How community pharmacy teams can help

There are four main ways pharmacy teams can help patients with asthma:

• Providing counselling and information for patients with newly diagnosed asthma who are prescribed AIR or MART
• Supporting the transition to AIR/MART for patients with existing asthma
• Spotting and referring patients who are over-reliant on SABA use
• Supporting patients who are continuing with existing separate ICS and SABA or LABA inhalers.

Advising on asthma and exercise is also important, as is smoking cessation advice (see boxout).

Pharmacies will see patients with new prescriptions for ICS/formoterol combination inhalers. The patient’s asthma might be newly diagnosed or they may have been switched to a combination inhaler. Either could prompt an NMS consultation (in England) or support for a patient who is registered for the Medicines: Care and Review (MCR) service in Scotland.

Using a SABA on three or more days a week for symptomatic relief constitutes a pragmatic threshold for uncontrolled asthma.

Overuse of SABAs is higher in the UK than in other European countries and is associated with an increased risk of exacerbations and mortality. Spotting over-reliance on SABA inhalers should be happening in GP practices, but some patients may fall through the net. Community pharmacy teams can conduct a simple PMR check when receiving a SABA prescription by working out the ratio of ICS and SABA usage in the past 12 months (e.g. 2 ICS: 6 SABA = urgent referral). There is a progressive risk of hospital admission when more than three SABA inhalers are prescribed in a year.

The SABINA study highlighted that there were twice the number of asthma attacks in people using three or more SABA canisters a year than patients using fewer than three. Referral for change to the AIR or MART regimens should be considered for patients over-reliant on SABAs, or those who are not using their ICS regularly.

Most SABA inhalers contain 200 puffs so, in theory, this should mean two SABA inhalers a year are sufficient for a patient who is well controlled, although they may need a couple of extra inhalers (e.g. to keep at another home). Most people should carry their reliever at all times.

Alarm bells should go off when six SABA prescriptions have been collected by a patient in the past six months without a single ICS prescription being issued. Many respiratory specialists argue this should happen sooner – i.e. when two or three canisters are prescribed in a 12-month period without ICS. Inappropriate prescriptions for LABAs alone in asthma should also raise an alarm.

For patients using separate ICS and SABA or LABA inhalers, adherence to ICS is a common problem: research shows that only between 22-63 per cent of the population use ICS as intended. SABAs train the brain to think this device is the most important inhaler as it provides immediate relief, but these inhalers do not treat the underlying inflammation.

Before any new drug treatment is initiated, adherence to existing therapies and inhaler technique should be checked. Re-check inhaler technique, ask for a spacer if applicable, and consider possible referral for temporary ICS dose step-up and adjust the PAAP if required.

The Asthma Control Test can be used by patients to provide a snapshot of the effectiveness of their asthma control. It consists of five questions, only takes around a minute to do and can be found at: asthmacontroltest.com/en-gb/welcome.

In conclusion, community pharmacy teams can make a difference to their patients with asthma by spotting over-reliance on short-acting beta-agonists and referring patients to their GP. They can also help by motivating patients to use their ICS correctly, suggesting AIR or MART as appropriate, and using Asthma Right Care tools and the RightBreathe website in everyday practice.