Transcript Patients should be maintained at the lowest possible dose of

Asthma project 2015
Vikki Knowles
Respiratory Nurse
Consultant
G & W CCG
Financial Burden
● Asthma UK estimates that the direct healthcare costs
associated with this condition are £1 billion.
● Latest available statistics on incapacity benefit suggest
that asthma is responsible for at least 12.7 million lost
working days per year.
● GP prescriptions alone were estimated at £600 million a
year in 2002
● Over £2 million spent on combination inhalers
(inhaled corticosteroid and long-acting ß2-agonist)
in G & W
● NHS data for 2013–2014 suggests that, in England, of
the 242 million ICS-containing inhalers dispensed at a
cost of almost £355m, 39% were for high-dose inhalers.
Overall aims of treatment
● Overall aim is to control the
condition
● With the correct treatment and care
in most cases the symptoms of
asthma can be controlled and most
people can enjoy a healthy and
active life.
BTS / SIGN Guidelines - A step wise
approach to the management of asthma in
adults




Aims of pharmacological management of ‘asthma
control’:
- abolish symptoms as soon as possible
- optimise peak flow
Patients should start treatment at most appropriate step:
- according to the level of severity of their asthma
- aim to achieve early control
Change step according to control:
– stepping up treatment as necessary
– stepping down when control is good
The choice of device may be determined by the choice of
drug
British Thoracic Society and Scottish Intercollegiate Guidelines Network (Oct 2014). British Guideline on the Management of Asthma.
A National Clinical Guideline.
Availablewww.britthoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/sign101%20revised%June%2009.pdf Accessed April 2015.
Adults
BTS / SIGN Guidelines
Step 3
 Add-on therapy when there is inadequate control on low
dose inhaled corticosteroids
 First choice of add-on therapy is the addition of an
inhaled
long-acting ß2-agonist (LABA)
improves lung function and symptoms
decreases exacerbations
 Many patients will benefit more from add-on than from
increasing inhaled steroids above doses as low as
200mcg/day
 Combination inhalers have the advantage of
guaranteeing that the LABA is not taken without inhaled
steroid
Combination Tx
● Flutiform
(CCG preferred choice)
● Fostair
● Relvar
● Seretide (Sirdulpa generic)
● Symbicort
Advantages
● Simpler dose regime
● Fewer inhaler devices
● May enhance compliance
Minimising the risks
● Add in long acting beta agonist to moderate
dose inhaled cortico-steroid (fluticasone 200
mcg or equivalent)
● Step 3 of asthma guidelines.
Masoli M et al (2005) demonstrated improved
symptom control and greater clinical benefit
with the addition of a LABA than by increasing
the dose of inhaled steroid.
● Regular review and consider step down
when control achieved and asthma
symptoms stable.
Addition of combination ICS therapy
in asthma
Covey J R et al (2014) found that the dose of ICS patients were
receiving was increased when patients were initiated on combination
inhaler therapy. Among people who had previously used an ICS, the
mean standard-ised dose before the start of combination therapy was
677 μg. Once a combination inhaler was prescribed, the mean dose
increased to 1,043 μg.
ICS dose prior to Combination
tx
No of patients
No of patients changed to
high dose ICS combination
No of patients changed to
high dose ICS combination
Low dose
250
122
49%
Medium Dose
151
94
62%
High dose
113
85
75%
No prior ICS
144
81
56%
Local Data
● Seretide® (fluticasone/salmeterol) is by
far the most commonly prescribed brand
of combination inhaler in G&W, and it is
the highest strength devices (i.e. the
Seretide 250 Evohaler® and Seretide
500 Accuhaler® devices) that are the
most commonly prescribed doses.
● Seretide® accounted for 73% cost of all
respiratory prescribing in 2013/14
● In most patients with asthma, there
is limited evidence that increasing
the dose of ICS above 800mcg
BDP equivalent per day improves
asthma control, although high
doses are associated with an
increased risk of adverse events.
Masoli M, Holt S, Weatherall M et al. The dose-response relationship of inhaled corticosteroids in asthma. Curr Allergy Asthma Rep 2004;4(2):144–148.
Assessment: Royal College of
Physicians of London three questions
IN THE LAST WEEK / MONTH
YES
“Have you had difficulty sleeping because of your asthma
symptoms (including cough)?”
