Quality prescribing strategy for respiratory: a guide for improvement
Background details - age, sex, occupation, baseline function
- 47-year-old female
- Works as cleaner in local high school, but currently on sick leave
- Has had 16 courses of oral prednisolone therapy in 12 months without any face-to-face review with a clinician
- Has ordered 24 salbutamol pMDIs in 12 months
- Breathless, nocturnal wheeze most nights
- Never tested positive for Covid
History of presentation/reason for review
- Referred to primary care healthcare professional due to OCS use and high-volume ordering of salbutamol, despite current treatment with Airflusal® pMDI (fluticasone 250 micrograms /salmeterol 25 micrograms) two puffs twice daily
- Worsening symptoms over the past year
- Multiple courses of oral prednisolone therapy
Current medical history and relevant co-morbidities
- Asthma
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Airflusal® pMDI 250/25 two puffs twice daily, only ordered six inhalers in 12 months
- Salbutamol pMDI two puffs, as required, 24 inhalers ordered in 12 months
Lifestyle and current function (incl. frailty score for >65yrs) alcohol/smoking/diet/exercise
- Lives with husband and 3 children
- Has 2 dogs, 1 cat
- Current smoker of 10 cigarettes per day with 18 pack years
- Overweight with BMI 31
- Little motivation to engage with physical activity
Results e.g. biochemistry, other relevant investigations or monitoring
- Asthma Control Test (ACT) 7/25
- RadioAllergosorbent Test (RAST) – High positive dogs, moderate positive cats, low positive pollen, dust mite. Await Total IgE and aspergillus serology
- Normal eosinophils. TFTs, FBC, U&Es, bone, glucose, ANA, ANCA, CRP, iron studies and B12- normal
- Referred chest X-Ray (CXR) and pulmonary function tests (PFTs)
Most recent consultations
First consultation
- Discussed symptoms and ACT 7/25. Carried out full asthma serology screen. Referred for full PFTs, CXR and DEXA scan
- Chest exam-NAD. SpO2 98% room air
- Discussed concerns over multiple prednisolone courses, high volume salbutamol use and poor adherence to Airflusal® in the context of symptoms and ACT score, adherence to preventer therapy discussed
- Agreed move to Fobumix® Easyhaler® DPI (budesonide 320 micrograms/ formoterol 9 micrograms) two puffs twice daily and Easyhaler® salbutamol, as inhaler technique poor with MDI and good with Easyhaler®. Discussed this in line with health board’s green agenda. Discussed physiology of asthma and concerns, as identified as at risk
- Explained side effect risks from prednisolone and need for DEXA scan
- Discussed smoking cessation and Very Brief Advice (VBA) given. Will consider referral to Quit Your Way
- Full asthma screen and review arranged for following week
Follow up appointment
- Given blood results and awaiting Total IgE and Aspergillus serology. Discussed addition of montelukast given RAST positivity and pets. Agreed with plan
- Awaiting date for PFTs and CXR
- Further education and discussion around managing asthma
- Aware dependent on awaited results may need referral onto Difficult Asthma Clinic
- Personalised Asthma Action Plan discussed, agreed and written copy issued. Advised that this may change dependent on results
- Further appointment made for four weeks for review
7 Steps: Person specific issues to address for asthma case study
1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
Ask patient to complete Patient Reported Outcomes Measures (PROMs) questions to prepare for my review before their review
Person specific actions
- Worsening symptoms of asthma and poor control, resulting in multiple courses of oral steroids and high volume of salbutamol use
- Getting back to work as a cleaner
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice*)
- Drugs that have essential replacement functions (e.g. levothyroxine)
- Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)
Person specific actions
- Inhaled corticosteroids for asthma control, currently prescribed as a combination MDI, Airflusal® (not being ordered regularly)
3. Need: Does the individual take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific actions
- Salbutamol is used frequently (24 inhalers ordered in 12 months), unnecessary if preventer therapy used effectively
- Past frequent courses of oral steroids (16 courses in 12 months) increasing potential for adverse effects
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific actions
- Discussion and education regarding adherence to preventer therapy and salbutamol use. MART therapy also discussed as an option
- Checked inhaler technique with MDI to ensure able to use
- Inhaler changed to a DPI (Fobumix® Easyhaler®, containing an ICS/LABA) as MDI technique was poor
- RAST positivity and presence of pets at home, therefore addition of montelukast to trial
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the person know what to do if they’re ill?
Identify individual safety risks by checking for
- appropriate individual targets
- drug-disease interactions
- drug-drug interactions (see ADR table)
- monitoring mechanisms for high-risk drugs
- risk of accidental overdosing
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
Person specific actions
- Advised of potential for adverse effects from multiple oral steroid courses. DEXA scan arranged. Inhaled corticosteroids treat the condition with reduced exposure to systemic effects, therefore reduced ADRs
- Risk of hypokalaemia with salbutamol over-use, U and Es were normal
- Personalised Asthma Action Plan reinforces advice to take when symptoms of asthma control deteriorate
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives (but balance against effectiveness, safety, convenience)
Consider the environmental impact of
- Inhaler use
- Single use plastics
- Medicines waste
- Water pollution
Person specific actions
- MDI changed to DPI (Easyhaler®) due to inhaler technique, and discussed environmental impact of propellant gases in MDI compared to DPI
- Salbutamol DPI (Easyhaler®) has a dose counter, so will provide reassurance of medication availability, but with education and discussion about management of asthma to reinforce the importance of regular preventer therapy
7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
- Consider teach-back
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- agree with them what medicines have an effect of sufficient magnitude to consider continuation or discontinuation
- inform relevant health and social care providers of changes in treatments across the transitions of care
Ask patient to complete the post review PROMs questions after their review
Agreed plan
- Regular preventer therapy issued in an inhaler which they are able to use correctly
- Personalised Asthma Action Plan discussed and agreed, with a written copy given
- Discussed smoking cessation and Very Brief Advice (VBA) given. Considering referral to Quit Your Way
- Possible that a further referral to the Difficult Asthma Clinic may be needed, dependent on full results and outcomes from improved education and inhaler technique
- Review appointment made for four weeks’ time.