Respiratory conditions - quality prescribing strategy: improvement guide 2024 to 2027

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] The 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 guide 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 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 idiopathic pulmonary fibrosis (IPF)) in the appropriate use of medicines, taking a person-centred approach whilst applying the principles of value-based healthcare and realistic medicine.

This guide will consider the effective treatment of 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 beta-2-agonists (SABA) inhalers a year should be prioritised for a review, as this is a marker of poor asthma control and increased healthcare utilisation. Boards may need to review those taking six or more initially, then move on to those taking three or more SABA inhalers per year. Reduction in over-reliance on SABA inhalers, through improved respiratory disease control, will also 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 from inhalers.

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 at risk of 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 where appropriate.

In people with COPD, ICS are prescribed (as part of combination therapy) for those who have a severe exacerbation (requiring hospitalisation) 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, 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 prophylaxis with azithromycin. Oral corticosteroids should be avoided in patients with bronchiectasis unless there is a clear indication for an alternative comorbidity such as asthma. