Medicines Use Review Supporting Information for Asthma Patients

Transcription

1 Medicines Use Review Supporting Information for Asthma Patients What is asthma? Asthma is a chronic inflammatory disorder of the airways. The inflammation causes an associated increase in airway hyper-responsiveness, which leads to recurrent episodes of wheezing, breathlessness, tightness in the chest and coughing. These symptoms often present early in the morning or at night. Episodes are usually associated with some degree of airflow obstruction that will resolve spontaneously or with medication. Symptoms may appear variably and patients sometimes may not experience any symptoms for several weeks or months (unlike COPD). As patients get older they may develop fixed airways disease (particularly if inadequately treated) What causes asthma? There is no single known cause of asthma, but there are a number of genetic and environmental factors that may contribute to the development of the condition, including: Family history of asthma or other atopic condition such as eczema or allergic rhinitis Having had bronchiolitis as a child Exposure to tobacco smoke as a child, particularly if mother smoked during pregnancy Being born prematurely or at a low birth weight What can trigger an exacerbation of asthma? Irritants in air such as cigarette smoke, chemical fumes, pollution Allergens such as pollen, dust mite faeces, animal dander or feathers Respiratory tract infections Weather conditions such as cold air Sulphite-containing foods such as beer, wine, shrimp, many processed or precooked meals Emotional factors such as stress or laughter Medicines, such as non-steriodal anti-inflammatories, beta-blockers Exercise What are the signs of completely controlled asthma? A patient with completely controlled asthma will have:

2 No daytime symptoms No night-time awakening due to asthma No need for rescue medication No exacerbations No limitation on activity, including exercise Normal lung function with minimal side effects from medication How can I support patients with asthma? The goals of asthma treatment are discussed in detail in the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines. As a pharmacist you can support patients by: Helping patients prevent exacerbations Providing information and support to facilitate self-management Identifying and promoting adherence with medication Advising on correct inhaler technique Identifying poor asthma control Support should be tailored to individual patients, taking into account their medical history and what they already know about their condition and treatment. It may also be useful to provide information about the condition, explaining that it is a long-term condition that cannot be cured but that symptoms can be adequately managed. Tackling myths about their condition will also help manage patient expectations. How can I help patients prevent exacerbations and self-manage their condition? Patients should be educated about signs of poor asthma control and signs of an exacerbation, thus enabling them to take steps according to their personalised written action plan, and know when to seek further medical help. You should also counsel patients on their medicines and ensure that they are using them correctly. For example, do they understand the difference between preventer and reliever medication and why it is important that they use their preventer regularly? Also see section How do I help promote adherence? Further information about points to cover when counselling patients on their medicines can be found in the RPS Support Counselling Patients on their Medicines quick reference guide. You can also offer advice about avoiding known triggers and allergens (recommended only in those with confirmed allergy): House dust mite avoidance measures, e.g. washing linen at high temperatures, using anti-dust mite bedding, using agents to kill dust mites. Avoiding foods and additives, such as sulphites (in beer, wine, shrimps)

3 Patients whose asthma is triggered by outdoor factors should be advised to minimize exposure, e.g. not doing strenuous exercise in cold weather or low humidity. If a clinically significant allergen cannot be avoided referring the patient to their GP for onward referral for immunotherapy may be appropriate. Exercise-induced symptoms can be managed with various medicines, however these symptoms are often an indication of poorly controlled asthma and a review of therapy is usually required. Work-related asthma should be referred to a GP. Patients with asthma should be reviewed regularly by specialist doctors and nurses and have a personalised written action plan for management of their condition. You should check that patients have an action plan, understand points in the plan and know how to use it. Some patients (e.g. adults with more severe disease and in those with poor perception of bronchoconstriction) may be required to monitor their condition with a peak flow meter. You should make sure that your patient is aware how to use the device, what the readings mean, how often to conduct a reading and how to care for the meter. How can I help promote adherence? You can help ensure that patients adhere to their asthma medicines by providing simple but clear information about them (if appropriate). Corticosteroids ( preventer ) advise patients about the importance of using their preventer inhaler regularly and inform them about how to avoid more common side effects such as oral thrush. The risk of oral thrush can be reduced by using a spacer device with a corticosteroid inhaler; rinsing the mouth with water (or cleaning a child s teeth) after inhalation of a dose may also be helpful. Additionally be aware that brands of CFC-free beclometasone inhalers are not bioequivalent and should not be interchanged. Also inform patients of the adverse effects associated with prolonged and/or frequent courses of oral therapy as extra monitoring may be required, e.g. for signs of osteoporosis, diabetes (serious adverse effects are more likely with oral therapy than inhlaed corticosteroids). Patients who have been instructed to stop oral corticosteroid treatment should be provided with clear instructions on how to stop to reinforce the prescriber s directions. Steroid cards should be issued where appropriate for oral therapy and ensure that you provide an explanation about their use and purpose. Details of where steroid cards can be obtained can be found in the BNF. Beta 2 agonists ( reliever ) ask about the use of reliever medicines as using inhalers more frequently (more than twice a week) may be a sign of uncontrolled asthma. Warn about effects associated with overuse, e.g. tremors, palpitations. Also ensure that patients understand the difference between short- and long-acting medicines and when to use each type, as not all long acting beta 2 agonists are quick relievers. Short-acting beta 2

