Polypharmacy icon of two pills

A polypharmacy review (following the 7 Steps approach) should ensure optimal management of respiratory conditions, and include addressing aggravating lifestyle factors, consideration of the most appropriate medication at the right dose with regular review.

The 7 Steps to appropriate polypharmacy demonstrate that the review process is not a linear single event, but cyclical, requiring regular repeat and review as shown in the image below.

The circle is centred on what matters to the individual, ensuring they are provided with the right information, tools and resources to make informed decisions about their medicines and treatment options.

Step 1 - What matters to the patient?

  • Ask the patient what matters to them. 
  • Ask patient to complete Patient Reported Outcomes Measures (PROMs) (questions to prepare for my review) before the review
  • How does the condition affect patients' day to day life/activities?
  • Take account of co-morbidities when prescribing for asthma, by using the Polypharmacy 7-Steps approach
  • Ensure patient has a personalised asthma action plan
  • Do environmental prescribing issues matter? (see Environmental impact of inhalers)

 

Step 2 - Identify essential drug therapy

  • Asthma diagnosis confirmed?
  • Fractional exhaled nitrous oxide (FeNO)test could be used as an optional investigation to test for eosinophilic inflammation when there is diagnostic uncertainty.6 In the absence of FeNO, assessing eosinophil levels as part of a full blood count (FBC) may assist with review. FBC would give access to eosinophil results as part of an asthma assessment26
  • Ensure asthma therapy is optimised as per local / SIGN / BTS guidelines6
  • Consider the use of Maintenance and Reliever therapy (MART) regimen in patients where there is poor control or adherence when on separate medium dose ICS/LABA and SABA6
  • Consider use of an anti-inflammatory reliever (AIR) inhaler, that is a low-dose ICS-formoterol, as this approach reduces risk of severe exacerbations compared with using a SABA reliever26
  • Assess adherence, review inhaler technique and eliminate trigger factors prior to initiating or adjusting therapy using an asthma action plan
  • Confirm ongoing need for and effectiveness of medication and screen for side effects

 

Step 3 - Does the patient take unnecessary drug therapy?

  • Discuss SABA use with patients prescribed more than three SABAs annually as this is a marker of poor control
  • When asthma is controlled and stable, clinicians should consider stepping down inhaled corticosteroid (ICS) treatment, slowly, every three months reducing by 25-50% each time and monitoring for deterioration.6 as part of a holistic asthma review

 

Step 4 - Are therapeutic objectives being achieved?

  • Can the patient use their inhalers properly? Assess asthma control using a validated questionnaire such as the Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ).21 Consider addition of spacer to aid MDI lung deposition or consider DPI/SMI if appropriate
  • Any patient who has asthma medicine started or changed should be reviewed within three months
  • Medication should be titrated to a dose which balances maximum clinical efficacy with minimal risk and stopped if found to be ineffective or if adverse effects outweigh benefits
  • If asthma is not adequately controlled on recommended initial or additional therapies, as per BTS/SIGN,6 patient should be referred for specialist assessment
  • Exacerbations should be considered as an opportunity to review therapy, optimise treatment and ensure self-management plans are updated.
  • Consider risk factors for future risk of asthma attack and address these when prescribing - for instance, patients:
    • with an asthma attack in the past
    • who have received more than one course of oral corticosteroids in one year
    • who have received more than six SABA inhalers a year should be prioritised for an asthma review
    • on high dose inhaled steroids
    • with multiple morbidities e.g. COPD, depression, Gastro-oesophageal reflux disease
    • with poor asthma control
    • who smoke
  • Review those who have received emergency hospital treatment for an asthma attack within two working days6
  • Once the dose is stable and effectiveness has been established, ongoing review should occur as clinically appropriate, with follow up at least annually if asthma control has been achieved
  • Delivery of a SABA via a pMDI and spacer or a DPI leads to a similar improvement in lung function as delivery via a nebulizer for treatment of acute exacerbations. A person-centred approach to treatment plans for acute exacerbations should be taken and that individuals have a reliever inhaler that they can use26
  • Consider switch to pMDI with lower global-warming potential where this is clinically appropriate
  • Ensure awareness of how allergies (pet, pollen, dust), air pollution can affect respiratory conditions
  • Vaccinations should be offered if not up to date as per national guidance
  • Individuals should be encouraged to engage in appropriate physical activity. Social prescribing such as exercise would be dependent on ability
  • A breathing exercise program can reduce symptoms
  • Smoking cessation should be advised and the adverse effects of smoking on children highlighted. Offer appropriate support - signpost patients to the NHS Inform Quit Your Way Scotland website (includes community pharmacy services)
  • Weight reduction should be considered in patients who are overweight (BMI 25 – 29.9) or obese (BMI >30) to reduce respiratory symptoms6

 

Step 5 - Is the patient at risk of Adverse Drug Reactions (ADR)s or suffer actual ADRs?

  • Steroid treatment cards should be provided to patients on high dose steroids (both oral and inhaled). A steroid emergency card may also be required18
  • Review risk of osteoporosis if on long term or frequent (more than three or four courses a year) oral corticosteroid treatment19
  • Take measures to reduce the risk of and increase awareness of oral thrush - ensure correct technique to reduce incidence - a spacer device is recommended for use with a pMDI and will reduce oral thrush side effects
  • Yellow card reporting of ADRs

 

Step 6 - Sustainability

  • Opportunities for sustainable prescribing and cost minimisation should be explored but only considered if effectiveness, safety or adherence would not be comprised
  • For new drugs, ensure prescribing is in line with Health Board formulary recommendations
  • For environmental considerations, using a patient centred approach, consider switch to low GWP inhalers for patients with asthma who have an adequate inspiratory flow

 

Step 7 - Is the patient willing and able to take drug therapy as intended?

  • A personalised asthma action plan is key to this approach, with focus on inhaler technique, peak flow monitoring, worsening symptom advice, appropriate use of a spacer and avoidance of new trigger factors
  • Make patient aware of support information e.g. My lungs my life
  • Non-attenders should be followed up – alternative strategies to encourage engagement may be required, (e.g., through community pharmacy/Near Me/telehealth acknowledging limitations)
  • Agree with the patient arrangements for repeat prescribing. Signpost to Medicines Care and Review service in community pharmacy where appropriate
  • Ask patient to complete the post-review PROMs questions after their review