Quality prescribing for respiratory illness 2024 to 2027 - draft guidance: consultation

2. Summary of Prescribing Recommendations

For all people with respiratory conditions:

• recommend that patients receive medication reviews using the Polypharmacy 7-Steps approach

Asthma

• recommend that a patient prescribed six or more inhalers annually is a trigger for timely, priority review - an immediate prescription may be necessary but review should take place before authorisation of the next prescription
• review patients on SABA inhalers alone, clarifying the diagnosis and establishing reasons for SABA only use
• review patients with asthma prescribed SABA and LABA without ICS
• review patients with asthma who have been prescribed an ICS inhaler and do not currently order on their repeat prescription - assess adherence and understanding of treatment to establish appropriate use of SABA inhalers
• review inappropriate use of high strength corticosteroid inhalers (maintaining patients at the lowest possible dose of inhaled corticosteroid)
• reductions in high dose ICS should be considered every three months, decreasing the dose by approximately 25–50% each time, arranging regular review as treatment is reduced
• issue a steroid treatment card to patients on inhaled high dose corticosteroids – a steroid emergency card may also be required
• review montelukast at four to eight weeks following initiation to ensure a response and that therapy is still required

In 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

In children with asthma

Whilst this guidance is not for children and prescribers should refer to guidance on asthma management in children, there are two medication safety points to highlight:

• record regular growth monitoring when treating children with ICS
• ensure children on medium / high-dose ICS are under the care of a specialist paediatrician

COPD

• inhaled ICS are prescribed for people with COPD who have a severe exacerbation or more than two exacerbations in one year or if there are asthmatic features. Review patients with COPD following initiation of inhaled ICS after three months and stop if there is insufficient response or if there are adverse effects
• mucolytic therapy is considered for symptoms of chronic cough with productive sputum and should be reviewed four weeks after commencing therapy, stopping 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 with COPD on separate LAMA and LABA/ ICS inhalers and, if appropriate change to triple therapy inhalers
• review antibiotic course length (five-day course recommended) if needed for infective exacerbations of COPD, with sputum cultures for treatment failure

Bronchiectasis

• antibiotic choice should be directed by previous positive cultures - in the absence of previous positive sputum cultures, broad spectrum oral antibiotics to cover common respiratory pathogens are recommended, using local formulary guidance where available
• azithromycin 250mg three times a week is recommended for patients with four or more exacerbations in any 12-month period, usually started after advice from secondary care
• recommend six-month review of the effectiveness of mucolytic therapy

Idiopathic pulmonary fibrosis

• anti-fibrotics prescribed only by a clinician with experience of treating IPF
• only prescribe anti-fibrotics when there is confirmed fibrotic lung disease with evidence of physiological progression

Environmental considerations

• promote patient reviews to optimise disease controland reduce inappropriate prescribing of inhalers
• prioritise review of patients with asthma who are over-reliant on SABA inhalers, defined as ordering more than three inhalers per year (see asthma chapter)
• streamline devices for patients, avoiding mixed device use where possible
• review separate inhalers where a combination inhaler device would be possible
• review patients prescribed SABA alone, check diagnosis and if appropriate consider a DPI
• update local formularies to highlight and promote inhalers which have lower CO2 emissions
• use ScriptSwitch to promote environmental messages e.g.
  • highlighting SABA overuse
  • prescribe small cannister Salbutamol pMDI with lower global warming potential (GWP) (Salamol® or Airomir®)
• raise local public awareness to promote improvements in asthma care and the environmental impact of respiratory prescribing
• utilise resources to support environmentally friendly prescribing (see appendix 1)
• for new patients:
  • use inhalers with low global warming potential when they are as equally effective
  • where there is no alternative to a pMDIs, lower volume HFA 134a pMDIs should be used in preference to large volume or HFA 227ea pMDIs
• for existing patients:
  • switch to DPI if appropriate, following a patient review - we do not recommend a blanket switch
  • consider switch to DPI inhalers for patients with asthma who:
• have an adequate inspiratory flow (e.g. use an In-Check® device)
• have been stable for two years
• have had no asthma attack for two years
• have never been admitted to hospital /ITU
• not under secondary carereview