What support should be offered to patients if their asthma device needs to be changed?

Pharmacist and Primary Care Respiratory Society (PCRS) executive committee member Darush Attar-Zadeh gives advice for asthma-related pharmacy queries during the coronavirus pandemic.

The virtual asthma review and the New Medicine Service (NMS) offer the ideal opportunity for pharmacists to find the right inhaled treatment (including device) for the right patient.

If inhaled treatments are switched to other brands (maybe because of stock issues or a new preferable inhaled treatment) it is important to offer a NMS or counselling service for the patient, as the changes may lead to confusion particularly around inhaler technique and medication dosing.

If changes to inhaled treatments are made, it is important for inhalers to be prescribed by brand, to ensure the intended medication and device is issued.

For pMDI devices, you may expect to see differences in device colour, tastes, aerosol plume velocity, temperatures that can produce differences in lung depositions, dose counter, and, importantly, a change in mouthpiece shape that may affect compatibility with spacers.

For Dry Powder Inhaler (DPI) devices, a change is usually particularly significant, and the device may require altogether different manipulations by the patient, e.g. twisting, pulling, shaking. Some new equivalent medicines have different licensed indications, e.g. not licensed for under 18 years of age.

Another way that pharmacy teams can minimise inhaler technique errors is to ensure the patient, wherever possible is given the same type of device, e.g. not issuing a preventer in a DPI and reliever in a pMDI.

According to NICE, if optimal inhaler technique can be achieved with pMDI, DPI and softmist. DPI or softmist class should be prioritised.

Optimising inhaled asthma treatments

It may also be possible to reduce and simplify the number of devices a person is on, where appropriate, to reduce waste and optimise inhaled treatments.

For example, triple therapy medicine is available in a single device for appropriate COPD patients with an asthma phenotype. Inhaled corticosteroids (ICS) and short acting beta agonists (SABA) (in asthma) – where SABA over-reliance has been detected. It is possible to move to a single inhaler and consider a licensed Maintenance and Reliever Therapy (MART) regime containing ICS + Formoterol. Step 4 and 4a on www.RightBreathe.com show some options.

SABA is not needed in a MART regimen, the bronchodilator Formoterol (a long acting beta2 agonist (LABA)) sets in rapidly (within one to three minutes) and is still significant 12 hours after inhalation. Importantly, the ICS is delivered to dampen down inflammation.

The Asthma Right Care team have produced some good resources to assist pharmacy professionals regarding SABA over-reliance. See https://www.pcrs-uk.org/resource/arc [Edit: link no longer live] and https://www.ipcrg.org/asthmarightcare

SABA inhalers usually contain 200 puffs. Be aware of people with asthma who maybe using SABA more often as a preventer treatment instead of ICS or maybe using SABA inappropriately to manage other differential diagnosis, e.g. breathlessness due to anxiety (which maybe more prevalent in the current environment). Daily use of SABA, instead of for emergency relief less than three times a week, can cause common side-effects: tremor, palpitations, peripheral vasodilatation, and as a result a small increase in heart rate. Studies show that the risk of hospitalisation increases if a person needs three or more 200-puff inhalers a year. Also be aware of stockpiling, that may lead to people who need SABA going without.

When counselling patients with asthma, during a remote consultation for example, you could say: “This (SABA inhaler) should last you six months. Come back if you still have symptoms or if you run out before the six months, because that indicates that something is wrong, and your asthma may not be fully controlled”.

For more advice, signpost patients to Asthma UK and their Personal Asthma Action Plan (PAAP) if they have one.

The advice above does not apply to people living with COPD, where SABA can be used liberally.

Environmental considerations

The carbon footprint of inhalers should also be factored into the decision-making processes. NICE has produced a patient decision aid that may be useful.