Spacers

Prescribing And Dispensing Information

Not available for NHS prescription. Babyhaler (GlaxoSmithKline UK Ltd) 1 device. No NHS indicative price available. Drug Tariff (Part IXa) HALERAID ® Device to place over pressurised (aerosol) inhalers to aid when strength in hands is impaired (e.g. in arthritis). For use with Flixotide ®, Seretide ®, Serevent ®, and Ventolin ® inhalers. Not available for NHS prescription. Haleraid-120 (GlaxoSmithKline UK Ltd) 1 device. No NHS indicative price available. Drug Tariff (Part IXa) Haleraid-200 (GlaxoSmithKline UK Ltd) 1 device. No NHS indicative price available. Drug Tariff (Part IXa) OPTICHAMBER ® For use with all pressurised (aerosol) inhalers. OptiChamber (Respironics (UK) Ltd) 1 device. NHS indicative price = £4.28. Drug Tariff (Part IXa) OPTICHAMBER ® DIAMOND For use with all pressurised (aerosol) inhalers. OptiChamber Diamond (Respironics (UK) Ltd) 1 device. NHS indicative price = £4.49. Drug Tariff (Part IXa) OptiChamber Diamond with large LiteTouch mask 5 years- adult (Respironics (UK) Ltd) 1 device. NHS indicative price = £7.49. Drug Tariff (Part IXa) OptiChamber Diamond with medium LiteTouch mask 1-5 years (Respironics (UK) Ltd) 1 device. NHS indicative price = £7.49. Drug Tariff (Part IXa) OptiChamber Diamond with small LiteTouch mask 0- 18 months (Respironics (UK) Ltd) 1 device. NHS indicative price = £7.49. Drug Tariff (Part IXa) POCKET CHAMBER ® Small volume device. For use with all pressurised (aerosol) inhalers. Pocket Chamber (nSpire Health Ltd) 1 device. NHS indicative price = £4.18. Drug Tariff (Part IXa) Pocket Chamber with adult mask (nSpire Health Ltd) 1 device. NHS indicative price = £9.75. Drug Tariff (Part IXa) Pocket Chamber with child mask (nSpire Health Ltd) 1 device. NHS indicative price = £9.75. Drug Tariff (Part IXa) Pocket Chamber with infant mask (nSpire Health Ltd) 1 device. NHS indicative price = £9.75. Drug Tariff (Part IXa) Pocket Chamber with teenager mask (nSpire Health Ltd) 1 device. NHS indicative price = £9.75. Drug Tariff (Part IXa) SPACE CHAMBER PLUS ® For use with all pressurised (aerosol) inhalers. Space Chamber Plus (Medical Developments International Ltd) 1 device. NHS indicative price = £4.26. Drug Tariff (Part IXa) Space Chamber Plus with large mask (Medical Developments International Ltd) 1 device. NHS indicative price = £6.98. Drug Tariff (Part IXa) Space Chamber Plus with medium mask (Medical Developments International Ltd) 1 device. NHS indicative price = £6.98. Drug Tariff (Part IXa) Space Chamber Plus with small mask (Medical Developments International Ltd) 1 device. NHS indicative price = £6.98. Drug Tariff (Part IXa) Respiratory system VOLUMATIC ® Large-volume device. For use with Clenil Modulite ®, Flixotide ®, Seretide ®, Serevent ®, and Ventolin ® inhalers. Volumatic (GlaxoSmithKline UK Ltd) 1 device. NHS indicative price = £3.88. Drug Tariff (Part IXa) Volumatic with paediatric mask (GlaxoSmithKline UK Ltd) 1 device. NHS indicative price = £6.83. Drug Tariff (Part IXa) VORTEX ® Medium-volume device. For use with all pressurised (aerosol) inhalers. Allergic conditions Antihistamines, allergen immunotherapy and allergic emergencies Antihistamines All antihistamines are of potential value in the treatment of nasal allergies, particularly seasonal allergic rhinitis (hayfever), and they may be of some value in vasomotor rhinitis. They reduce rhinorrhoea and sneezing but are usually less effective for nasal congestion. Antihistamines are used topically in the eye, in the nose, and on the skin. Oral antihistamines are also of some value in preventing urticaria and are used to treat urticarial rashes, pruritus, and insect bites and stings; they are also used in drug allergies. Injections of chlorphenamine maleate p. 297 or promethazine hydrochloride p. 301 are used as an adjunct to adrenaline/epinephrine p. 236 in the emergency treatment of anaphylaxis and angioedema. Antihistamines (including cinnarizine p. 457, cyclizine p. 449, and promethazine teoclate p. 458) may also have a role in nausea and vomiting. Buclizine is included as an anti-emetic in a preparation for migraine. Antihistamines may also have a role in occasional insomnia. All older antihistamines cause sedation but alimemazine tartrate p. 297 and promethazine may be more sedating whereas chlorphenamine maleate and cyclizine may be less so. This sedating activity is sometimes used to manage the pruritus associated with some allergies. There is little evidence that any one of the older, ’sedating’ antihistamines is superior to another and patients vary widely in their response. Non-sedating antihistamines such as acrivastine p. 293, bilastine p. 293, cetirizine hydrochloride p. 294, desloratadine p. 294 (an active metabolite of loratadine p. 296), fexofenadine hydrochloride p. 295 (an active metabolite of terfenadine), levocetirizine hydrochloride p. 295 (an isomer of cetirizine hydrochloride), loratadine and mizolastine p. 