“I am a community pharmacist working in rural Aberdeenshire,Scotland. I am currently undertaking my independent prescribing course at the Robert Gordon University in Aberdeen. I have completed my supervised time in practice and all summative assessments however I am awaiting sign off as an independent prescriber in June. All the cases in my blog are fictitious but are related to my experience during supervised practice as part of my course. Please feel free to take ideas from my blog and the cases included however the responsibility of the prescriber lies with the person signing the prescription. All information contained in the piece above should not be used for treatment by patients. Always consult your doctor or relevant health professional. I hope you find this and other blog entries interesting and informative.”
He is on SIGN 101 step 2 and his repeat prescriptions are for Salbutamol cfc inhaler and a Clenil Modulite 100mcg inhaler.
SIGN stands for Scottish Intercollegiate Guideline network. This is a group of a number of professions who collaborate to sift through the research evidence and then decide best practice in many diseases including asthma. There are five steps of severity in the treatment of asthma with step five being the most severe and one being quite mild.
So our patient is using a salbutamol inhaler which gives the asthmatic quick relief from the closing of the airways typical in asthma. He is also using clenil modulite which is an inhaled steroid that works as a preventative medication. Oral steroids basically calm the airways down, reducing inflammation and therefore make an asthma attack less likely.
Patients tend to rely on the reliever inhaler inhaler as it gives them short term relief from their symptoms. Overuse can be a sign of poor asthma control.
You noticed that when labelling his prescription for Salbutamol, the reliever, this time he has had it dispensed quite a few times recently. In fact he has had 18 of these salbutamol reliever inhalers dispensed in the last 12 months and the rate of dispensing has increased recently. You note he is a non-attender at the annual asthma review. The last time he attended was 20 months ago.
So the question is what kind of pharmacist are you and what are you going to do?
Dispense as normal, move on and have a coffee, or intervene and get this patient’s asthma controlled?
Unfortunately unless my approach is adopted then the ‘dispense as usual’ approach is the only one available.
Let’s assume the latter…
Based on his non-attendance and his overuse of the reliever Salbutamol you decide to do a chronic medication service intervention and conduct an Asthma UK control test. The chronic medication service is a pharmacy based service in Scotland where community pharmacists are paid a modest fee to make sure patients know how and when to use their medicines.
You do this on his visit to pick up his Salbutamol opportunistically. His score comes out at 14/25 which is indicative of poor asthma control.
In the pharmacy consultation room you use your stethoscope to listen to his chest and hear a classic asthma wheeze. His peak flow is below expected.
The weather has just recently turned colder and he admits that the cold weather can trigger him to cough a lot. You update his basic values of O2 sats, BP, pulse and record on his patient record.
So you decide to put your prescribing hat on and trigger a ‘prescribing encounter’. You log on to the patient record and do the normal checks of his history and, most importantly, confirm his diagnosis of asthma.
He clearly needs to be stepped up to regain control. The SIGN 101 guideline recommends going in at the step that regains control.
Before you do anything you check his technique… terrible… surprise! He is unable to co-ordinate the use of either inhaler. As with any prescribing decision there are many options but you decide to step him up to step three — try him on a Symbicort 200 Turbohaler and use Terbutaline as a reliever inhaler. This is evidence based in the SIGN 101 guideline and is also in line with your local formulary.
You use your video on your iPad of you demonstrating the use of a Turbohaler and then observe his technique there and then. His natural speed of inhalation is better suited to a Turbohaler.
Many cases of poor asthma control are down to poor inhaler technique resulting in little or none of the inhaled drug reaching deep into the lungs where needed. Toby Capstick below describes the importance of good technique.
You use the patient record in the pharmacy to make a note about the assessments you have undertaken and the plan put in place. This is a common record shared with the GP practice so the local healthcare team can see your input immediately.
You agree a written asthma plan and you prescribe him a peak flow meter then give him an Asthma UK peak flow diary. You use the access to his records to make him an appointment at your asthma clinic in two weeks to follow up on his progress.
You tell him you will do his flu jab at this review.
He is overwhelmed by the proactive nature of the care he has received and is very happy to attend for follow up at you Saturday morning clinic. Remember, most asthmatics are either working or at school and hence are poor attenders for review. He confides that he has struggled for years with his asthma but thought that was just part of the illness.
This example, I believe, is a model for how we, as community pharmacists, should be operating for many long term disease states now and into the future. Payment by volume must be superseded by fair payment based on clinical outcomes I.e. If we make the patient better we should get paid more in a similar way to general practitioners.
By adopting this approach as pharmacists we have the chance to ‘manage’ a patient from start to finish. The only limiting factor could potentially be our level of competence as pharmacists and when that happens the ball is firmly back in our court.
My work in asthma has been inspired by a family member but also the recent report titled the national report on asthma deaths by the royal college of physicians. See below.
Community pharmacy is uniquely placed to act on these recommendations and deliver reduced hospital admissions, reduced asthma exacerbations, cost savings, overall reduced pressure on the wider NHS system and all in a location acceptable to patients.
Here’s another case on respiratory issues you need to check out!
Super cool case/story. Question: might we consider keeping him on the same asthma meds without stepping up and expect that improving his technique would improve his control?
Definitely would be a consideration, judgment call for sure – you’re thinking the right way…
I have to agree with Sean. Since it was noticed that he wasn’t following the correct techniques with the inhalers, I believe I would have kept him on the same therapy and request that him come back to the clinic after a couple of weeks for follow up. And maybe then, if no improvement noticed, then step it up..
Great case though! Thank you for sharing!
Jonathan Lairds approach appears to be the most appropriate given, the poor asthma control of the patient and his mental set up. He would definitely not turn back for a review after the stipulated time if he were to be asked to continue the same medication albeit a corrected technique of inhalation, thinking that no useful purpose would be served as the same medicines are asked to be continued. However even though this is only a hypothetical case, if you were a good Community Pharmacist, I think you would not have neglected the case for more than an year and do not understand alte realization if the patient were relying on you for so long for filling and refilling his asthma medication.