4 agonists should only be used when required for symptoms and there is no benefit of using if bronchoconstriction is not present. Theophylline and aminophylline both theophylline and aminophylline have a narrow therapeutic range and interact with a number of medicines. Be aware of the cautions and interactions (including effect of smoking) and advise patients accordingly. Brands of modified release preparations differ in the rate of absorption, thus the brand should be specified on the prescription so you know which one to supply. Patients should have blood levels checked every 12 months and if they present with symptoms suggesting that it is out of range. Leukotriene receptor antagonists advise patients that leukotriene receptor antagonists should not be used to relieve symptoms associated with an acute exacerbation. Sodium cromoglicate and nedocromil these inhalers should be used regularly and are not to be used to relieve symptoms associated with an acute exacerbation. Nebuliser check that the patient understands how to use a nebuliser, how to choose between a mouth piece and facemask, who to contact regarding servicing, where to obtain replacement parts, how to change filters, and how to clean. Also offer advice on how to manage adverse effects of using nebulised solutions. Spacers ensure that the spacer prescribed fits the inhaler. Check that the patient understands how to how to use a spacer, and how to clean and care for it. How can I help patients select the most appropriate device and check that they are using it correctly? There are a number of inhalers available and there are advantages and disadvantages of each device. The choice of inhaler device may also depend on the drug itself, and patient preference and ability. The best way of checking inhaler technique is to ask the patient to demonstrate how they use their inhaler. Each type of inhaler has a different delivery mechanism therefore you should be familiar with instructions for individual inhalers and brands. If the patient is not using the inhaler properly you should perform a demonstration. It is suggested that you have dummy/placebo inhalers for this purpose; these can be obtained from most manufacturers. Placebo/dummy inhalers are single patient use and should not be used for more than one patient. Patient information leaflets often contain pictures and clear instructions for use and you may want to refer patients to this. It is suggested that you check the patient s technique during their next visit to the pharmacy and regularly to ensure that they are still using it correctly. The following devices (which can be sold over the counter/obtained from manufacturer) may help improve inhaler technique:

5 Spacers may help those who find it difficult to use metered dose inhalers (does not require co-ordination of pressing down of the inhaler and inhaling the dose). Many spacers are available on NHS prescriptions. Inhaler aids help patients with manual dexterity problems, e.g. arthritis, press down the chamber of metered dosage inhalers. A winged attachment can help patients with manual dexterity problems, e.g. arthritis, twist the dial on Turbohalers (from manufacturer only). If a patient cannot use a particular inhaler correctly they should be referred to their GP/practice nurse for an alternative. What lifestyle advice should I provide patients with asthma? Smokers should be advised to stop smoking and be provided with supportive therapies, and/or referred to local stop smoking services. Parents who smoke and have a child with asthma should also be advised of the adverse effects of smoking and how it might impact on their child s condition. Obese patients with asthma should be advised about how to lose weight as there seems to be an association between Body Mass Index and symptoms of asthma (ideal BMI kg/m 2). Include advice about eating a balanced diet and adopting an exercise regime to sustain a healthy lifestyle. A diet consisting of fresh fruit and vegetables has been shown (in observational studies) to be associated with fewer asthma symptoms and better lung function. What other support/information can I provide? Other support/information that may be appropriate for your patient could include the following: Influenza vaccination is recommended for all those aged 6 months or over in the clinical risk group (this includes people with asthma who require continuous or repeated use of a steroid preventer inhaler or oral steroids or those that have had asthma attacks requiring hospital admission). Pneumococcal vaccination is recommended for patients who have severe asthma and who require continuous or frequent treatment with oral corticosteroids. Patients with asthma often also suffer from rhinitis. Intranasal steroids can be recommended where appropriate. You should check nasal spray technique when supplying/selling. Explain that facial pain, nasal symptoms, indigestion, and snoring are symptoms of co-existing conditions that may worsen asthma, and may require treatment. Other conditions that may co-exist with asthma include sinusitis, gastrooesophageal reflux disease, and sleep apnoea. Offer treatment and advice or refer to a doctor where appropriate. It is suggested that to improve adherence, any verbal advice is supported with written information that patients can take away. Referring the patient to the

