Transcript Respiratory Prescribing in Tower Hamlets

Respiratory Prescribing
in Tower Hamlets
Bill Sandhu
Head of Medicines Management, Tower Hamlets
Medicines Management Team
Prescribing Expenditure April-November 13-14
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Cost of Inhalers for all
indications is £2.6 Million
This is 9% of the total budget
for prescribing
We are spending around
£280K a quarter on fluticasone
alone
Change in Prescribing Spend Versus Prevalence
Background – Uncontrolled
Asthma is a European Issue
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Patients with
controlled asthma
Comprises 51% of ICS users
across Europe1
Fewer symptoms and less need
for SABAs than patients with
uncontrolled asthma2
No emergency visits2
Ability to take part in everyday
activities2
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ICS = inhaled corticosteroids
SABA = short-acting β2-agonists
Patients with
uncontrolled asthma
Comprises 49% of ICS users
across Europe1
Asthma attacks3
Increased symptoms versus
patients with controlled asthma3
Sleep disturbances3
Unscheduled healthcare visits:
hospitalisations; GP visits3
Major limitations on activities3
1. Cazzoletti L, et al. J Allergy Clin Immunol 2007;120:1360–7
2. Bateman ED, et al. Eur Respir J 2008;31:143–78
3. Rabe K, et al. Eur Respir J 2000;16: 802–7
Mortality rates for asthma in adults in the
UK and Europe
Mortality due to asthma in Europe (per 100,000 population)1
<2
2–4
4–8
>8
UK
Spain
Ireland
Finland
The Netherlands
Greece
Slovakia
Czech Republic
Ukraine
Slovenia
France
Denmark
Sweden
Austria
Lithuania
Poland
Germany
Belgium
Russia
Portugal
In the UK:
• >1,143 deaths from asthma in 2010
• On average three people die from
asthma/day
• 90% of these are preventable2
1. Loddenkemper R, ed. European Lung White Book. Part 2, Major Respiratory Diseases, 2003
2. Asthma UK. http://www.asthma.org.uk/asthma-facts-and-statistics; accessed May 2013
What’s the Issue?
Cost per Prescription
Symbicort_Turbohaler 400mcg/12mcg (60 D)
Symbicort_Turbohaler 200mcg/6mcg (120 D)
Symbicort_Turbohaler 100mcg/6mcg (120 D)
Seretide 500_Accuhaler
500mcg/50mcg(60D)
Seretide 50_Evohaler 50mcg/25mcg (120 D)
Seretide 250_Evohaler
250mcg/25mcg(120D)
Seretide 250_Accuhaler
250mcg/50mcg(60D)
Seretide 125_Evohaler
125mcg/25mcg(120D)
Seretide 100_Accuhaler
100mcg/50mcg(60D)
Fostair_Inh 100mcg/6mcg (120D) CFF
£0.00
£10.00
£20.00
£30.00
£40.00
£50.00
£60.00
£70.00
£80.00
£90.00
Inhaler Use
• With the correct technique, only 1/3 of the drug
reaches the lungs,
• What happens if inhaler is used incorrectly?
• NICE :
– recognises inhaler technique is often neglected
– recommends it should be regularly reassessed and retaught
• Where more than 1 type of inhalers is used, further
problems can occur
– studies have found an association with increased errors in
the use of inhalers when different types of inhalers were
used
Healthcare professionals have sufficient
knowledge of inhaler technique?
• 150 Healthcare professionals (from 74 PCTs and 76
Acute Trusts) asked to demonstrate how to
administer a pMDI
• Included hospital doctors, hospital nurses, GPs,
practice nurses, hospital and community pharmacy
staff
• Of 150 HCPs assessed:
• Only 7% could demonstrate all the recognised steps
• 75% of HCPs said they were involved in the teaching of inhaler
technique
• 48% were prescribers or involved in prescribing
• 63% had received some training on inhaler technique in the past
of which 67% said took place > a year ago
Ref: Thorax Dec 2010 Vol 65 Suppl 4
Requirements for an optimal device
• Simple handling
• Device should facilitate
– optimal respiratory flow of drug when device is used
– correct inhalation technique
– patient to verify medication inhalation has been successful
• Dosage and deposition of active ingredient in the lungs must be
sufficiently high and reproducible
• Dose counter – so they know how much is left
• Require minimal maintenance itself
• Be acceptable to the patient so they will use it
Virchow JC, et al. Respir Med 2007;102:10–9
What do experts say about the importance of
inhaler device selection?
“When prescribing a new inhaler, or reviewing patients’ progress,
inhaler technique should be demonstrated by the clinician, followed
by the patient. Many people forget how to use their inhaler devices,
and this is likely to affect clinical outcomes”
“The least cost effective inhaler device is the one that patients
cannot use. In deciding which device and drug formulation to
prescribe determine the patients ability to use the prescribed device
correctly”
General Practice Airways Group (GPIAG) Opinion Sheet on Inhaler Devices No.20; 2008
BTS recommends the “THREE CHECKS”
• Before initiating or adjusting a new therapy, practitioners should
always re-check:
– 1. Adherence with existing therapy
– 2. Inhaler technique
– 3. Eliminate trigger factors
BTS recommends:
1. Prescribe inhalers only after patients have received training in
the use of the device by a competent healthcare professional
and have demonstrated satisfactory technique
2. Reassess technique as part of the clinical review