Quality prescribing for respiratory illness 2024 to 2027 - draft guidance: consultation

Consultation Questions

We have a total of 12 questions with some being multi-part, please answer as many as you feel able to.

1. Approach to review

We recommend for all patients, medications are reviewed using a person-centred approach using the standardised Polypharmacy 7-Steps guidance.

Question 1a

Do you agree with this recommendation?

(Yes/No/Not sure)

Question 1b

To what extent do you think this recommendation will be effective in improving patient care, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 1c

Please tell us more about your views on our approach to review:

2. For adults with asthma

We recommend that people should have a person-centred medication review if they are:

• prescribed more than three short-acting beta agonist (SABA) reliever inhalers per year
• using high strength corticosteroid inhalers
• only using a reliever inhaler to manage their symptoms
• not ordering their preventer inhalers

We recommend that people should be seen for a priority review if they are prescribed six or more reliever inhalers a year.

People taking high dose inhaled corticosteroids should be given a steroid safety card. And if the dose of inhaled corticosteroids needs to be reduced, this should be decreased by approximately a quarter to a half, every three months.

Review montelukast 4 to 8 weeks following initiation to ensure that there has been a response and that it is still required.

Question 2a

Do you agree with this recommendation?

(Yes/No/Not sure)

Question 2b

To what extent do you think this recommendation will be effective in improving patient care, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 2c

Please tell us more about your views on our recommendations for treatment of adults with asthma:

3. For adults with severe asthma:

Identify patients with severe asthma and where modifiable risk factors are addressed and asthma care remains suboptimal, refer to secondary care for treatment optimisation.

Question 3a

Do you agree with this recommendation?

(Yes/No/Not sure)

Question 3b

To what extent do you think this recommendation will be effective in improving patient care, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 3c

Please tell us more about your views on our recommendations for treatment of adults with severe asthma:

4. For people with chronic obstructive pulmonary disease (COPD)

We recommend:

• review patients following initiation of inhaled corticosteroids (ICS) and stop if there is insufficient response or adverse effects.
• mucolytic therapy (a medicine to break up phlegm) should be reviewed four weeks after commencing therapy and should be stopped if symptoms have not improved with use.
• regular review of mucolytic therapy during the annual COPD review should be undertaken and may be stopped if there is no productive cough.
• review patients on separate long-acting muscarinic antagonist (LAMA) and long-acting beta-2 agonist (LABA) or ICS inhalers and, if appropriate change to triple therapy inhalers. Recommend review to assess benefit, discontinuing the ICS if there is no improvement.

Question 4a

Do you agree with these recommendations?

(Yes/No/Not sure)

Question 4b

To what extent do you think this recommendation will be effective in improving patient care, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 4c

Please tell us more about your views on our recommendations for treatment for people with chronic obstructive pulmonary disease (COPD):

5. For people with bronchiectasis:

We recommend that:

• people taking mucolytics should have a review every six months to determine how well the medicine is working.
• antibiotics for acute exacerbations should be selected based on positive sputum cultures where possible.

Question 5a

Do you agree with this recommendation?

(Yes/No/Not sure)

Question 5b

To what extent do you think this recommendation will be effective in improving patient care, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 5c

Please tell us more about your views on our recommendations for treatment of people with bronchiectasis:

6. For people with Idiopathic Pulmonary Fibrosis (IPF):

We recommend that antifibrotics should only be prescribed:

• by a clinician with experience of treating IPF; and
• when there is confirmed fibrotic lung disease with evidence of physiological progression.

Question 6a

Do you agree with this recommendation?

(Yes/No/Not sure)

Question 6b

To what extent do you think this recommendation will be effective in improving patient care, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 6c

Please tell us more about your views on our recommendations for treatment of people with Idiopathic Pulmonary Fibrosis (IPF):

7. Wider considerations

The healthcare industry is increasingly asked to account for the negative environmental impact generated through providing medical care. Regular medication reviews to address inappropriate polypharmacy in respiratory conditions and other co-morbidities (when a person has more than one disease or condition at the same time) should ensure that the environmental impact of prescribing is reduced.