6 product information leaflet may be sufficient in some cases; however leaflets about the condition may also be of use. A range of leaflets can be obtained from Asthma UK. When should I refer patients? You should discuss with other healthcare professionals local procedures for referral of patients. Patients who may require referral to a doctor or other healthcare professional could include: Those who have noticed an increase in asthma exacerbations and symptoms which may indicate that their condition is not well controlled Those who have not responded to treatment with medicines Those who are experiencing side effects with their medicine Those presenting with a severe or life threatening acute asthma exacerbation Those with suspected occupational asthma Those with co-existing conditions Those with haemoptysis The following specialists may also be involved in the management of asthma at any stage: dieticians, physiotherapists, occupational therapists and respiratory nurse specialists, and you should be familiar with referral pathways to these specialis Where can I signpost patients wanting further information? Asthma UK British Lung Foundation European Federation of Allergy and Airway Diseases Patients Association NHS Choices Patient.co.uk Where can I go for further information? RPS members can contact RPS Support on , or complete a web form at UKCPA Respiratory Group , RPS Support Resources Counselling Patients on Medicines quick reference guide Smoking cessation quick reference guide Obesity and weight management quick reference guide Supporting patients with COPD quick reference guide

7 Asthma UK is the charity dedicated to changing the outlook on asthma. It has patient management plans, leaflets and an inhaler demonstration video. How to make the most of being asthmatic Your health, your choices. Has videos on asthma and inhaler technique. Offers medical information and support with printable leaflets Video demonstrations on correct inhaler technique

8 Medicines Use Review Supporting Information for Asthma Patients What is asthma? Asthma is a chronic inflammatory disorder of the airways. The inflammation causes an associated increase in airway hyper-responsiveness, which leads to recurrent episodes of wheezing, breathlessness, tightness in the chest and coughing. These symptoms often present early in the morning or at night. Episodes are usually associated with some degree of airflow obstruction that will resolve spontaneously or with medication. Symptoms may appear variably and patients sometimes may not experience any symptoms for several weeks or months (unlike COPD). As patients get older they may develop fixed airways disease (particularly if inadequately treated) What causes asthma? There is no single known cause of asthma, but there are a number of genetic and environmental factors that may contribute to the development of the condition, including: Family history of asthma or other atopic condition such as eczema or allergic rhinitis Having had bronchiolitis as a child Exposure to tobacco smoke as a child, particularly if mother smoked during pregnancy Being born prematurely or at a low birth weight What can trigger an exacerbation of asthma? Irritants in air such as cigarette smoke, chemical fumes, pollution Allergens such as pollen, dust mite faeces, animal dander or feathers Respiratory tract infections Weather conditions such as cold air Sulphite-containing foods such as beer, wine, shrimp, many processed or precooked meals Emotional factors such as stress or laughter Medicines, such as non-steriodal anti-inflammatories, beta-blockers Exercise What are the signs of completely controlled asthma? A patient with completely controlled asthma will have:

9 No daytime symptoms No night-time awakening due to asthma No need for rescue medication No exacerbations No limitation on activity, including exercise Normal lung function with minimal side effects from medication How can I support patients with asthma? The goals of asthma treatment are discussed in detail in the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines. As a pharmacist you can support patients by: Helping patients prevent exacerbations Providing information and support to facilitate self-management Identifying and promoting adherence with medication Advising on correct inhaler technique Identifying poor asthma control Support should be tailored to individual patients, taking into account their medical history and what they already know about their condition and treatment. It may also be useful to provide information about the condition, explaining that it is a long-term condition that cannot be cured but that symptoms can be adequately managed. Tackling myths about their condition will also help manage patient expectations. How can I help patients prevent exacerbations and self-manage their condition? Patients should be educated about signs of poor asthma control and signs of an exacerbation, thus enabling them to take steps according to their personalised written action plan, and know when to seek further medical help. You should also counsel patients on their medicines and ensure that they are using them correctly. For example, do they understand the difference between preventer and reliever medication and why it is important that they use their preventer regularly? Also see section How do I help promote adherence? Further information about points to cover when counselling patients on their medicines can be found in the RPS Support Counselling Patients on their Medicines quick reference guide. You can also offer advice about avoiding known triggers and allergens (recommended only in those with confirmed allergy): House dust mite avoidance measures, e.g. washing linen at high temperatures, using anti-dust mite bedding, using agents to kill dust mites. Avoiding foods and additives, such as sulphites (in beer, wine, shrimps)

