Guidance on what to consider when mixing nebuliser solutions and advice on which combinations are compatible.

Legalities when mixing

Mixing nebuliser solutions creates an unlicensed product unless you use a combination recommended by a manufacturer. See our section of this article on combinations recommended by manufacturers.

When prescribing an unlicensed medicine, you must:

  • be satisfied that there is sufficient evidence or experience of using the medicine to demonstrate its safety and efficacy
  • take responsibility for prescribing the medicine and for overseeing the individual’s care
  • make a legible record of all medicines prescribed and your reasons for prescribing an unlicensed medicine
  • be an independent prescriber with the legal right to prescribe an unlicensed medicine. This is currently a doctor, dentist, pharmacist, nurse or supplementary prescriber.

When administering an unlicensed nebulised combination, you must include a record of:

  • what nebulised solutions have been combined
  • how you have combined the nebulised solutions

Nebulised compatibility considerations

Important general considerations before mixing nebuliser solutions.

Administration

Mixing nebuliser solutions can simplify the administration procedure and save time. Only mix solutions if there is evidence of compatibility.

Mixing nebuliser solutions can impact chemical stability, particle size, and lung distribution. Where possible, test the mixtures for chemical and physical compatibility before use.

Mix unlicensed combinations immediately before administration and discard any remaining admixture. Discard mixtures if turbidity, colour changes, or precipitation occur.

Always check your local guidance on nebuliser solution mixing.

Impact of preservatives

Some preservatives, like benzalkonium chloride and disodium edetate, can reduce the effectiveness of colistimethate or dornase alfa nebuliser solutions.

Ipratropium bromide and salbutamol nebuliser solutions may contain benzalkonium chloride.

Always check ipratropium bromide and salbutamol products are preservative-free before mixing them with colistimethate or dornase alfa.

Nebuliser systems

Various nebuliser systems exist but not all of them are compatible with every nebulised medicine.

For example, Vantobra, a brand of tobramycin, is licensed for use with the Tolero nebuliser handset and should not be mixed with other medicines.

Check the Summary of Product Characteristics (SmPC) for information on which nebuliser to use with licensed medicines.

Use licensed combinations of nebulised solutions as stated in the SmPC whenever possible.

Mix budesonide with ipratropium bromide for co-administration. Use the admixture within 30 minutes.

Mix budesonide with salbutamol for co-administration. Use the admixture within 30 minutes.

Mix budesonide with terbutaline for co-administration. Use the admixture within 30 minutes.

A licensed ready made combination of ipratropium bromide and salbutamol is available.

Mix ipratropium bromide with salbutamol for co-administration when the ready made combination is not available. Use the admixture as soon as possible.

Dual combinations

Click on the relevant medicine to see which combination is compatible.

Triple combinations

Triple combinations of nebulised solutions are often used in cystic fibrosis. Some compatible combinations include:

  • salbutamol with ipratropium bromide and budesonide
  • salbutamol with ipratropium bromide and tobramycin
  • salbutamol with ipratropium bromide and dornase alfa (when all solutions are preservative free)
  • salbutamol with ipratropium bromide and colistimethate (when all solutions are preservative free)

Update history

  1. Full article update. Fluticasone and sodium cromoglicate nebuliser solutions discontinued.
  2. Published
  1. Clarified licensed status of nebuliser combinations and implications for PGDs
  1. Tool changed for accordion feature to improve visibility of information

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