“Have you had your usual asthma symptoms during the day
(cough, wheeze, chest tightness or breathlessness)?”
“Has your asthma interfered with your usual activities
(e.g. housework, work, school, etc)?”
Date
/
•
•
/
/
Applies to all patients with asthma aged 16 and over.
Only use after diagnosis has been established. © Imperial College London
Page 12
Outcomes and audit. Thorax 2003; 58 (Suppl I): i1-i92
NO
BTS SIGN Asthma 2014 6.6
Stepping down
● Stepping down therapy once asthma is
controlled is recommended, but often not
implemented leaving some patients overtreated.
● There are few studies that have investigated
the most appropriate way to step down
treatment.
● A study in adults on at least 900 micrograms
per day of inhaled steroids has shown that for
patients who are stable it is reasonable to
attempt to halve the dose of inhaled steroids
every three months.
BTS SIGN Asthma 2014 6.6
● Regular review of patients as treatment is
stepped down is important. When deciding
which drug to step down first and at what rate,
the severity of asthma, the side effects of the
treatment, time on current dose, the beneficial
effect achieved, and the patient’s preference
should all be taken into account.
● Patients should be maintained at the lowest
possible dose of inhaled steroid.
● Reduction in inhaled steroid dose should be
slow as patients deteriorate at different rates.
Reductions should be considered every three
months, decreasing the dose by approximately
25-50% each time.
GP Practice Audit
EMIS Number
Inhaler prescribed
READ Code
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
Other
Seretide 250 accuhaler
COPD
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
COPD
Seretide 250 evohaler
Asthma
Seretide 500 accuhaler
COPD
Seretide 250 evohaler
Asthma /
Seretide 250 evohaler
COPD
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
Asthma
Seretide 500 accuhaler
Asthma
Seretide 250 evohaler
Asthma /
Seretide 250 evohaler
COPD
Seretide 250 evohaler
Other
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
Asthma /
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
Asthma
Seretide 500 accuhaler
COPD
Seretide 500 accuhaler
COPD
Seretide 250 evohaler
COPD
Seretide 250 evohaler
Asthma
Seretide 500 accuhaler
Asthma /
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
COPD
Seretide 250 evohaler
Asthma /
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
Asthma
Seretide 250 evohaler
COPD
Seretide 250 evohaler
Asthma
Asthma Review
Smoking Status date
Never
Never
Ex
Never
Current
Never
Ex
COPDEx
Ex
Never
Never
Never
COPDNever
Ex
Ex
Current
COPDEx
Current
Ex
Current
Ex
Never
Ex
Never
COPDCurrent
Ex
Ex
COPDEx
Current
Ex
Never
Ex
Never
none listed
none listed
none listed
none listed
High Dose Steroid Refer to PN for Prescriptions
Step down possible
warning card
review
refilled
Nov-14 Yes
No
Apr-15 No
Mar-15 Yes
Jun-15 No
Apr-15 Yes
Mar-14 No
Mar-15 No
Apr-14 No
Yes
Oct-13 Yes
May-14 Yes
Dec-14 Yes
Mar-15 No
No
Sep-14 Yes
Oct-11 Yes
Feb-14 Yes
Feb-14 Yes
No
Mar-15 No
Mar-12 Yes
Jul-14 No
Apr-15 Yes
Oct-14 No
Apr-15 Yes
Nov-14 No
Mar-13 No
Mar-15 Yes
Apr-15 Yes
Aug-14 Yes
Apr-15 No
Mar-15 Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
No
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
Yes
No
Yes
Comments
yes
yes
yes
yes
2% av usage
no Diagnosis under RSCH
bronchiectasis
56% av usage
consider alt ICS
Consider alt ICS
Consider alt ICS
yes
21% av usage
no
yes
Consider alt ICS
consider alt ICS - RSCH
yes
yes
yes
21% av usage
consider alt ICS
likely COPD
likely COPD
likely asthma
consider alt ICS
yes
yes
consider alt ICS
consider alt ICS
yes
no
yes
yes
1% av usage
under RSCH
bronchiectasis
consider alt ICS
Reviewing high dose ICS in asthma
Guidance for asthma reviews
Patient identified on high dose ICS
Seretide 250 mcg evohaler
Seretide 500 mcg accuhaler
Confirm diagnosis
Lifestyle and comorbidity review
Assess Control
RCP 3 questions
Assess Risk
Assess Control
and Risk
Symptoms and PEFR
Previous history of life
threatening asthma
Rescue beta2 agonist use
Number of Exacerbations in
last 12 months
Poor control
Assess inhaler technique
Previous history of ventilation
for asthma
Check adherence
Poor adherence with therapy
Adverse psychological issues
Good control AND low risk
Step down ICS
Consider Flutiform if pMDI
preferred device
Personal Asthma Action Plan
Poor control OR high risk
Consider alternate cause of
symptoms including lifestyle
Review inhaler technique and
adherence
Optimise treatment according
to local guidelines
Review
Reassess control and risk
Self-management education
Consider referral to specialist
asthma service
Step Down Protocol: G & W CCG
Asthma Step Down Protocol
Good Control
Seretide 500 mcg Accuhaler
(salmeterol / fluticasone)
Seretide 250 mcg
Accuhaler
Assess control
1 puff b.d.
