotion to Primary Care prescribers via Medicine Management Team Evaluation maintenance managed by the NEL N&WPRG To be prepared by the NEL CSU Medicines Management Team, Approved by the N&WPRG, signed off by the PRG- added to NHS Knowledge Anglia, Disseminated to the Norfolk Waveney CCGs for adoption as a working document to advise the Primary Care Prescribers within their CCG. Norfolk Prescribing Reference Group, 06-14 Drugs Therapeutics Committee see below see below Version Date Author Comment 1 17/05/2013 Draft 1.0 01/05/2014 Draft 1.1 04/06/2014 Version 2 19/06/2014 Passed at SMT To remove the nedocromil option leave sodium cromoglycate. To add Olopatadine as a second line option has Mast cell stabilisation antihistamine action can be used for children over 3 twice daily application for up to 4 months treatment. Add note to state Otrivine Antistin useful product, over 12 can be purchased OTC. Add a link to the British Society for Allergy & Clinical Immunology (BSACI). Update the links to CKS. PRG passed Sodium Cromoglycate first line, Olopatadine as second line. Addition of 999 emergency information to Adrenaline autoinjector. Link to BSACI approved. Approved by D&T for publication. Version 2.1 draft April 2015 Update of all links. Update of listed drugs from SPC information. Version 2.1 draft April 2015 remove 999 information add information re carrying of TWO autoinjectors. Version 3.0 draft May-15 Add Mometasone as generic instead of Fluticasone (Avamys br) as cost effective choice. Links to BNF NPC removed as no longer active. Version 3.0 FINAL May-15 Removed Mometasone to simplify choices.final Approved from D&T. Version 3.1 FINAL Oct-15 Ammendment - list preferred cost effective choice of Adrenaline Autoinjector as Emerade add prescribing information for all strengths150, 300 500 micrograms. Version 4.0 May-16 Added - Emerade info - approximately double the expiry date of others. Self care strap line at the start. Added Mometasone for children first line. Added advice leaflet OTC product guide for professionals use.