Asthma

• Clinical recommendations are to review patients that are taking three or more reliever inhalers annually. However, the clinical and patient consensus was to prioritise those prescribed six or more reliever inhalers annually. This is a trigger for timely, priority review. An immediate prescription may be necessary, but review should take place before authorisation of the next prescription.
• Review patients on SABA inhalers alone, clarifying the diagnosis and establishing reasons for SABA only use.
• Review patients with asthma prescribed SABA and LABA without ICS.
• Review patients with asthma who have been prescribed an ICS inhaler and do not currently order on their repeat prescription - assess adherence and understanding of treatment to establish appropriate use of SABA inhalers.
• Review inappropriate use of high strength corticosteroid inhalers (maintaining patients at the lowest possible dose of inhaled corticosteroid).
• Reductions in high dose ICS should be considered every three months, decreasing the dose by approximately 25 to 50% each time and arranging regular review as treatment is reduced.
• Issue a steroid treatment card to patients on high dose inhaled corticosteroids – a steroid emergency card may also be required.
• Review montelukast at four to eight weeks following initiation to ensure a response and review continued need at regular intervals.

Severe asthma

• Identify patients at risk of severe asthma and where modifiable risk factors are addressed and asthma control remains suboptimal, refer to secondary care for treatment optimisation.

Children with asthma

This guidance is not for children, therefore prescribers should refer to guidance on asthma management in children, however, there are two medication safety points to highlight:

• Record regular growth monitoring when treating children with ICS.
• Ensure children on medium / high-dose ICS are under the care of a specialist paediatrician.

COPD

• ICS (licensed only as part of combination therapy with LABA and/or LAMA) are prescribed for people with COPD who have a severe exacerbation, more than two exacerbations in one year or if there are features of asthma.
• Review patients with COPD following initiation of ICS as part of combination therapy after three months.  Stop ICS if there is insufficient response or if there are adverse effects that outweigh benefits.
• Mucolytic therapy is considered for symptoms of chronic cough with productive sputum and should be reviewed four weeks after commencing therapy, stopping if symptoms have not improved with use.
• Review of mucolytic therapy during the annual COPD review should be undertaken and may be stopped if no productive cough.
• Review patients with COPD on separate LAMA and LABA/ ICS inhalers and, if appropriate, change to triple therapy inhalers.
• Review antibiotic course length (five-day course recommended) if needed for infective exacerbations of COPD, with sputum cultures for treatment failure.
• Repeated use of 'rescue medication' (steroid and/or antibiotic) (two or more per year) should trigger a review to optimise long-term management.

Bronchiectasis

• Antibiotic choice should be directed by previous positive cultures. In the absence of previous positive sputum cultures, broad spectrum oral antibiotics to cover common respiratory pathogens are recommended, using local formulary guidance where available.
• Azithromycin 250mg three times a week is recommended for patients with four or more exacerbations in any 12-month period, usually started after advice from secondary care.
• Recommend six-month review of the effectiveness of mucolytic therapy.

Idiopathic pulmonary fibrosis

• Anti-fibrotics should only be prescribed by a clinician with experience of treating IPF.
• Only prescribe anti-fibrotics when there is confirmed fibrotic lung disease with evidence of physiological progression.

• Promotion of person-centred reviews to optimise disease control and ensure quality prescribing in line with national guidance
• Prioritise review of patients with asthma who are over-reliant on SABA reliever inhalers as a marker of poor asthma control (see 'Asthma')
• Streamline devices for patients, avoiding multiple device use where possible
• Review separate inhalers where a combination inhaler device would be possible
• Review individuals prescribed SABA alone, check diagnosis and if appropriate consider a low GWP inhaler
• Update local formularies to highlight and promote inhalers with lower CO2 emissions 
• Use ScriptSwitch in GP Practices to promote better asthma care and environmental messages e.g.
  • highlighting SABA overuse
  • prescribe low volume cannister Salbutamol pMDI with lower GWP
• Raise public awareness to promote good asthma care and the environmental impact of respiratory prescribing
• Utilise resources to support patients and clinicians in environmentally friendly and sustainable prescribing (see 'Resources for clinicians and patients')

For new patients:

• Use inhalers with low global warming potential where they are as equally effective.
• Where there is no alternative to a pMDIs, lower volume HFA 134a pMDIs should be used in preference to large volume or HFA 227ea pMDIs.

For existing patients:

• Switch to DPI or SMI if appropriate, following a patient review - we do not recommend a blanket switch.
• Consider switch to DPI for individuals with asthma who are interested and have an adequate inspiratory flow. If there is concern regarding inspiratory ability due to age or frailty, it can be checked using an inspiratory flow device, such as placebo whistles or In-check^® device.

Clinicians should:

• Develop a clear management plan collaboratively with patients at the centre adopting the “what matters to me?” principles and the 7-Steps medication review process. Clinicians should optimise prescribing of medicines, reduce the potential for harm, manage patient expectations and consider the environmental impact of their prescribing.
• Follow a clinically appropriate approach to initiation of medication, discussing risks and benefits and incorporating agreed criteria for stopping/continuing medication. Inhaler technique remains a key component of co-production of positive clinical outcomes. Therefore, review of inhaler technique should be undertaken as a priority. This is of particular importance due to the growing variety of inhaler devices – ongoing review is recommended.
• Review effectiveness, tolerability and adherence on a regular basis. Medicine burden and waste should be reduced where possible, in line with the Scottish Government's Polypharmacy guidance
• Ensure awareness of relevant changes to inhaler formularies, new inhalers to market, carbon emissions of inhalers and updated guidance            
• Pursue non-pharmaceutical approaches wherever possible, either alone or in conjunction with medicines. Self-management should be actively encouraged and supported for appropriate patients.

Clusters should:

• Engage with local Medicines Management Teams and review respiratory prescribing data. The national therapeutic indicators for respiratory prescribing including prescribing information by GP cluster can be found on the shinyapp.⁷⁴
• Respiratory prescribing issues should be included in the Cluster Quality Improvement plan if deemed a priority. Reduction of carbon emissions is a national priority and this guidance describes how to reduce carbon emissions due to respiratory prescribing.

Secondary care should:

• Engage with pharmacy teams to ensure hospital prescribing is in line with local formulary.
• Understand the influence that secondary care prescribing has in the primary care setting and educate associated staff.

Health Boards should:

• Consider this guidance alongside the data provided on prescribing positions and trends. Prescribing action plans set out local priorities for how Health Boards will continue to improve quality of medicines management. These action plans should, where appropriate, encourage use of this document to drive that improvement.
• Nominate a local lead from within Medicines Management and a local clinical lead from within the local Managed Clinical Network or Respiratory Community. The two leads should work closely together to drive delivery and implementation of the recommendations within this document with the local Managed Clinical Network, where possible.
• Ensure the primary/secondary care interface is appropriately developed. Given the considerable influence that local secondary care prescribing culture has on primary care clinicians, it is vital to ensure engagement with secondary care clinicians. Encourage ownership of primary care data by clinicians in both settings.
• Review local prescribing pathways and formulary and support clinicians, based on current SIGN guidance and environmental issues.
• Ensure non-pharmacological management is promoted within prescribing action plans.