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PCRS Respiratory Conference20th and 21st September 2019
SABA Guardians - creating the followers
SABA over-reliance - the bottom up approach
Katherine Hickman GP Low Moor Medical Practice
Darush Attar-Zadeh Pharmacist – Barnet CCG
IPCRG & PCRS received funding from AstraZeneca
to develop the Asthma Right Care Initiative
2019 PCRS Respiratory Conference
What does Asthma Right Care (ARC) mean to you?
2019 PCRS Respiratory Conference
What does basic care look like?
https://www.asthma.org.uk/globalassets/get-involved/external-affairs-campaigns/publications/annual-
asthma-care-survey/annual-asthma-survey-2018/asthmauk-annual-asthma-survey-2018-v7.pdf
2019 PCRS Respiratory Conference
Asthma Right Care – starting with SABA (one of the
NRAD recommendations)
• Use of SABA in asthma in need of major improvement
• Over-reliance, but how to define?
• Note choice of language: not ”use” but “reliance” = type of dependency
• 1st conversations about SABAs may effect future use
• Occur in many places eg community pharmacies, EDs, GP/FP
• We need to know more about these
• Asthma is low priority for change in general HCP despite evidence of
• unwarranted variation in outcomes
• avoidable mortality, morbidity and healthcare utilisation
• education programmesUK data: Variation in proportion of patients receiving 6+
short-acting beta2 agonist (SABA) inhalers for asthma
Respiratory Dashboard, published June 2018 NHS Business Services Authority https://www.nhsbsa.nhs.uk/epact2/epact2-dashboardsspecifications/respiratory-
dashboard. “CCG” is clinical commissioning group – a population of between 250-500,000
2019 PCRS Respiratory Conference
How can we create less comfort
with current asthma care?
Is there enough noise about
asthma?
Does it get the coverage that
Diabetes, CVD gets?
NHS LTP opportunities
2/3rds deaths are preventable, is
there more we can do? How?
Affects young & old, rich & poor,
rural/urban, all ethnicities
2019 PCRS Respiratory Conference
SABA overuse: An indicator of poor control (2)
● “There is a progressive risk of hospital admission associated with the prescription of more than three SABA inhalers a year”
Hull SA, et al. NPJ Prim Care Respir Med. 2016;26:16049.
Healthcare resource use 1-3 inhalersN=5888
4-12 inhalersN=2054
>13 inhalersN=285
Inpatient episodes 20 33 2
Crude inpatient episode rate per 100 population
0.34 1.61 0.70
2019 PCRS Respiratory Conference
2019 PCRS Respiratory Conference
• We are passionately, frustrated with current asthma care in the UK
• Dr Noel Baxter GP South London, PCRS Policy Lead
Doing things
2019 PCRS Respiratory Conference
SABA Confusion/Paradox
● Is it important to draw clinician's attention to the inconsistencies and paradoxes that exist in current national and international recommendations on asthma management?
● On the one hand, the bronchodilating inhalers -- known as "relievers" -- are a good temporary measure
● But patients often are so impressed by the rapid response of the inhalers that they don't use the anti-inflammation inhalers -- known as "controllers"
● As the inflammation on the walls of the airway gets worse, the reliever inhalers fail to work properly as they become overwhelmed
2019 PCRS Respiratory Conference
The resources
What does good asthma control look like?
What does bad asthma control look like?
2019 PCRS Respiratory Conference
What conversation do you have about asthma and SABA use?
1. I follow asthma guidelines, so I tell patients to use SABA’s for asthma treatment in step 1 (for infrequent, intermittent wheeze).
2. SABA’s should only be used for a short time; if you need it a lot contact your physician.
3. I seldom talk to my patients about SABA use as it’s a common, low cost medicine
4. I seldom see the patient and lose track of the excess prescriptions or sales
5. SABA’s only relieve your symptoms, they don’t treat your asthma.
IPCRG 2019 Jaime Correia de Sousa, MD, PhD, on behalf of the Asthma Right Care Team
2019 PCRS Respiratory Conference
Identifying some Asthma RISKS(S)
Ratio of ICS/SABA
ICS appropriate use – non-adherence and over
prescribing
SABA – over-reliance/dependency in asthma
Knowledge – Asthma Reviews, PAAP, Inhaler
technique
Smoking cessation offered and 2nd hand smoke,
environmental exposure
Spacer use
2019 PCRS Respiratory Conference
Pharmacy PMR
SABA & ICS ratio
Oral steroids, hospital discharge
Co-morbidities e.g. hayfever,
reflux (GORD)
Medicine interactions e.g.
smoking
Sense check of diagnosis
Pharmacy label:
PAAP
Only use for cough, wheeze,
breathlessness, tight chest
Seek urgent medical help if not
lasting 4 hours
Inhaler SLOW & STEADY (pMDI)
Health promotion
zone – making
more noise about
Pharmacy
AsthmaRightCare
Creating followers –
patients and peers
Management & Treatment
Discussion aids (ICE)
Slide Rule, Select Q&C cards, Lung tubes
Reframing ICS – Natural Balance
ACT & SABA questionnaires – monitoring asthma control
Diagnostic tools - PEFR, micro-spirometry, CO
Medicines optimisation – including inhaler technique
OTC sales, excess
Rx’s, non-
adherence to ICS
(not collecting?)
SABA
Cough mixture
Hayfever treatments
Antibiotics
Prevention &
Treatment
Flu-vaccination
Weight
management
Physical activity
Smoking cessation
Trigger
management
(know your CO?)