10 Patients whose asthma is triggered by outdoor factors should be advised to minimize exposure, e.g. not doing strenuous exercise in cold weather or low humidity. If a clinically significant allergen cannot be avoided referring the patient to their GP for onward referral for immunotherapy may be appropriate. Exercise-induced symptoms can be managed with various medicines, however these symptoms are often an indication of poorly controlled asthma and a review of therapy is usually required. Work-related asthma should be referred to a GP. Patients with asthma should be reviewed regularly by specialist doctors and nurses and have a personalised written action plan for management of their condition. You should check that patients have an action plan, understand points in the plan and know how to use it. Some patients (e.g. adults with more severe disease and in those with poor perception of bronchoconstriction) may be required to monitor their condition with a peak flow meter. You should make sure that your patient is aware how to use the device, what the readings mean, how often to conduct a reading and how to care for the meter. How can I help promote adherence? You can help ensure that patients adhere to their asthma medicines by providing simple but clear information about them (if appropriate). Corticosteroids ( preventer ) advise patients about the importance of using their preventer inhaler regularly and inform them about how to avoid more common side effects such as oral thrush. The risk of oral thrush can be reduced by using a spacer device with a corticosteroid inhaler; rinsing the mouth with water (or cleaning a child s teeth) after inhalation of a dose may also be helpful. Additionally be aware that brands of CFC-free beclometasone inhalers are not bioequivalent and should not be interchanged. Also inform patients of the adverse effects associated with prolonged and/or frequent courses of oral therapy as extra monitoring may be required, e.g. for signs of osteoporosis, diabetes (serious adverse effects are more likely with oral therapy than inhlaed corticosteroids). Patients who have been instructed to stop oral corticosteroid treatment should be provided with clear instructions on how to stop to reinforce the prescriber s directions. Steroid cards should be issued where appropriate for oral therapy and ensure that you provide an explanation about their use and purpose. Details of where steroid cards can be obtained can be found in the BNF. Beta 2 agonists ( reliever ) ask about the use of reliever medicines as using inhalers more frequently (more than twice a week) may be a sign of uncontrolled asthma. Warn about effects associated with overuse, e.g. tremors, palpitations. Also ensure that patients understand the difference between short- and long-acting medicines and when to use each type, as not all long acting beta 2 agonists are quick relievers. Short-acting beta 2

11 agonists should only be used when required for symptoms and there is no benefit of using if bronchoconstriction is not present. Theophylline and aminophylline both theophylline and aminophylline have a narrow therapeutic range and interact with a number of medicines. Be aware of the cautions and interactions (including effect of smoking) and advise patients accordingly. Brands of modified release preparations differ in the rate of absorption, thus the brand should be specified on the prescription so you know which one to supply. Patients should have blood levels checked every 12 months and if they present with symptoms suggesting that it is out of range. Leukotriene receptor antagonists advise patients that leukotriene receptor antagonists should not be used to relieve symptoms associated with an acute exacerbation. Sodium cromoglicate and nedocromil these inhalers should be used regularly and are not to be used to relieve symptoms associated with an acute exacerbation. Nebuliser check that the patient understands how to use a nebuliser, how to choose between a mouth piece and facemask, who to contact regarding servicing, where to obtain replacement parts, how to change filters, and how to clean. Also offer advice on how to manage adverse effects of using nebulised solutions. Spacers ensure that the spacer prescribed fits the inhaler. Check that the patient understands how to how to use a spacer, and how to clean and care for it. How can I help patients select the most appropriate device and check that they are using it correctly? There are a number of inhalers available and there are advantages and disadvantages of each device. The choice of inhaler device may also depend on the drug itself, and patient preference and ability. The best way of checking inhaler technique is to ask the patient to demonstrate how they use their inhaler. Each type of inhaler has a different delivery mechanism therefore you should be familiar with instructions for individual inhalers and brands. If the patient is not using the inhaler properly you should perform a demonstration. It is suggested that you have dummy/placebo inhalers for this purpose; these can be obtained from most manufacturers. Placebo/dummy inhalers are single patient use and should not be used for more than one patient. Patient information leaflets often contain pictures and clear instructions for use and you may want to refer patients to this. It is suggested that you check the patient s technique during their next visit to the pharmacy and regularly to ensure that they are still using it correctly. The following devices (which can be sold over the counter/obtained from manufacturer) may help improve inhaler technique:

12 Spacers may help those who find it difficult to use metered dose inhalers (does not require co-ordination of pressing down of the inhaler and inhaling the dose). Many spacers are available on NHS prescriptions. Inhaler aids help patients with manual dexterity problems, e.g. arthritis, press down the chamber of metered dosage inhalers. A winged attachment can help patients with manual dexterity problems, e.g. arthritis, twist the dial on Turbohalers (from manufacturer only). If a patient cannot use a particular inhaler correctly they should be referred to their GP/practice nurse for an alternative. What lifestyle advice should I provide patients with asthma? Smokers should be advised to stop smoking and be provided with supportive therapies, and/or referred to local stop smoking services. Parents who smoke and have a child with asthma should also be advised of the adverse effects of smoking and how it might impact on their child s condition. Obese patients with asthma should be advised about how to lose weight as there seems to be an association between Body Mass Index and symptoms of asthma (ideal BMI kg/m 2). Include advice about eating a balanced diet and adopting an exercise regime to sustain a healthy lifestyle. A diet consisting of fresh fruit and vegetables has been shown (in observational studies) to be associated with fewer asthma symptoms and better lung function. What other support/information can I provide? Other support/information that may be appropriate for your patient could include the following: Influenza vaccination is recommended for all those aged 6 months or over in the clinical risk group (this includes people with asthma who require continuous or repeated use of a steroid preventer inhaler or oral steroids or those that have had asthma attacks requiring hospital admission). Pneumococcal vaccination is recommended for patients who have severe asthma and who require continuous or frequent treatment with oral corticosteroids. Patients with asthma often also suffer from rhinitis. Intranasal steroids can be recommended where appropriate. You should check nasal spray technique when supplying/selling. Explain that facial pain, nasal symptoms, indigestion, and snoring are symptoms of co-existing conditions that may worsen asthma, and may require treatment. Other conditions that may co-exist with asthma include sinusitis, gastrooesophageal reflux disease, and sleep apnoea. Offer treatment and advice or refer to a doctor where appropriate. It is suggested that to improve adherence, any verbal advice is supported with written information that patients can take away. Referring the patient to the

13 product information leaflet may be sufficient in some cases; however leaflets about the condition may also be of use. A range of leaflets can be obtained from Asthma UK. When should I refer patients? You should discuss with other healthcare professionals local procedures for referral of patients. Patients who may require referral to a doctor or other healthcare professional could include: Those who have noticed an increase in asthma exacerbations and symptoms which may indicate that their condition is not well controlled Those who have not responded to treatment with medicines Those who are experiencing side effects with their medicine Those presenting with a severe or life threatening acute asthma exacerbation Those with suspected occupational asthma Those with co-existing conditions Those with haemoptysis The following specialists may also be involved in the management of asthma at any stage: dieticians, physiotherapists, occupational therapists and respiratory nurse specialists, and you should be familiar with referral pathways to these specialis Where can I signpost patients wanting further information? Asthma UK British Lung Foundation European Federation of Allergy and Airway Diseases Patients Association NHS Choices Patient.co.uk Where can I go for further information? RPS members can contact RPS Support on , or complete a web form at UKCPA Respiratory Group , RPS Support Resources Counselling Patients on Medicines quick reference guide Smoking cessation quick reference guide Obesity and weight management quick reference guide Supporting patients with COPD quick reference guide

14 Asthma UK is the charity dedicated to changing the outlook on asthma. It has patient management plans, leaflets and an inhaler demonstration video. How to make the most of being asthmatic Your health, your choices. Has videos on asthma and inhaler technique. Offers medical information and support with printable leaflets Video demonstrations on correct inhaler technique

15 Medicines Use Review Supporting Information for Asthma Patients What is asthma? Asthma is a chronic inflammatory disorder of the airways. The inflammation causes an associated increase in airway hyper-responsiveness, which leads to recurrent episodes of wheezing, breathlessness, tightness in the chest and coughing. These symptoms often present early in the morning or at night. Episodes are usually associated with some degree of airflow obstruction that will resolve spontaneously or with medication. Symptoms may appear variably and patients sometimes may not experience any symptoms for several weeks or months (unlike COPD). As patients get older they may develop fixed airways disease (particularly if inadequately treated) What causes asthma? There is no single known cause of asthma, but there are a number of genetic and environmental factors that may contribute to the development of the condition, including: Family history of asthma or other atopic condition such as eczema or allergic rhinitis Having had bronchiolitis as a child Exposure to tobacco smoke as a child, particularly if mother smoked during pregnancy Being born prematurely or at a low birth weight What can trigger an exacerbation of asthma? Irritants in air such as cigarette smoke, chemical fumes, pollution Allergens such as pollen, dust mite faeces, animal dander or feathers Respiratory tract infections Weather conditions such as cold air Sulphite-containing foods such as beer, wine, shrimp, many processed or precooked meals Emotional factors such as stress or laughter Medicines, such as non-steriodal anti-inflammatories, beta-blockers Exercise What are the signs of completely controlled asthma? A patient with completely controlled asthma will have:

16 No daytime symptoms No night-time awakening due to asthma No need for rescue medication No exacerbations No limitation on activity, including exercise Normal lung function with minimal side effects from medication How can I support patients with asthma? The goals of asthma treatment are discussed in detail in the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines. As a pharmacist you can support patients by: Helping patients prevent exacerbations Providing information and support to facilitate self-management Identifying and promoting adherence with medication Advising on correct inhaler technique Identifying poor asthma control Support should be tailored to individual patients, taking into account their medical history and what they already know about their condition and treatment. It may also be useful to provide information about the condition, explaining that it is a long-term condition that cannot be cured but that symptoms can be adequately managed. Tackling myths about their condition will also help manage patient expectations. How can I help patients prevent exacerbations and self-manage their condition? Patients should be educated about signs of poor asthma control and signs of an exacerbation, thus enabling them to take steps according to their personalised written action plan, and know when to seek further medical help. You should also counsel patients on their medicines and ensure that they are using them correctly. For example, do they understand the difference between preventer and reliever medication and why it is important that they use their preventer regularly? Also see section How do I help promote adherence? Further information about points to cover when counselling patients on their medicines can be found in the RPS Support Counselling Patients on their Medicines quick reference guide. You can also offer advice about avoiding known triggers and allergens (recommended only in those with confirmed allergy): House dust mite avoidance measures, e.g. washing linen at high temperatures, using anti-dust mite bedding, using agents to kill dust mites. Avoiding foods and additives, such as sulphites (in beer, wine, shrimps)

17 Patients whose asthma is triggered by outdoor factors should be advised to minimize exposure, e.g. not doing strenuous exercise in cold weather or low humidity. If a clinically significant allergen cannot be avoided referring the patient to their GP for onward referral for immunotherapy may be appropriate. Exercise-induced symptoms can be managed with various medicines, however these symptoms are often an indication of poorly controlled asthma and a review of therapy is usually required. Work-related asthma should be referred to a GP. Patients with asthma should be reviewed regularly by specialist doctors and nurses and have a personalised written action plan for management of their condition. You should check that patients have an action plan, understand points in the plan and know how to use it. Some patients (e.g. adults with more severe disease and in those with poor perception of bronchoconstriction) may be required to monitor their condition with a peak flow meter. You should make sure that your patient is aware how to use the device, what the readings mean, how often to conduct a reading and how to care for the meter. How can I help promote adherence? You can help ensure that patients adhere to their asthma medicines by providing simple but clear information about them (if appropriate). Corticosteroids ( preventer ) advise patients about the importance of using their preventer inhaler regularly and inform them about how to avoid more common side effects such as oral thrush. The risk of oral thrush can be reduced by using a spacer device with a corticosteroid inhaler; rinsing the mouth with water (or cleaning a child s teeth) after inhalation of a dose may also be helpful. Additionally be aware that brands of CFC-free beclometasone inhalers are not bioequivalent and should not be interchanged. Also inform patients of the adverse effects associated with prolonged and/or frequent courses of oral therapy as extra monitoring may be required, e.g. for signs of osteoporosis, diabetes (serious adverse effects are more likely with oral therapy than inhlaed corticosteroids). Patients who have been instructed to stop oral corticosteroid treatment should be provided with clear instructions on how to stop to reinforce the prescriber s directions. Steroid cards should be issued where appropriate for oral therapy and ensure that you provide an explanation about their use and purpose. Details of where steroid cards can be obtained can be found in the BNF. Beta 2 agonists ( reliever ) ask about the use of reliever medicines as using inhalers more frequently (more than twice a week) may be a sign of uncontrolled asthma. Warn about effects associated with overuse, e.g. tremors, palpitations. Also ensure that patients understand the difference between short- and long-acting medicines and when to use each type, as not all long acting beta 2 agonists are quick relievers. Short-acting beta 2

18 agonists should only be used when required for symptoms and there is no benefit of using if bronchoconstriction is not present. Theophylline and aminophylline both theophylline and aminophylline have a narrow therapeutic range and interact with a number of medicines. Be aware of the cautions and interactions (including effect of smoking) and advise patients accordingly. Brands of modified release preparations differ in the rate of absorption, thus the brand should be specified on the prescription so you know which one to supply. Patients should have blood levels checked every 12 months and if they present with symptoms suggesting that it is out of range. Leukotriene receptor antagonists advise patients that leukotriene receptor antagonists should not be used to relieve symptoms associated with an acute exacerbation. Sodium cromoglicate and nedocromil these inhalers should be used regularly and are not to be used to relieve symptoms associated with an acute exacerbation. Nebuliser check that the patient understands how to use a nebuliser, how to choose between a mouth piece and facemask, who to contact regarding servicing, where to obtain replacement parts, how to change filters, and how to clean. Also offer advice on how to manage adverse effects of using nebulised solutions. Spacers ensure that the spacer prescribed fits the inhaler. Check that the patient understands how to how to use a spacer, and how to clean and care for it. How can I help patients select the most appropriate device and check that they are using it correctly? There are a number of inhalers available and there are advantages and disadvantages of each device. The choice of inhaler device may also depend on the drug itself, and patient preference and ability. The best way of checking inhaler technique is to ask the patient to demonstrate how they use their inhaler. Each type of inhaler has a different delivery mechanism therefore you should be familiar with instructions for individual inhalers and brands. If the patient is not using the inhaler properly you should perform a demonstration. It is suggested that you have dummy/placebo inhalers for this purpose; these can be obtained from most manufacturers. Placebo/dummy inhalers are single patient use and should not be used for more than one patient. Patient information leaflets often contain pictures and clear instructions for use and you may want to refer patients to this. It is suggested that you check the patient s technique during their next visit to the pharmacy and regularly to ensure that they are still using it correctly. The following devices (which can be sold over the counter/obtained from manufacturer) may help improve inhaler technique:

19 Spacers may help those who find it difficult to use metered dose inhalers (does not require co-ordination of pressing down of the inhaler and inhaling the dose). Many spacers are available on NHS prescriptions. Inhaler aids help patients with manual dexterity problems, e.g. arthritis, press down the chamber of metered dosage inhalers. A winged attachment can help patients with manual dexterity problems, e.g. arthritis, twist the dial on Turbohalers (from manufacturer only). If a patient cannot use a particular inhaler correctly they should be referred to their GP/practice nurse for an alternative. What lifestyle advice should I provide patients with asthma? Smokers should be advised to stop smoking and be provided with supportive therapies, and/or referred to local stop smoking services. Parents who smoke and have a child with asthma should also be advised of the adverse effects of smoking and how it might impact on their child s condition. Obese patients with asthma should be advised about how to lose weight as there seems to be an association between Body Mass Index and symptoms of asthma (ideal BMI kg/m 2). Include advice about eating a balanced diet and adopting an exercise regime to sustain a healthy lifestyle. A diet consisting of fresh fruit and vegetables has been shown (in observational studies) to be associated with fewer asthma symptoms and better lung function. What other support/information can I provide? Other support/information that may be appropriate for your patient could include the following: Influenza vaccination is recommended for all those aged 6 months or over in the clinical risk group (this includes people with asthma who require continuous or repeated use of a steroid preventer inhaler or oral steroids or those that have had asthma attacks requiring hospital admission). Pneumococcal vaccination is recommended for patients who have severe asthma and who require continuous or frequent treatment with oral corticosteroids. Patients with asthma often also suffer from rhinitis. Intranasal steroids can be recommended where appropriate. You should check nasal spray technique when supplying/selling. Explain that facial pain, nasal symptoms, indigestion, and snoring are symptoms of co-existing conditions that may worsen asthma, and may require treatment. Other conditions that may co-exist with asthma include sinusitis, gastrooesophageal reflux disease, and sleep apnoea. Offer treatment and advice or refer to a doctor where appropriate. It is suggested that to improve adherence, any verbal advice is supported with written information that patients can take away. Referring the patient to the

20 product information leaflet may be sufficient in some cases; however leaflets about the condition may also be of use. A range of leaflets can be obtained from Asthma UK. When should I refer patients? You should discuss with other healthcare professionals local procedures for referral of patients. Patients who may require referral to a doctor or other healthcare professional could include: Those who have noticed an increase in asthma exacerbations and symptoms which may indicate that their condition is not well controlled Those who have not responded to treatment with medicines Those who are experiencing side effects with their medicine Those presenting with a severe or life threatening acute asthma exacerbation Those with suspected occupational asthma Those with co-existing conditions Those with haemoptysis The following specialists may also be involved in the management of asthma at any stage: dieticians, physiotherapists, occupational therapists and respiratory nurse specialists, and you should be familiar with referral pathways to these specialis Where can I signpost patients wanting further information? Asthma UK British Lung Foundation European Federation of Allergy and Airway Diseases Patients Association NHS Choices Patient.co.uk Where can I go for further information? RPS members can contact RPS Support on , or complete a web form at UKCPA Respiratory Group , RPS Support Resources Counselling Patients on Medicines quick reference guide Smoking cessation quick reference guide Obesity and weight management quick reference guide Supporting patients with COPD quick reference guide

21 Asthma UK is the charity dedicated to changing the outlook on asthma. It has patient management plans, leaflets and an inhaler demonstration video. How to make the most of being asthmatic Your health, your choices. Has videos on asthma and inhaler technique. Offers medical information and support with printable leaflets Video demonstrations on correct inhaler technique