296 cause less sedation and psychomotor impairment than the older antihistamines because they penetrate the blood brain barrier only to a slight extent. Considerations in the elderly The use of first-generation antihistamines in elderly patients is potentially inappropriate (STOPP criteria) as safer, less toxic antihistamines are widely available. For further information, see STOPP/START criteria in Prescribing in the elderly p. 33. Allergen immunotherapy Immunotherapy using allergen vaccines containing house dust mite, animal dander (cat or dog), or extracts of grass and tree pollen can reduce symptoms of asthma and allergic rhinoconjunctivitis. A vaccine containing extracts of wasp Respiratory system and bee venom is used to reduce the risk of severe anaphylaxis and systemic reactions in individuals with hypersensitivity to wasp and bee stings. An oral preparation of grass pollen extract (Grazax ®) is also licensed for disease- modifying treatment of grass pollen-induced rhinitis and conjunctivitis. Those requiring immunotherapy must be referred to a hospital specialist for accurate diagnosis, assessment, and treatment. Omalizumab p. 282 is a monoclonal antibody that binds to immunoglobulin E (IgE). It is used as additional therapy in individuals with proven IgE-mediated sensitivity to inhaled allergens, whose severe persistent allergic asthma cannot be controlled adequately with high dose inhaled corticosteroid together with a long-acting beta2 agonist. Omalizumab should be initiated by physicians in specialist centres experienced in the treatment of severe persistent asthma. Omalizumab is also indicated as add-on therapy for the treatment of chronic spontaneous urticaria in patients who have had an inadequate response to H1 antihistamine treatment. Anaphylaxis and allergic emergencies Anaphylaxis Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by the rapid onset of respiratory and/or circulatory problems and is usually associated with skin and mucosal changes; prompt treatment is required. Patients with pre-existing asthma, especially poorly controlled asthma, are at particular risk of life-threatening reactions. Insect stings are a recognised risk (in particular wasp and bee stings). Latex and certain foods, including eggs, fish, cow’s milk protein, peanuts, sesame, shellfish, soy, and tree nuts may also precipitate anaphylaxis (see Food allergy p. 91). Medicinal products particularly associated with anaphylaxis include blood products, vaccines, hyposensitising (allergen) preparations, antibacterials, aspirin and other NSAIDs, and neuromuscular blocking drugs. In the case of drugs, anaphylaxis is more likely after parenteral administration; resuscitation facilities must always be available for injections associated with special risk. Anaphylactic reactions may also be associated with additives and excipients in foods and medicines. Refined arachis (peanut) oil, which may be present in some medicinal products, is unlikely to cause an allergic reaction— nevertheless it is wise to check the full formula of preparations which may contain allergens. Treatment of anaphylaxis Adrenaline/epinephrine provides physiological reversal of the immediate symptoms associated with hypersensitivity reactions such as anaphylaxis and angioedema. First-line treatment includes: . securing the airway, restoration of blood pressure (laying the patient flat and raising the legs, or in the recovery position if unconscious or nauseous and at risk of vomiting); . administering adrenaline/epinephrine (by intramuscular injection in a dose of 500 micrograms (a dose of 300 micrograms may be appropriate for immediate self- administration); the dose should be repeated if necessary at 5-minute intervals according to blood pressure, pulse, and respiratory function. Patients receiving beta-blockers require special consideration; . administering high-flow oxygen and intravenous fluids is also of primary importance; . administering an antihistamine, such as chlorphenamine maleate, by slow intravenous injection or intramuscular injection is a useful adjunctive treatment, given after adrenaline. . Administering an intravenous corticosteroid such as hydrocortisone p. 713 (preferably as sodium succinate) is of secondary value in the initial management of anaphylaxis because the onset of action is delayed for several hours, but should be given to prevent further deterioration in severely affected patients. Continuing respiratory deterioration requires further treatment with bronchodilators including inhaled or intravenous salbutamol p. 267, inhaled ipratropium bromide p. 261, intravenous aminophylline p. 287, or intravenous magnesium sulfate p. 1112 [unlicensed indication] (as for acute severe asthma); in addition to oxygen, assisted respiration and possibly emergency tracheotomy may be necessary. When a patient is so ill that there is doubt about the adequacy of the circulation, the initial injection of adrenaline/epinephrine