Respiratory : Quality prescribing strategy - a guide for improvement
Background details - age, sex, occupation, baseline function
- Male
- Age 78
- MRC Grade 4 shortness of breath
History of presentation/reason for review
- Presented to clinic with persistent cough which impacted on his ability to work
- Slow progression of condition
Current medical history and relevant co-morbidities
- No previous medical history, previously fit and well
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Struggled to tolerate therapy, with multiple side effects but treatment eventually established - had to switch from pirfenidone to nintedanib
- Opiates (morphine sulfate 10mg/5ml oral solution, 2.5ml) to control cough/breathlessness due to progression
- Oxygen (maintain saturation/promote mobility)
Lifestyle and current function (incl. frailty score for >65yrs) alcohol/smoking/diet/exercise
- Condition slowly progressed – required opiates to control breathlessness
Results e.g. biochemistry, other relevant investigations or monitoring
- Investigations confirmed IPF
- Monitored at clinic - when lung function showed evidence of progression antifibrotic treatment started
Most recent consultations
- Despite progressive condition and high symptom burden he was able to maintain a reasonable quality of life, socialising, spending time with family, travelling and painting.
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
- Persistent cough, impacting ability to work
- Slow progression of condition
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
- Nintedanib, started by specialist respiratory consultant to reduce loss of lung function
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
- Cough and breathlessness symptoms due to progression of IPF controlled by addition of opiates (morphine sulfate 10mg/5ml solution, 2.5ml dose)
- Oxygen therapy to maintain saturation and promote mobility
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
- Side effect profiles for the anti-fibrotic drugs differ and previous therapy not tolerated due to side effects. Now established on nintedanib. Side effects associated with nintedanib are liver injury, blood monitoring required
- Common side effects of nintedanib are diarrhoea, nausea, abdominal pain, weight loss and decreased appetite
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
- Anti-fibrotic therapy is monitored and reviewed by specialist IPF teams
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
- Continued treatment with nintedanib
- Opiate use for control of cough and breathlessness symptoms
- Oxygen for mobility