Environmental impact of inhalers is a key consideration. Prescribers are asked to consider inhalers with a lower global warming potential where it is appropriate for the patient.

The guide sets out the following general considerations which will help reduce the environmental impact of inhaler use:

a) promote patient reviews to optimise disease controland reduce inappropriate prescribing of inhalers

b) prioritise review of patients with asthma who are over-reliant on SABA inhalers, defined as ordering more than three inhalers per year

c) streamline devices for patients, avoiding mixed device use where possible

d) review separate inhalers where a combination inhaler device would be possible

e) update local formularies to highlight and promote inhalers which have lower CO2 emissions

f) raise local public awareness to promote improvements in asthma care and the environmental impact of respiratory prescribing

g) utilise resources to support environmentally friendly prescribing

Question 7a

Do you agree with these recommendations?

(Yes/No/Not sure)

Question 7b

To what extent do you think this recommendation will be effective, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 7c

Please tell us more about your views on how best to support environmentally friendly prescribing:

8. The guide recommends the following when prescribing for new and existing patients:

a. Where appropriate, prescribe inhalers with low global warming potential when they are equally effective.

b. Review patients prescribed SABA alone, check diagnosis and if appropriate consider a DPI.

c. Consider switching to dry powder inhalers, after a person-centred medication review, for patients with asthma who have:

• an adequate inspiratory flow (e.g. use an In-Check^® device)
• been stable for many years
• had no asthma attack for two years
• never been admitted to hospital /ITU
• not been admitted under secondary care.

Question 8a

Do you agree with these recommendations?

(Yes/No/Not sure)

Question 8b

To what extent do you think this recommendation will be effective, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 8c

Please tell us more about your views on our recommendations for considering prescribing inhalers with low global warming potential to new and existing patients:

9. CO2 emissions in Scotland

An ambitious target of 70% reduction in CO2 emissions from inhalers by 2028 has been set, as NHS Scotland works towards the commitment of net-zero emissions by 2040. The 70% reduction has been split into biennial targets as follows:

• a 25% reduction of CO2 emissions is required by the end of 2024
• a 50% reduction of CO2 emissions is required by 2026 and
• a 70% reduction by end of 2028

Question 9a

Do you agree with these recommendations?

(Yes/No/Not sure)

Question 9b

To what extent do you think this recommendation will be effective, on a scale of 1-5, where 1 is not effective at all and 5 is extremely effective?

Question 9c

Please tell us more about your response. For example, how do you feel about the percentage reduction from 25% to 50% to 70%, over the time period up to 2028?

10. Resources for further information

Resource

NHS Inform Lungs and airways | NHS inform has information on the symptoms, causes and treatment for a range of respiratory illnesses.

My Lungs My Life

My Lungs My Life is a comprehensive, free website for anyone living with COPD, asthma or for parents/guardians of children with asthma. The resource is a collaboration between NHS, third sector and the University of Edinburgh.

Don’t Waste a Breath

The Don’t Waste a Breath website, developed by NHS Grampian, provides information for patients on inhaler technique and how to recycle inhalers. This website complements My Lungs My Life.

Charity Resources The Chest Heart and Stroke Scotland and Asthma + Lung UK | Asthma home have lots of information to support patients including patient leaflets, booklets and toolkits and both have a patient helpline providing advice.

Personal Asthma Action Plans

There is substantial evidence to support the value of personalised actions plans for asthma in both adults and children. Access a generic template from Asthma + Lung UK.

Question 10a

Are you aware of any other resources that people with respiratory conditions may find useful?

(Yes/No/Not sure)

Question 10b

If your answer to question 10a was Yes, please list any other resources that you are aware of:

11. Implementation of this guidance

We have a few questions, which will help us implement the recommendations from this prescribing guide.

Question 11a

Do you feel there are any barriers to implementing the recommendations from this guidance?

(Yes/No/Not sure)

Question 11b

If you answered yes to Question 11a, how do you feel these barriers could be addressed?

Question 11c

What are the key factors that will enable successful implementation of these recommendations?

12. Finally

Question 12

Do you have any further comments on this prescribing guide or patient information guide?