Opportunities in the pharmacy
2019 PCRS Respiratory Conference
Pharmacy Module on
Asthma Right Care
2019 PCRS Respiratory Conference
Barnet – North London
Follower
2019 PCRS Respiratory Conference
Patient Case – 10 year old Raj
● A 10 year old boy diagnosed with asthma at 5, co-existing eczema, hayfever
● Attended an ARC group education workshop (1 hour session)
● First SABA experience - Pre-school, viral induced acute wheeze (SABA through a large volume spacer @ ED)
● On beclometasone (clenil®) and salbutamol/albuterol (12 SABA and 2 ICS shown on records – last year), spacer and mask
● Father has asthma and a smoker (CO reading 12ppm, Raj = 4ppm), smokes outside kitchen window.
VBA offered – PCRS Become a Quit Catalysthttps://www.pcrs-uk.org/resource/tobacco-dependency-pragmatic-guide
2019 PCRS Respiratory Conference
Patient Case – 10 year old Raj
● ACT score of 14, episodes of wheeze (heard on auscultation), SOB, night time awakening > twice a week.
● Avoids exercise at school as symptoms get worse, (He wishes he was like other kids – ICE).
● PEFR 212 l/min – best = 254 l/min (6 months ago) – 83% of capacity
● Triggers – Pollen, flu, cold weather, laughter, smoke, perfume, worse when going back to school (psychosocial?), exercise (likely to be due to poorly controlled asthma)
● Receives annual flu vaccine
ICE = Ideas, concerns, expectations
VBA offered – PCRS Become a Quit Catalysthttps://www.pcrs-uk.org/resource/tobacco-dependency-pragmatic-guide
2019 PCRS Respiratory Conference
Given Raj’s situation, what are the clinician’s main tasks at this point?
(there may be more than one right answer)
1. Confirm the diagnosis of asthma & other causes of symptoms
2. Review the medical history
3. Request a new spirometry &/or peak flow at home monitoring
4. Inhaler technique, consistency of device where possible (DPI, pMDI)
5. CO reading for exposure
6. Review the medication with the patient, adherence, ICS concerns?
7. Address SABA dependency as a matter of urgency as there’s an increased morbidity/mortality risk
8. Order allergy skin (prick) tests
9. Work more collaboratively with other clinicians e.g. community pharmacist
10. All of the above
IPCRG 2019 Jaime Correia de Sousa, MD, PhD, on behalf of the Asthma Right Care Team
2019 PCRS Respiratory Conference
Patient Case – Raj’s Journey
● What is asthma?
● Asthma control
● Trigger avoidance
● Inhaler technique with spacer and without mask
● Understanding the numbers – potential breathless moments
VBA offered – PCRS Become a Quit Catalysthttps://www.pcrs-uk.org/resource/tobacco-dependency-pragmatic-guide
Co-creation
12 canister = 2400 puffs = 1-2 puffs = 1 dose
1200-2400 breathless moments in the last 12 months
2019 PCRS Respiratory Conference
Patient Case – Raj’s Journey
● Addressing ICS non-adherence (Concerns of side effects? Cost? Beliefs?)
● Airway lung models, importance of ICS and how it can help recover any loss of lung openness. Salbutamol only used to help with the outside of the lungs and as an emergency treatment.
Natural steroids
Our lungs are reacting too strongly to triggers
Natural steroids in the body are needed to address the
imbalance
Low dose ICS will help maintain the natural balance.
Inhaled medicines (with good technique) go directly to the
site it’s needed at far lower strengths than tablets.
With thanks to Prof Rob Horne (Psychologist - UCL London)
www.rightbreathe.com
2019 PCRS Respiratory Conference
Behaviour change tools and arrange follow up
4 week follow up.2 puffs in the last 4 weeks and regular low dose beclometasone inhaler use –amazing! Look where you are nowSABA Guardian
2019 PCRS Respiratory Conference
Using the resources
● Lets get practicing
2019 PCRS Respiratory Conference
2019 PCRS Respiratory Conference
In the Community Pharmacy
● Making Every Contact Count (MECC) – what does this brief conversation look like?
● 1) Patient 2) Peer/clinician
Pharmacy PMR
SABA & ICS ratio
Recent asthma attack, oral steroids
Co-morbidities
Medicines interactions e.g. smoking
How different will this
conversation look:
(12 month period)
1st ever issue of SABA?
3rd issue of SABA?
6th Issue of SABA?
What matters to the patient?
2019 PCRS Respiratory Conference
● Records flag up that the 3rd SABA is being issued in the first 3 months, after a patient request.
● Records flag up that 6 or more SABA have been issued in the last 12 months, patient request.
● Records flag up that ICS prescriptions are not being requested or being collected from the pharmacy
In the GP surgery
Making Every Contact Count (MECC) –
what does this conversation look like?
1) Patient 2) Peer/clinic
How different will this
conversation look:
(12 month period)
1st ever issue of SABA?
3rd issue of SABA?
6th Issue of SABA?
What matters to the patient?
2019 PCRS Respiratory Conference
Question cards
2019 PCRS Respiratory Conference
Patients &
Clinicians
2019 PCRS Respiratory Conference
Pharmacists Health Care
Professionals
2019 PCRS Respiratory Conference
2019 PCRS Respiratory Conference
Conclusion
PCRS Respiratory Conference20th and 21st September 2019
SABA Guardians - creating the followers
SABA over-reliance - the bottom up approach
What is your pledge?
IPCRG & PCRS received funding from AstraZeneca
to develop the Asthma Right Care Initiative
2019 PCRS Respiratory Conference
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