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Respiratory Prescribing
Maureen Reid and Katie Johnston
Primary Care Pharmacists
Edinburgh CHP
Wednesday 26th November 2014
Respiratory medication
(Diagnosis, Drug, Dose)
Diagnosis - determines treatment.
 Treatment – usually includes medication
but all medicines have the potential to
cause harm as well as provide benefit.
 Respiratory medicines can have more
than one licensed indication.
 Use LJF and eLJF.
 Medication needs to be used correctly to
be effective- Compliance and
concordance essential .
Graph showing each Health Board / September
2012 to August 2013 / 03 Respiratory Cost per
Quality and good practice are
Quality is never an accident; it is always the result of high
intention, sincere effort, intelligent direction and skillful
execution; it represents the wise choice of many alternatives.”
~William A. Foster
“Quality begins on the inside… then works its way out.” ~Bob Moawad
“The definition of insanity is doing the same
thing over and over again and expecting
different outcomes.” – Einstein
Scottish Therapeutic Utility
Lothian Joint Formulary
Medicines and devices can have more than
one licensed use and this can be at different
Seretide® Evohalers® 50,125,250
Seretide® 250 Accuhaler ®
Asthma maintenance – 1-2 puffs BD : for maintenance and reliever I puff BD, for relief
of symptoms, 1 puff as needed (max 8 puffs)
COPD – Two puffs BD
Symbicort ® – 400/12
licensed for asthma and COPD – One puff BD
Fostair ®
only licensed for asthma – One puff BD
Seretide® 500 Accuhaler ®
only licensed for asthma – Two puffs BD
Asthma (maintenance only) – 1 puff BD reduced to 1 puff once daily if control
COPD – 1 puff BD
Symbicort ® – 200/6
Asthma (maintenance and reliever) – 2 puffs in 1-2 divided doses, increased to 2 puffs
BD: for reliever of symptoms (SMART regimen) – 1 puff as needed up to 6 puffs at a
time, max 8 puffs daily. (12 puffs for limited time)
COPD – 2 puffs BD
Recent LJF COPD changes
COPD (choice determined by inhaler
 Meter Dosed Inhaler - Fostair ®
(beclometasone plus formoterol)
 Dry powder - Relvar Ellipta ® (fluticasone
furoate plus vilanterol)
LJF COPD changes
SMC restriction - in patients with severe COPD (FEV1 <50% predicted
No planned switch as the potency of the steroids in the components is
different to what has been used before. Start all new patients on LJF
products. Corticosteroids are not licensed on their own in COPD.
Both have set doses for COPD:
 Relvar Ellipta 92mcg/22mcg (low strength) ONE inhalation ONCE a
 Fostair TWO puffs TWICE a day
The colour of Relvar Ellipta is currently blue but this is due to change to
All new inhalers have a short expiry once opened. Relvar is 6 weeks.
Fostair is 5 months once dispensed and out of the fridge.
From the Respiratory Prescribing Strategy
Figure 10: Prescribing of combination
inhalers in children
Types of Inhaler Device?
Think of inhalers in 2
Aerosol: Liquid medication or
Dry powder preparation
Effectiveness of the inhaler
depends on:
patient effort
patient technique
Inhaler devices
These are the main ones!
Metered Dose
Inhaler (MDI)
 Accuhaler ®
Turbohaler ®
Genuair ®
 Ellipta ®
Easi-breathe ®
Handihaler ®
Respimat ®
Novolizer ®
Autohaler ®
 NEXThaler ®
Integra ®
Spacehaler ®
Syncroner inhaler ®
Easyhaler® device
LJF first choice for dry powder
 Available for Salbutamol, beclomethasone,
budesonide, formoterol.
 eLJF updated so Salamol® Easybreath no
longer first choice.
 Change all Salbutamol dry powder to
National Therapeutic Indicators
High Strength Steroid inhalers (not Fostair®) as a
percentage of all Steroid inhalers (items)
Report Period: July 2014 to September 2014
Scotland Baseline (January 2014 to March 2014)
NHS LOTHIAN for period of report
What is considered “high dose” ICS?
