1. Prescribing Update - Respiratory July 2019

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

3. 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.

4. 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.

5. 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.

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

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

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

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

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

12. 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.

13. 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

14. 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

15. 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

16. 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).

18. Myth or Fact Tiotropium is contraindicated in people
with cardiovascular disease

19. 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

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

22. 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

23. Myth or Fact
Routinely use mucolytic drugs to
prevent exacerbations

24. 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