THE short answer to this question as mentioned in the National Review of Asthma Deaths is simple – the fewer relievers required by a patient, the better the control of asthma: “Well-controlled asthma is associated with little or no need for short-acting bronchodilator (SABA or reliever) inhalers, so the need for excess SABA inhalers is a signal that asthma is poorly controlled.”
The day-to-day reality is a little more complex, and in my view is certainly worth consideration. This could be a unique opportunity for community pharmacists, especially as we recently learned that community pharmacy has the greatest patient footfall of all NHS services in the UK.
So to get down to brass tacks, the consensus at the moment is that use of a SABA by an asthmatic patient more than three times per week is a sign of reduced asthma control. Indeed, one of the questions in Asthma UK’s asthma control test is: How often do you use your reliever inhaler?
“National guidelines state that those regularly using SABA inhalers more than three times a week should be prescribed regular corticosteroid (preventer or inhaled corticosteroid) inhalers. From information on 194 of the 195 people who died, 189 (97%) were prescribed SABAs at the time of death. The number of SABA inhalers issued was recorded in 165; only three did not have any SABA prescription in the year before death. For these 165 patients, the number of prescribed inhalers ranged from 0 to 112, with a median of 10 (IQR 2–21), per year. Ninety-two (56%) of the 165 were prescribed more than six and 65 (39%) more than 12 SABA inhalers in the year before they died. Six patients (4%) had been prescribed more than 50 SABA inhalers in the previous year. Those prescribed multiple SABA (reliever) inhalers were likely to have poorly controlled asthma.” (NRAD 2014)
How can community pharmacists support patients with asthma?
Spotting asthmatics who are using too many reliever inhalers, and are therefore not optimally controlled can have a positive impact.
If we take, for example, the 200 dose Ventolin Evohaler (other brands are available!) then the frequency of re-ordering on a repeat prescription becomes important as a sign of the person’s asthma control. A 200 dose Ventolin will last a patient for the following time periods depending on usage. To be reasonable, I have assumed the patient takes two puffs every time they use it for a wheezy episode.
2 puffs per week = 100 weeks = controlled
4 puffs per week = 50 weeks = controlled
6 puffs per week = 33 weeks = controlled
8 puffs per week = 25 weeks = not controlled
10 puffs per week = 20 weeks = not controlled
12 puffs per week = 16 weeks = not controlled
So, if you are dispensing a repeat prescription for a Ventolin Evohaler and you notice that the patient has been ordering it more than every 25 weeks (approximately every 6 months), then you would be well justified in engaging the patient to understand how well their asthma is controlled.
There are of course a few caveats to these results. For example, if inhaler technique is particularly poor, the patient may waste doses along the way. Also, it is well known that patients often like to keep multiple reliever inhalers at work, school or at home in case of emergency.
The only way to rule the list of exceptions out is to speak to the patient as they pick up their inhaler. You might even have the confidence to carry out an asthma control test to assess recent asthma control before feeding back to the prescriber. This conversation naturally leads the community pharmacist into a discussion around the management of the person’s Asthma. The diagnosis and assessment of asthma is still predominantly a clinical one. With this in mind, taking a good history, using the asthma control test, and looking at reliever usage can develop the clinical picture thus leading to better decisions being made.
I wrote this blog after revisiting the NRAD 2014 report. Page 33 stuck in my mind and I would like to explain why. On that page there is a graph of reliever usage by the patient population covered by the report. I invite you to compare the data below gathered as part of a prescribing course to the data in the report (NRAD chapter 5, page 33).
Now, remember that the patients in the graph above thankfully are alive, but the patients in the report tragically are not. As health professionals we have work to do to make sure preventable asthma deaths are avoided. Working in partnership with patients and fellow health professionals is the key.
The diligent community pharmacist who can spot the overuse of a Ventolin Evohaler might just save a life.
Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is a member of the Royal Pharmaceutical Society Scottish Board, and is based in Aberdeen
Follow Johnathan @johnathanlaird
SIGN 153: British guideline on the management of asthma, 2016.