<800mcg/day BDP Eq (FP 400mcg, QVAR 400mcg)
unlikely to cause any detrimental effects apart from
Marked HPA suppression at dose above 1500mcg/day
(FP 750mcg) Lipworth et al. Ach Intern Med 1999; 159;941-55
Considerable inter-individual susceptibility
Also consider:
Standard doses of ICS used in conjunction with other steroids
(such as oral/nasal steroids)
Use of ICS with concomitant medicines that inhibit their
metabolism (cytochrome P450 inhibiting drugs: e.g. HIV
protease inhibitors)
Minimising the steroid load with inhaled
LPB 57 Sept 2012
Dose of ICS ?
1. Masoli M et al. Thorax 2004; 59:16-20
2. Holt S et al. BMJ 2001: 323:253-256
Top of clinical dose
response curve:
500 mcg/day FP1,2 =
~400 mcg/day Qvar =
800 mcg/day Clenil =
800 mcg/day Bud
90% effect achieved at doses:
200 mcg/day FP1,2 =
200 mcg/day Qvar =
400 mcg/day Clenil =
400 mcg/day Bud
Starting a combination steroid
inhaler in COPD
Scottish Medicines Consortium (SMC)
states these preparations can be used in
the treatment of adults with severe COPD
(FEV1 <50% predicted normal).
Should be reviewed after 3 months – not
everyone has a benefit.
COPD review
Measure treatment effectiveness by;
Improvement in symptoms
Increase in activies of daily living
Improvement in exercise tolerance
Questions to assessment response to therapy
has your treatment made any difference to you?
Is your breathing any easier?
Can you do things now that you could not do before?
Can you do things faster than before?
Can you do the same things now but with less breathlessness?
The cost of Prescribing .....
...... the Harms of high dose ICS
The cost of Prescribing .....
...... the Harms of high dose ICS
Prolonged use of high doses of ICS
carries a risk of systemic side-effects,
including adrenal suppression or crisis, growth retardation
in children and adolescents, decrease in bone mineral
density, cataract and glaucoma
In addition, a range of psychological or behavioural effects
may also occur. These include psychomotor hyperactivity,
sleep disorders, anxiety, depression, and aggression
(particularly in children)
Other side-effects: Diabetes* (risk of onset over 5.5 yrs –
RR 1.34, High dose RR 1.64 – NNH 21)
* Suissa S, et al. Am J Med 2010;123:1001–6
Patient Adherence
Medication adherence by patients is generally poor, with
reports citing adherence rates to various treatment
regimens of approximately 50%.
25% of patients have asthma adherence rates estimated
at 30% or less
Non-adherence is thought to contribute to 18% to 48% of
asthma deaths
Optimise lung deposition: Inhaler technique
Overall, up to 90% of patients show incorrect inhaler
technique in clinical studies
Patients’ inhaler technique can be significantly improved by
brief instruction given by trained HCP
However, 25% of patients have never received verbal inhaler
 Only an estimated 11% of patients receive follow-up assessment
and education
Ask “Can you show me how you use your inhaler?”
75% of patients using an inhaler for on average 2-3 years reported
they were using their inhaler correctly but on checking only 10%
demonstrated correct technique (Basheti IA et al (2008)
Why is it important?
Essential to ensure patients are receiving inhaled
May prevent basic treatment failure
Correct device for patient may improve symptom
Prevent inappropriate escalation of treatment – reduce
Reduce risk of adverse effects
We wouldn’t let a patient put a tablet in their ear, what's
the difference of letting them have bad inhaler
Asthma - 3 key things to
Follow guidelines – add in a LABA before
increasing steroid
Check inhaler technique, and compliance
before any alteration in therapy (device
Review regularly, using ACT and step
down (need to be familiar with equivalent
COPD- 3 things to remember
Review new treatment after 3 months –
check compliance and if no benefit stop
Dual diagnosis – treat as asthma
Be familiar with licensed devices and
doses for COPD
Asthma and COPD are different conditions and
are treated differently
Licensed inhaler products and doses vary
depending on the condition
Always check inhaler technique
Always check compliance
Use Scottish Therapeutic Utility (STU) to review
patients who don’t order their inhalers