22 Medicines Use Review Supporting Information for Asthma Patients What is asthma? Asthma is a chronic inflammatory disorder of the airways. The inflammation causes an associated increase in airway hyper-responsiveness, which leads to recurrent episodes of wheezing, breathlessness, tightness in the chest and coughing. These symptoms often present early in the morning or at night. Episodes are usually associated with some degree of airflow obstruction that will resolve spontaneously or with medication. Symptoms may appear variably and patients sometimes may not experience any symptoms for several weeks or months (unlike COPD). As patients get older they may develop fixed airways disease (particularly if inadequately treated) What causes asthma? There is no single known cause of asthma, but there are a number of genetic and environmental factors that may contribute to the development of the condition, including: Family history of asthma or other atopic condition such as eczema or allergic rhinitis Having had bronchiolitis as a child Exposure to tobacco smoke as a child, particularly if mother smoked during pregnancy Being born prematurely or at a low birth weight What can trigger an exacerbation of asthma? Irritants in air such as cigarette smoke, chemical fumes, pollution Allergens such as pollen, dust mite faeces, animal dander or feathers Respiratory tract infections Weather conditions such as cold air Sulphite-containing foods such as beer, wine, shrimp, many processed or precooked meals Emotional factors such as stress or laughter Medicines, such as non-steriodal anti-inflammatories, beta-blockers Exercise What are the signs of completely controlled asthma? A patient with completely controlled asthma will have:

23 No daytime symptoms No night-time awakening due to asthma No need for rescue medication No exacerbations No limitation on activity, including exercise Normal lung function with minimal side effects from medication How can I support patients with asthma? The goals of asthma treatment are discussed in detail in the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines. As a pharmacist you can support patients by: Helping patients prevent exacerbations Providing information and support to facilitate self-management Identifying and promoting adherence with medication Advising on correct inhaler technique Identifying poor asthma control Support should be tailored to individual patients, taking into account their medical history and what they already know about their condition and treatment. It may also be useful to provide information about the condition, explaining that it is a long-term condition that cannot be cured but that symptoms can be adequately managed. Tackling myths about their condition will also help manage patient expectations. How can I help patients prevent exacerbations and self-manage their condition? Patients should be educated about signs of poor asthma control and signs of an exacerbation, thus enabling them to take steps according to their personalised written action plan, and know when to seek further medical help. You should also counsel patients on their medicines and ensure that they are using them correctly. For example, do they understand the difference between preventer and reliever medication and why it is important that they use their preventer regularly? Also see section How do I help promote adherence? Further information about points to cover when counselling patients on their medicines can be found in the RPS Support Counselling Patients on their Medicines quick reference guide. You can also offer advice about avoiding known triggers and allergens (recommended only in those with confirmed allergy): House dust mite avoidance measures, e.g. washing linen at high temperatures, using anti-dust mite bedding, using agents to kill dust mites. Avoiding foods and additives, such as sulphites (in beer, wine, shrimps)

24 Patients whose asthma is triggered by outdoor factors should be advised to minimize exposure, e.g. not doing strenuous exercise in cold weather or low humidity. If a clinically significant allergen cannot be avoided referring the patient to their GP for onward referral for immunotherapy may be appropriate. Exercise-induced symptoms can be managed with various medicines, however these symptoms are often an indication of poorly controlled asthma and a review of therapy is usually required. Work-related asthma should be referred to a GP. Patients with asthma should be reviewed regularly by specialist doctors and nurses and have a personalised written action plan for management of their condition. You should check that patients have an action plan, understand points in the plan and know how to use it. Some patients (e.g. adults with more severe disease and in those with poor perception of bronchoconstriction) may be required to monitor their condition with a peak flow meter. You should make sure that your patient is aware how to use the device, what the readings mean, how often to conduct a reading and how to care for the meter. How can I help promote adherence? You can help ensure that patients adhere to their asthma medicines by providing simple but clear information about them (if appropriate). Corticosteroids ( preventer ) advise patients about the importance of using their preventer inhaler regularly and inform them about how to avoid more common side effects such as oral thrush. The risk of oral thrush can be reduced by using a spacer device with a corticosteroid inhaler; rinsing the mouth with water (or cleaning a child s teeth) after inhalation of a dose may also be helpful. Additionally be aware that brands of CFC-free beclometasone inhalers are not bioequivalent and should not be interchanged. Also inform patients of the adverse effects associated with prolonged and/or frequent courses of oral therapy as extra monitoring may be required, e.g. for signs of osteoporosis, diabetes (serious adverse effects are more likely with oral therapy than inhlaed corticosteroids). Patients who have been instructed to stop oral corticosteroid treatment should be provided with clear instructions on how to stop to reinforce the prescriber s directions. Steroid cards should be issued where appropriate for oral therapy and ensure that you provide an explanation about their use and purpose. Details of where steroid cards can be obtained can be found in the BNF. Beta 2 agonists ( reliever ) ask about the use of reliever medicines as using inhalers more frequently (more than twice a week) may be a sign of uncontrolled asthma. Warn about effects associated with overuse, e.g. tremors, palpitations. Also ensure that patients understand the difference between short- and long-acting medicines and when to use each type, as not all long acting beta 2 agonists are quick relievers. Short-acting beta 2