Quality prescribing strategy for respiratory: a guide for improvement
Background details - age, sex, occupation, baseline function
- 51-year-old male
- Self-employed businessman
History of presentation/reason for review
- Orders at least two Salbutamol pMDIs per month, therefore highlighted for a respiratory review with a primary care healthcare professional
Current medical history and relevant co-morbidities
- Salbutamol pMDI originally started about 3 years ago, for occasional breathlessness
- No confirmed respiratory diagnosis
- No other medical history of note
- No allergies
- No family history of respiratory conditions
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Salbutamol pMDI, inhale two puffs when required for breathlessness
Lifestyle and current function (incl. frailty score for >65yrs) alcohol/smoking/diet/exercise
- Smokes 20 a day including regular cannabis use
- Drinks alcohol on a regular basis, at least six units a day (shares a bottle of wine with his partner most days)
- Sedentary lifestyle, ‘No time to exercise’ due to pressures of work
“What matters to me” (patient ideas, concerns and expectations of treatment)
- Wants to improve his symptoms of breathlessness and does not see the problem with use of frequent salbutamol
- Patient acknowledges stress of job and smokes to relieve this, clearly states that he cannot stop
Results e.g. biochemistry, other relevant investigations or monitoring
- Spirometry reversibility testing confirmed diagnosis of COPD (Fev1/FVC ratio 66)
- Sats on air 97%
- BMI 28
- MRC score 2
Most recent consultations
- Commenced regular long-acting bronchodilator therapy, tiotropium in a soft mist inhaler (tiotropium and olodaterol Respimat®), demonstrating inhaler technique and explaining the need to order refills every month and to replace the device every six months, for environmental reasons.
- In addition, offered the option to change to a salbutamol DPI for environmental reasons as well as the presence of a dose counter. Checked inhaler technique and changed to Easyhaler® Salbutamol.
- Organized influenza and pneumococcal vaccination
- Encouraged to stop smoking. The patient was not keen to do this at the present time due to ongoing stress at work but acknowledged the need to think about this. Signposted to the Stop smoking service at the local community pharmacy for the time he is ready to quit. In the meantime, advised to reduce amount smoked, particularly in relation to cannabis.
- Discussed stress management strategies including making time for some cycling and swimming which he was keen to do. Increased activity will also help with lung function, pulmonary rehabilitation may be appropriate for referral in the future. Acknowledges that he needs to make time to do this.
- Also highlighted problem alcohol drinking and advice to have two alcohol free days at least.
- Issued with a COPD management plan so that symptoms of exacerbations were clear and actions to follow in that case were explained.
7 Steps: Person specific issues to address for COPD 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 the review
Person specific actions
- No confirmed respiratory diagnosis
- Would like to improve symptoms of breathlessness
- High volume of salbutamol use (which he does not see a problem with)
- Stressful job, smokes as relief
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
- Salbutamol is used frequently (Two salbutamol MDIs ordered every month) originally prescribed for occasional breathlessness three years ago
- Spirometry performed to establish diagnosis, confirmed as COPD
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
- Add long-acting bronchodilator therapy, checking inhaler technique to ensure able to use, tiotropium and olodaterol Respimat®
- Influenza and pneumococcal vaccinations organised
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
- Risk of hypokalaemia with salbutamol over-use
- Personalised COPD management plan reinforces action to take when symptoms of COPD 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
- Tiotropium and olodaterol Respimat is a soft mist inhaler which does not contain propellant, so has a very low global warming potential. It has a refill which can be issued every month, only needing to replace the inhaler device every six months which has a lower environmental impact
- Salbutamol 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, however long-acting bronchodilator should provide better symptom control
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-acting bronchodilator inhaled therapy to improve symptom control
- Personalised COPD management plan discussed and agreed, with a written copy given
- Discussed smoking cessation but as not keen to do this at present, encouraged to reduce and in particular reduce cannabis use.
- Stress management strategies and alcohol advice discussed