may need to be given as a dilute solution by the intravenous route. Cardiopulmonary arrest may follow an anaphylactic reaction; resuscitation should be started immediately. On discharge, patients should be considered for further treatment with an oral antihistamine and an oral corticosteroid for up to 3 days to reduce the risk of further reaction. Patients should be instructed to return to hospital if symptoms recur and to contact their general practitioner for follow-up. Patients who are suspected of having had an anaphylactic reaction should be referred to a specialist for specific allergy diagnosis. Avoidance of the allergen is the principal treatment; if appropriate, an adrenaline/epinephrine auto- injector should be given for self-administration or a replacement supplied. Intramuscular adrenaline (epinephrine) The intramuscular route is the first choice route for the administration of adrenaline/epinephrine p. 236 in the management of anaphylaxis. Adrenaline/epinephrine is best given as an intramuscular injection into the anterolateral aspect of the middle third of the thigh; it has a rapid onset of action after intramuscular administration and in the shocked patient its absorption from the intramuscular site is faster and more reliable than from the subcutaneous site. Patients with severe allergy should be instructed in the self-administration of adrenaline/epinephrine by intramuscular injection. Prompt injection of adrenaline/epinephrine is of paramount importance. The adrenaline/epinephrine doses recommended for the emergency treatment of anaphylaxis by appropriately trained healthcare professionals are based on the revised recommendations of the Working Group of the Resuscitation Council (UK). The MHRA/CHM have released important safety information regarding the use of adrenaline auto-injectors. For further information, see Important safety information for adrenaline/epinephrine. Intravenous adrenaline (epinephrine) Intravenous adrenaline/epinephrine should be given only by those experienced in its use, in a setting where patients can be carefully monitored. When the patient is severely ill and there is real doubt about the adequacy of the circulation and absorption after intramuscular injection, adrenaline/epinephrine can be given by slow intravenous injection repeated according to response; if multiple doses are required, adrenaline/epinephrine should be given as a slow intravenous infusion stopping when a response has been obtained. It is important that, where intramuscular injection might still succeed, time should not be wasted seeking intravenous access. The intravenous route is also used for cardiac resuscitation. Angioedema Angioedema is dangerous if laryngeal oedema is present. In this circumstance adrenaline/epinephrine injection and oxygen should be given as described under Anaphylaxis; antihistamines and corticosteroids should also be given. Tracheal intubation may be necessary. Hereditary angioedema The treatment of hereditary angioedema should be under specialist supervision. Unlike allergic angioedema, adrenaline/epinephrine, corticosteroids, and antihistamines should not be used for the treatment of acute attacks, including attacks involving laryngeal oedema, as they are ineffective and may delay appropriate treatment—intubation may be necessary. The administration of C1-esterase inhibitor p. 304, an endogenous complement blocker derived from human plasma, (in fresh frozen plasma or in partially purified form) can terminate acute attacks of hereditary angioedema; it can also be used for short-term prophylaxis before dental, medical or surgical procedures. Conestat alfa p. 304 and icatibant p. 305 are licensed for the treatment of acute attacks of hereditary angioedema in adults with C1-esterase inhibitor deficiency. Tranexamic acid p. 117 and danazol p. 783 [unlicensed indication] are used for short-term and long-term prophylaxis of hereditary angioedema. Short-term prophylaxis with tranexamic acid or danazol is started several days before planned procedures (e.g. dental work) and continued for 2–5 days afterwards. Danazol should be avoided in children because of its androgenic effects. Dose of intramuscular injection of adrenaline (epinephrine) for the emergency treatment of anaphylaxis by healthcare professionals Age Dose Volume of adrenaline ▶Child 1 month– 150 micrograms 0.15 mL 1 in 1000 (1 mg/mL) adrenaline1 5 years ▶Child 6–11 years 300 micrograms 0.3 mL 1 in 1000 (1 mg/mL) adrenaline ▶Child 12–17 years 500 micrograms 0.5 mL 1 in 1000 (1 mg/mL) adrenaline2 500 micrograms 0.5 mL 1 in 1000 ▶Adult (1 mg/mL) adrenaline These doses may be repeated several times if necessary at 5-minute intervals according to blood pressure, pulse and respiratory function. 1. Use suitable syringe for measuring small volume 2. 300 micrograms (0.3 mL) if child is small or prepubertal ANTIHISTAMINES › NON-SEDATING

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