1 puff b.d.
Assess control
Seretide 100 mcg
Accuhaler
1 puff b.d.
Review
Assess
Control
Good Control
Seretide 250 mcg evohaler
Flutiform 250/10 pMDI
(salmeterol / fluticasone)
(fluticasone / formoterol)
2 puffs b.d.
2 puff b.d.
Assess control
Asthma
Action
Plan
Flutiform 250 /10
pMDI
1 puff b.d
Flutiform 125/5 pMDI
2 puff b.d
Inhaler
Technique
Audit sheet
Patient identifier
Confirm diagnosis
Emis No
Drug name, dose device - smoking status
a
b
c
d
Seretide 250 evohaler
Seretide 250 evohaler
Seretide 250 evohaler
Seretide 250 evohaler
Inhaler Technique
checked and
satisfactory
RCP Score
Beta2 use
Yes
1
< or = 6 per Year
Concordance - check Exacerbation last
High dose steroid
ICS order hx
12 months
Medication changes card
Yes
0 Flutiform 250 Inhaler Yes
Personal Asthma
Action Plan
F/U
Yes
4 weeks
Comments
High dose inhaled ICS safety
card
https://www.networks.nhs.uk/.../ LRT%20Inhaled%20steroid%20safety%20card.pdf
● If it is clinically appropriate for a patient to
remain on a high dose ICS/LABA the HCP
should consider providing a High Dose Inhaled
Corticosteroid Safety Card.
Inhaled Corticosteroid Safety
Information card (LRT)
Self management
● Education
●
Inhaler technique
●
Personalised Asthma Action Plan
What to do when a ‘flare-up’ happens.
How to recognise worsening asthma:Your asthma is under control if:
You have no or minimal symptoms during the day and night (wheeze, cough, chest tightness or shortness of breath)
You can do all of your normal activities without asthma symptoms. Your PEFR reading is normal or near your personal best
of……………………
Symptoms
Column 1
Column 2
Column 3
Symptoms
Asthma is under
You need to use your reliever
Your reliever inhaler does not work
control
treatment more frequently.
One or more of your symptoms get worse
Minimal day/night
You are unable to manage your
You are too breathlessness to speak
symptoms
normal activities
You have symptoms during the
day or night
PEFR
Normal or near
PEFR 60% or less predicted or
PEFR less 40% predicted or usual best
personal best
usual best
PEFR
PEFR
Managing your flare-up (exacerbation)
Continue your
Start taking your steroid tablets Take one to two puffs of your reliever treatment.
usual treatment
Prednisolone 40mg-50mg daily
Sit up and take slow steady breaths.
Continue your usual treatment.
If no immediate improvement take two puffs of your
reliever treatment every 2 minutes through your spacer
(one puff at a time) You can take up to 10 puffs.
Seek help if no improvement – Call 999
Contact your GP surgery and advise the duty doctor that you have started your emergency treatment and request replacement
supplies as soon as possible. Request an urgent appointment if your symptoms do not start to improve.
Contact your Community Respiratory Care Team if you are already known to them on……………………………….
EMERGENCY:
If you become very short of breath and do not obtain relief from your reliever treatment (Blue Inhaler):- Call ‘999’ for an
ambulance.
Thank you
For any support with your asthma
audit please contact me on
[email protected]
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