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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 3: Respiratory system - Full Chapter
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03.07  Expand sub section  Mucolytics
Carbocisteine
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First Choice
Green

Capsule, Sachets (750mg/10ml), Oral solution (250mg/5ml)

  • When no sachets or liquid available, capsules can be opened (but only with a sharp knife) and the contents dispersed in water
  • Sachets more cost effective and preferred to liquid.
  • See prescribing guidelines below. Stop if ineffective.
 
Ivacaftor
(Kalydeco)
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Restricted Drug Restricted
Red
High Cost Medicine
CCG

Tablets (supplied through homecare), Sachets

  • NUH:Approved in accordance with the commissioning policy for treatment of cystic fibrosis (CF) in patients aged two years and over who have at least one copy of nine named gene mutations (G551D, G178R, S549N, S549R, G551S, G1244E, S1251N, S1255P, G1349D) causing their cystic fibrosis.
  • - Cystic fibrosis in patients with the R117H gene mutation.
  • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
 
Link  Clinical Commissioning Policy: Ivacaftor for children aged 2-5 years with cystic fibrosis (named mutations)
Link  Clinical Commissioning Policy: Ivacaftor for Cystic Fibrosis (named mutations)
Link  Link to reviews
   
Lumacaftor + Ivacaftor (Orkambi®)
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Restricted Drug Restricted
Red
Homecare

Tablets, Sachets


NUH only:
Approved in accordance with compassionate use scheme for the treatment of cystic fibrosis
Approved in accordance with Clinical Commissioning Urgent Policy Statement: Cystic Fibrosis Modulator Therapies (NHS England URN: 190137P)

Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information"

 
Link  NICE TA398: Lumacaftor–ivacaftor for treating cystic fibrosis homozygous for the F508del mutation
   
Sodium chloride 0.9% nebules
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Formulary
Amber 2
 
   
Tezacaftor + Ivacaftor (Symkevi®)
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Restricted Drug Restricted
Red
High Cost Medicine
Homecare

Tablets

Available at NUH only: Approved in accordance with NHS England commissioning for the treatment of patients with cystic fibrosis. Used in combination with ivacaftor.

 

Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information"

 
Link  NHS England: Commissioning position on CF modulator therapies: Ivacaftor; Lumacaftor/Ivacaftor; and Tezacaftor/Ivacaftor
   
03.07  Expand sub section  Dornase alfa
Dornase Alfa (Pulmozyme®)
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Formulary
High Cost Medicine
Homecare

Nebules
Red Traffic Light  For new patients.

  • Not routinely commissioned for indications other than cystic fibrosis - contact pharmacy (at SFH 3163) for more information.
  • Also available at NUH for non-CF paediatric patients for short term in-patient use on consultant recommendation only.


Amber Traffic Light  For existing patients already receiving supplies from primary care. Repatriation of these patients is not expected.

Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

 
Link  NHSE policy for inhaled therapies in cystic fibrosis
Link  NUH: Airway clearance guideline (Nottingham Children’s Hospital)
Link  SFH: Empyema and dornase guide
   
03.07  Expand sub section  Hypertonic Sodium Chloride
Sodium chloride 3% (Hypertonic)
(for nebulisation)
Restricted Drug Restricted
Amber 2

Nebule

  • Assisted clearance of airway secretions in children and young people where this is complicated by high secretion viscosity.
  • Recommended brand: PulmoClear®.
 
Link  NUH: Airway clearance guidance (Nottingham Children’s Hospital)
   
Sodium chloride 7% (Hypertonic)
(for nebulisation)
Restricted Drug Restricted
Amber 2

Nebule

  • Restricted for use as a mucolytic in cystic fibrosis patients and adult non-CF bronchiectasis.
  • Assisted clearance of airway secretions in children and young people where this is complicated by high secretion viscosity.
  • Recommended brand: PulmoClear®.
 
Link  NUH: Airway clearance guidance (Nottingham Children’s Hospital)
   
03.07  Expand sub section  Mannitol
Mannitol inhalation (Bronchitol ®)
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Restricted Drug Restricted
Red
High Cost Medicine
Homecare

Dry powder for inhalation

  • NUH: Restricted for cystic fibrosis in line with NICE guidance and commissioning policy
  • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information.
 
Link  NICE: Cystic fibrosis - mannitol dry powder for inhalation (TA266)
   
 ....
 Non Formulary Items
Acetylcysteine
(Mucolytic)

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Non Formulary
Grey
  • Oral use as a mucolytic reclassified as GREY at May 17 APC. On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.
  • For nebulisation (unlicensed use, not recommended) - Use 1-5mL of 20% injection, diluted up to 5ml with normal saline, TDS. (Higher doses less tolerable). Precede with salbutamol as may cause bronchoconstriction. No conclusive proof of efficacy has yet been found.
Link  Link to reviews
Link  NUH Memo: ORAL Acetylcysteine – change to formulary status (July2017)
 
Erdosteine  (Erdotin®)

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Non Formulary
Grey
Link  Click here for independent reviews
 
Mecysteine  (Visclair®)

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Non Formulary
Grey
  • Discontinued August 2013
  • Link  Click here for independent reviews
     
    Sodium chloride 6% (hypertonic)  (MucoClear®)

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    Non Formulary
    Grey
     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

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