Quality prescribing for respiratory illness 2024 to 2027 - draft guidance: consultation

1. Executive Summary

Respiratory conditions are a major contributor to ill health, disability, and premature death – the most common conditions being asthma and COPD. ¹ Scottish Health Survey reported the average incidence of asthma as 16% and COPD as 4%.²

The World Health Organisation has identified chronic respiratory disease as a non-communicable disease (NCD) along with diabetes, cancers and cardiovascular disease. NCDs are responsible for 71% of global death annually. ³

This guidance is designed to ensure people with respiratory conditions are at the centre of their treatment. They, their families and their carers should be actively involved and engaged with their treatment and care decisions at all stages of their condition.

This quality prescribing guide is intended to support clinicians and shared decision-making for people with respiratory conditions (asthma, COPD, bronchiectasis and IPF) in the appropriate use of medicines, whilst applying the principles of value-based healthcare and realistic medicine.

The guide will consider the effective use of treatment in respiratory conditions, as well as the delivery devices and their environmental impact. The vast majority of medicines for respiratory conditions are delivered via the inhaled route, either by pressurised metered dose inhaler (pMDI), dry powder inhaler (DPI) or soft mist inhaler (SMI).

In asthma, early control is the aim of treatment, using inhaled corticosteroids (ICS) as the most effective preventer drug. Add-on therapy should only be initiated after checks on inhaler technique, adherence and elimination of trigger factors.

People with asthma who order more than three short acting bronchodilator (SABA) inhalers a year should be prioritised for a review, as this is a marker of poor asthma control and increased healthcare utilisation. Reduction in over-reliance on SABA inhalers, through improved disease control, will support the reduction in CO2 emissions from pressurised metered dose inhalers (pMDIs). SABA pMDI’s currently account for the majority of pMDIs prescribed in Scotland and are a source of two-thirds of the CO2 emissions. Individuals who are prescribed SABA monotherapy should be reviewed to confirm their respiratory diagnosis and ensure that appropriate preventative treatment is prescribed, for example, ICS for asthma. People with asthma should be maintained on the lowest possible dose of ICS inhalers to effectively treat their symptoms and reduce the potential for side effects or harm from treatment.

People with severe asthma should be identified using criteria such as number of SABA reliever inhalers per year, number of exacerbations or poor symptom control and be referred to secondary care for treatment optimisation.

In people with COPD, inhaled ICS are prescribed who have a severe exacerbation or more than two exacerbations in one year or if there are asthmatic features. ICS therapy should be reviewed to reduce the risk of pneumonia and adrenal suppression. Triple therapy inhalers instead of multiple individual inhalers should be considered to improve adherence and cost effectiveness and reduce the carbon footprint from inhaler use.

Antibiotics should only be used for infective exacerbations in COPD (five-day course) and up to 14 days in bronchiectasis. Following advice from secondary care, some patients who have frequent exacerbations may require regular antibiotic treatment with azithromycin. Oral corticosteroids should be avoided in patients with bronchiectasis unless there is a clear indication. Long term oral corticosteroids are not recommended for people with COPD, but short courses may be used to treat exacerbations.

Idiopathic pulmonary fibrosis (IPF) is treated with anti-fibrotics, which should be prescribed and monitored by a clinician with experience of treating IPF.

The environmental impact of inhalers is a key consideration to contribute to the achievement of net-zero greenhouse gas emissions by NHS Scotland by 2040. Prescribers are asked to consider inhalers with a lower global warming potential (GWP) where appropriate and local formularies should highlight and promote inhalers with a lower GWP.

To support this work, a suite of safety and medication effectiveness indicators have been developed, with a multi-professional and patient group. These indicators provide data to enable benchmarking and help drive quality improvement by reducing unwarranted variation in prescribing practice.