1. Medicines Optimisation
SE London asthma and COPD guidelines
Finlay Royle
Senior Clinical Commissioning Pharmacist
Lambeth CCG

2. Medicines Optimisation Key theme:
Quality, Safety and Medicines Waste

3. Medicines are the most common therapeutic intervention in healthcare, but their use is often suboptimal for a variety of reasons and this can lead to medicines not being used as intended and ‘waste’ in the health economy.

5. Asthma pyramid outcomes for Lambeth CCG September 2015 against May 2016
The following metrics would be expected to decrease over time:
Proportion of patients issued more than 6 prescriptions of short-acting Beta-agonist inhalers
Proportion of patients at Step 4 (treatment with high-dose inhaled steroid)
The following metrics would be expected to increase over time:
Quit Smoking Treatment (in smokers)
Carbon monoxide check
Asthma action plan issued
Inhaled steroid adherence check
Spacer issued
Very brief advice (smoking cessation)
Inhaler technique check
These metrics were developed by a panel of asthma and respiratory experts alongside generalists in Lambeth, Southwark and KHP, to test whether they could measure ‘good quality asthma care’, based upon National Review of asthma deaths and BTS/SIGN guidelines on asthma. The metrics were used to assist individual practices assess their performance against these measures and to address specific issues within the practice.
Data will continue to be analysed to determine if further change occurs. Over time, these data should be aligned to asthma admission and outcomes data to see if there is correlation.
The biggest changes in Lambeth practices were seen in:
issuing of Personalised Asthma Action Plans
issuing of spacer devices for those using pressurised Meter Dose Inhalers
checking of inhaler technique
Areas for improvement identified amongst Lambeth practices: 1. Quit smoking treatment and CO check 2. Inhaler technique checks

6. Introduce the scheme

7. SEL Respiratory Guidelines: Management of COPD & Asthma
New inhaler treatments available on market:
New molecules
New combinations
New devices
Previous guidelines across L&S out of date
SE London group set up:
Consultants, nurses, pharmacists across SEL
Review evidence, safety and value
Patient feedback on devices
Guidelines for asthma & COPD

8. SEL Respiratory Guidelines: Management of COPD & Asthma
General recommendations:
Detect & treat tobacco addiction
Branded prescribing
Patient adherence / technique check
Self-management plans
High-dose inhaled steroid – specialist
Spacer device for Metered-dose inhalers

9. Asthma

11. Asthma – key changes In general practice:
Spiromax device for budesonide/formoterol
Fostair – Nexthaler / DPI
MART therapy
Specialist recommendations / step 4:
High-strength steroids:
Relvar Ellipta, or Flutiform NOT Seretide
Fostair (high-strength)
Tiotropium (softmist inhaler)

12. Respiratory – asthma New devices on formulary: DuoResp Spiromax
Fostair Nexthaler (& MDI)
Easyhalers
Lower lid to present dose
Open lid to present dose
Click to present dose
Budesonide + formoterol
Beclometasone + formoterol
Various drugs
Dose counter
If cap is opened, dose released, counter decreases
Counter only decreases if powder inhaled
If clicked, dose released, counter decreases
Nexthaler – powder stays in reservoir until inhaled. Ie if opened and then closed, but not inhaled, counter does not decrease and dose remains available in the reservoir.
DuoResp Spiromax – dose counter decreases and dose is released every time lid is opened
Easyhalers – beclometasone, budesonide, salbutamol and formoterol (separates). Double-clicking before inhaling results in double dosing. Simple click to release the dose. Dose counter

13. COPD

15. COPD – key changes In general practice:
New LAMA/LABA devices – place in therapy
Medicines Optimisation Scheme
PR, tobacco addiction and vaccinations
Specialist recommendations / step 4:
Refer to specialist for triple therapy and/or when patient exacerbates
Options for triple therapy

16. Lower cap to present dose
Respiratory – COPD
LABA / LAMA devices on formulary:
Ultibro Breezhaler
Duaklir Genuair
Anoro Ellipta
Insert capsule, pierce
Click to present dose
Lower cap to present dose
Once daily dosing
Twice-daily dosing
Visual indicator
Audible and visual indicators
Ellipta device available for steroid Rx
Follow-on from Seebri Breezhaler
Follow-on from Eklira Genuair
Follow-on from Incruse Ellipta

17. https://antibioticguardian.com/
Make a pledge to be an Antibiotic Guardian
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The campaign urges members of the public and healthcare professionals to take action in helping to slow antimicrobial resistance by making a pledge about how they can personally help conserve these vital medicines, ensuring they work now and in the future.