Respiratory Prescribing in Tower Hamlets Bill Sandhu Head of Medicines Management, Tower Hamlets Medicines Management Team

Prescribing Expenditure April-November Cost of Inhalers for all indications is £2.6 Million This is 9% of the total budget for prescribing We are spending around £280K a quarter on fluticasone alone

Change in Prescribing Spend Versus Prevalence

Background – Uncontrolled Asthma is a European Issue Patients with controlled asthma Comprises 51% of ICS users across Europe 1 Fewer symptoms and less need for SABAs than patients with uncontrolled asthma 2 No emergency visits 2 Ability to take part in everyday activities 2 Patients with uncontrolled asthma Comprises 49% of ICS users across Europe 1 Asthma attacks 3 Increased symptoms versus patients with controlled asthma 3 Sleep disturbances 3 Unscheduled healthcare visits: hospitalisations; GP visits 3 Major limitations on activities 3 1. Cazzoletti L, et al. J Allergy Clin Immunol 2007;120:1360–7 2. Bateman ED, et al. Eur Respir J 2008;31:143–78 3. Rabe K, et al. Eur Respir J 2000;16: 802–7 ICS = inhaled corticosteroids SABA = short-acting β 2 -agonists

Mortality rates for asthma in adults in the UK and Europe 1. Loddenkemper R, ed. European Lung White Book. Part 2, Major Respiratory Diseases, Asthma UK. accessed May 2013 In the UK: >1,143 deaths from asthma in 2010 On average three people die from asthma/day 90% of these are preventable 2 Mortality due to asthma in Europe (per 100,000 population) 1 <2 2–4 4–8>8 Portugal Germany Belgium Russia France Denmark Sweden Austria Lithuania Poland UK Spain Ireland Finland The Netherlands Greece Slovakia Czech Republic Ukraine Slovenia

What’s the Issue?

Inhaler Use With the correct technique, only 1/3 of the drug reaches the lungs, What happens if inhaler is used incorrectly? NICE : –recognises inhaler technique is often neglected –recommends it should be regularly reassessed and re- taught Where more than 1 type of inhalers is used, further problems can occur –studies have found an association with increased errors in the use of inhalers when different types of inhalers were used

Healthcare professionals have sufficient knowledge of inhaler technique? 150 Healthcare professionals (from 74 PCTs and 76 Acute Trusts) asked to demonstrate how to administer a pMDI Included hospital doctors, hospital nurses, GPs, practice nurses, hospital and community pharmacy staff Of 150 HCPs assessed: Only 7% could demonstrate all the recognised steps 75% of HCPs said they were involved in the teaching of inhaler technique 48% were prescribers or involved in prescribing 63% had received some training on inhaler technique in the past of which 67% said took place > a year ago Ref: Thorax Dec 2010 Vol 65 Suppl 4

Requirements for an optimal device Simple handling Device should facilitate –optimal respiratory flow of drug when device is used –correct inhalation technique –patient to verify medication inhalation has been successful Dosage and deposition of active ingredient in the lungs must be sufficiently high and reproducible Dose counter – so they know how much is left Require minimal maintenance itself Be acceptable to the patient so they will use it Virchow JC, et al. Respir Med 2007;102:10–9

What do experts say about the importance of inhaler device selection? “When prescribing a new inhaler, or reviewing patients’ progress, inhaler technique should be demonstrated by the clinician, followed by the patient. Many people forget how to use their inhaler devices, and this is likely to affect clinical outcomes” “The least cost effective inhaler device is the one that patients cannot use. In deciding which device and drug formulation to prescribe determine the patients ability to use the prescribed device correctly” General Practice Airways Group (GPIAG) Opinion Sheet on Inhaler Devices No.20; 2008

BTS recommends the “THREE CHECKS” Before initiating or adjusting a new therapy, practitioners should always re-check: –1. Adherence with existing therapy –2. Inhaler technique –3. Eliminate trigger factors BTS recommends: 1.Prescribe inhalers only after patients have received training in the use of the device by a competent healthcare professional and have demonstrated satisfactory technique 2.Reassess technique as part of the clinical review