Prescribing Update - Respiratory July 2019

All patients prescribed inhalers use them as directed Myth or Fact All patients prescribed inhalers use them as directed

Excessive prescribing of reliever medication What are the issues? Inhaler technique Excessive prescribing of reliever medication Under-prescribing of preventer medication All people with asthma who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review of their asthma control, with the aim of improving their asthma through education and change of treatment if required.

Use Patient Decision Aid What can we do? Use Patient Decision Aid Review people with asthma who have been prescribed more than 12 short-acting reliever inhalers Review people with asthma who have been prescribed less than 5 preventer inhalers All people with asthma who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review of their asthma control, with the aim of improving their asthma through education and change of treatment if required.

Which inhaler? All people with asthma who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review of their asthma control, with the aim of improving their asthma through education and change of treatment if required.

Patients should be advised to clean their spacer weekly Myth or Fact Patients should be advised to clean their spacer weekly

Inhalers should be prescribed generically Myth or Fact Inhalers should be prescribed generically

LABAs should not be used without ICS Myth or Fact LABAs should not be used without ICS for people with asthma

Fluticasone furoate 100mcg daily is Myth or Fact Fluticasone furoate 100mcg daily is Low dose ICS for adults

Scenario If asthma is uncontrolled in adults on a low dose of ICS as maintenance therapy Add LABA Add montelukast Increase ICS

Myth or Fact Consider decreasing maintenance therapy when a person's asthma has been controlled with their current maintenance therapy for at least 3 months.

Risks of high dose inhaled Corticosteroids : Adrenal suppression Pneumonia Growth retardation in children Developing Type 2 diabetes Fractures Psychological and behavioural risks: Psychomotor hyperactivity Sleep disorder Anxiety/ depression Aggression

Which ICS doses are high dose? Doses greater than Beclomethasone dipropionate Standard particle CFC-free inhalers 1000 mcg per day Extrafine particle CFC free inhalers 400mcg per day Budesonide dry powder inhalers 800mcg per day Ciclesonide metered dose inhaler 320mcg per day Fluticasone propionate metered dose & dry powder inhalers 500mcg per day Fluticasone furoate dry powder inhaler 100mcg per day Mometasone furoate dry powder inhaler

Scenario If patient with COPD (no asthmatic features) is breathless or has exacerbations on SABA or SAMA prn do you: Add LAMA Add LAMA + ICS Add LAMA +LABA

Cost-effectiveness Evidence review F, p 21 Starting with LAMA+LABA (or LABA+ICS) is more cost-effective than starting with monotherapy and then moving to combination therapy P19 Costs Five categories of cost were used in the model 1. Drug costs – acquisition costs of long-acting bronchodilators 2. Maintenance costs – routine healthcare resource use for each GOLD severity stage 3. Exacerbation costs – resource use associated with a hospitalised or non-hospitalised exacerbation 4. Adverse event costs – costs associated with treating acute and chronic adverse events 5. Treatment progression costs – healthcare costs associated with switching or stepping up treatment P 20 Table 6 shows results when treatment effects on both adverse events and mortality are included. These results show that LABA+ICS is now the strategy which generates the highest number of QALYs, but is associated with a mean ICER in excess of £20,000 per QALY (£21,308 per QALY). Probabilistic sensitivity analysis also shows that there is now a high degree of uncertainty surrounding results (LABA+ICS is cost effective in 37.2% of iterations, and LAMA+LABA in 34.7% of iterations at a threshold of £20,000 per QALY).

Myth or Fact Tiotropium is contraindicated in people with cardiovascular disease

Myth or Fact All patients currently having triple therapy as 2 inhalers should be changed to the single Inhaler containing the LABA+LAMA+ ICS as it is more cost effective and Increases compliance

Myth or Fact All patients having an acute exacerbation of COPD should be prescribed antibiotics

Fluoroquinolone antibiotics Small increased risk of aortic aneurysm and dissection Association with prolonged, serious, disabling and potentially irreversible drug reactions tendonitis, tendon rupture, arthralgia, pain in extremities, gait disturbance, neuropathies associated with paraesthesia, depression, fatigue, memory impairment, sleep disorders, and impaired hearing, vision, taste and smell. Indications for fluoroquinolones restricted Avoid in people who have previously had serious side effects Special caution in people over 60 years, people with kidney disease and organ transplantation Concomitant treatment with a fluoroquinolone and a corticosteroid should be avoided

Myth or Fact Routinely use mucolytic drugs to prevent exacerbations

Practice based pharmacists are focussing on respiratory July to Sept How can they help you? Ordering > 12 SABA /LABA inhalers per year Generic prescribing of salmeterol/fluticasone Prednisolone > 4 issues in the last year