Respiratory : Quality prescribing strategy - a guide for improvement
Background details - age, sex, occupation, baseline function
- 58-year-old female
- Works as a secondary school teacher
- Still working full time
History of presentation/reason for review
- Referred by GP due to productive cough, asking if she has COPD
- On presentation at clinic, has had two episodes of chest infection requiring antibiotics in last six months. On both occasions, sputum grew Haemophilus influenzae
- Daily production of yellow sputum
- Minimal breathlessness
- No chest pains
Current medical history and relevant co-morbidities
- Severe chest infection at eight years (spent three months in hospital)
- Was ‘chesty’ through adulthood
Current medication and drug allergies (include OTC preparation and herbal remedies)
- No current medication
- Had been given SABA inhaler with no benefit
- No drug allergies
Lifestyle and current function (incl. frailty score for >65yrs) alcohol/smoking/diet/exercise
- Never smoker
- Drinks alcohol on special occasions
- Enjoys walking holidays
Results e.g. biochemistry, other relevant investigations or monitoring
- Localised bronchiectasis (right lower lobe), otherwise normal
- No radiological evidence of NTM pulmonary disease
- Spirometry is normal
- Mycobacterial cultures were negative for NTM
Most recent consultations
First consultation
- Given the diagnosis of localized bronchiectasis, likely due to childhood pneumonia. No diagnosis of COPD.
- Given instruction in airway clearance techniques by specialist respiratory physiotherapist.
- Commenced on a mucolytic to assist sputum expectoration
- Pulmonary Function Test (PFTs) showed no diagnosis
Follow up 3 months
- Significant improvement in her ability to clear sputum
- Improvement of day-to-day symptoms reported
- However, further chest infection requiring antibiotics
- Discussion regarding long term azithromycin treatment
- consented to risks of reversible tinnitus/hearing loss associated with long term macrolide use
- ECG carried out, showing normal QTc of 405
- advised to continue azithromycin when on other antibiotics except quinolones
- Azithromycin 250mg Monday/Wednesday/Friday commenced
Follow up 6 month review
- Patient reported no further chest infection since commencing azithromycin
- Routine sputum samples continued to be negative
- Repeat mycobacterial culture was negative
- After discussion azithromycin has been continued long term with good effect
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 PROMs questions to prepare for my review before their review
Person specific actions
- Ongoing symptoms of productive cough, daily sputum production
- Diagnosis of COPD
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
- None
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
- None
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
- Localised bronchiectasis (right lower lobe), Normal spirometry. No diagnosis of COPD
- Commenced a mucolytic to assist sputum expectoration
- Airway clearance techniques taught by specialist respiratory physiotherapist
- Long-term azithromycin therapy commenced following further antibiotic courses for chest infection
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
- ECG carried out prior to long-term azithromycin therapy, normal QTc of 405
- Risks explained of reversible tinnitus/hearing loss associated with long term macrolide use
- If further antibiotics needed, can continue azithromycin apart from with quinolones
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
- Regular long-term azithromycin reduces need for repeated courses of short-term antibiotics and improved patient outcomes
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 long-term azithromycin commenced (Monday /Wednesday /Friday)
- Sputum clearance techniques
Key concepts in this case
- Confirm diagnosis of bronchiectasis to allow appropriate management
- Sputum management with mucolytics and sputum clearance techniques
- Use of long-term azithromycin for regular exacerbations and discussion of side effects