Table 1: equivalences and costs of various inhalers in COPD

Transcription

1 Title of Project: NHS Dumfries & Galloway Respiratory Bundle COPD: Inhaled steroid review April Reason for the review Respiratory prescribing is long term and can be costly. Appropriate choice and use of inhaled therapy is key to the successful management of COPD. In COPD, there is a need to review use of inhaled steroids as their use when FEV1 is above 50% is not recommended and can lead to increased risk of pneumonia and other respiratory infections. 1 This audit will highlight patients currently prescribed an inhaled corticosteroid for the treatment of COPD and will make recommendations where appropriate in order to stop or change to the most cost effective, formulary option. D&G formulary recommends either Duoresp Spiromax (a dry powder inhaler DPI) or Fostair MDI as first line choice in patients, over 18 years of age, with COPD. Duoresp Spiromax has been shown to have comparable quality and be bioequivalent to the same strengths of Symbicort turbohaler. It is also expected to have the same benefits as Symbicort in improving lung function and relieving symptoms in COPD. Table 1: equivalences and costs of various inhalers in COPD Inhalers licensed in COPD Adult dose BDP equivalent (mcg) Cost per month Annual cost Fostair 100/6 MDI (Beclomethasone/formoterol) Duoresp Spiromax DPI 160/4.5 (equivalent to budesonide 200mcg/formoterol 6mcg) Duoresp Spiromax 320/9 (equivalent to budesonide 320mcg/formoterol 9mcg) Symbicort 200/6 turbohaler * (budesonide 200mcg/formoterol 6mcg) Symbicort 400/12 turbohaler * (budesonide 400mcg/formoterol 9mcg) Seretide 500 accuhaler * (fluticasone 500mcg/salmeterol 50mcg) 2 puffs 2 inhalations 1 inhalation 2 puffs 1 puff 1 inhalation Costs based on BNF Sept 2014 Edition *Non formulary options Bold denotes formulary option

2 2 Inclusion Criteria Search for all COPD patients over the age of 18 prescribed an inhaled corticosteroid. 3 Exclusion Criteria Compliance issues refer to GP Patients with terminal cancer Previous switch to an alternative product which caused distress Any individual patient exclusions deemed necessary by the GP. (e.g. patients who are deemed to be not open to change, as judged by the GP) 4 Preparation and planning Implementation of the audit in selected GP practices is as follows: Protocol to be discussed with all GP s in the practice to ensure that agreement to proceed is reached Ensure all staff involved with the COPD review are familiar with review criteria and address any needs. Computer search of all patients according to the inclusion/exclusion criteria Review of patients medical notes and repeat prescribing records as per data collection sheet o Confirmed diagnosis of COPD o Details of last recorded FEV1, number of antibiotic and oral steroid courses in last 12 months and inhaler technique - if known. o Dose of inhaled corticosteroid, if using, and comment on appropriateness in accordance with NICE COPD guidelines (2) List of eligible patients to be checked by GP/GP s or practice nurse/nurse practitioner which will include; o Recommendations to stop ICS in patients with FEV1>50% predicted and less than 2 exacerbations o Patients who can potentially switch to a formulary combination inhaler (See table 2 below for possible formulary switches). Letters to be sent to eligible patients with invite for COPD medication review (with annual review if that is due) or telephone consultation to explain changes. Changes to medication to be recorded on the computer system. Table 2. Suggested conversions in combination inhaler to formulary options in COPD. Seretide 500 Accuhaler 1 puff Fostair MDI 100/6 2 puffs Symbicort turbohaler 200/6 1 puff ** Duoresp Spiromax 160/4.5 1 puff ** Symbicort 200/6 turbohaler 2 puffs Symbicort 400/12 1 puff Duoresp Spiromax 160/4.5 2 puffs Duoresp Spiromax 320/9 1 puff ** Notes:

3 This is for equivalence guidance only 1 puff is not a licensed dose in COPD Changing from Symbicort to Duoresp entails a change of device however the medication remains the same. However changing from Symbicort to Fostair, or from Seretide to an alternative will involve a change of device as well as changing the LAMA and ICS. Patients should be counseled accordingly. For patients who require an MDI with a spacer Fostair MDI can be used with an AeroChamber Plus spacer device. See other information sources within the Respiratory Bundle: NHS D&G Primary Care Guide to Inhalers NHS D&G Primary Care Guide to pharmacological treatment of COPD 5 Action Letters written/telephone consultations to all patients outlining the reasons for the stop/switch to ensure they are fully informed and given an opportunity to discuss the switch with either their GP, practice nurse or practice pharmacist. (Appendix 1 and 2) Where patient does not manage their own medication eg level C or care home resident, a family member or carer as appropriate will be informed as above. Administration staff in practices to be made aware of changes of repeat medication. Local pharmacies to be informed of need to reduce stock and of counselling for patients eg inhaler technique Report for practices will include number of switches made and projected cost savings as a result of the recommendations. References: Refs: 1. Drug Safety Update, MHRA Vol 1, issue 3. Oct NICE CG 101, Chronic Pulmonary Respiratory disease. June Review to be undertaken by: GP Authorisation: Date:

4 Appendix 1: Patient letter. Patient name Address Dear Mr/Mrs As part of a review of prescribing, NHS Dumfries and Galloway are currently reviewing all patients with COPD who use inhaled corticosteroids. Current evidence suggests that there is a reduced benefit than previously thought of inhaled corticosteroid inhalers, (like Clenil, QVAR, Fostair, Symbicort or Seretide) to patients with mild to moderate COPD. We would like to invite you to a COPD medication review (with or without the annual review) in order to discuss potential changes to your medication. Add details of face to face or telephone appointment or instructions for making the appointment here. These reviews take place in order to ensure that people are not taking medicines unnecessarily and it also helps doctors to make the most effective use of available resources. Should have any queries, please contact the Surgery on the number above or, alternatively, you can contact a member of the Prescribing Support Team on Yours sincerely Name Prescribing Support Technician On behalf of the Doctors

5 Data collection sheet: Patient name and DOB Usual GP Last COPD review (date): FEV1,FEV/FVC ratio, MRC score Number of Antibiotic courses in last 12 months? Number of Oral Steroid courses in last 12 months? Inhaled corticosteroid use include details of separate LABA if appropriate Recommendations GP approved Y / N Actioned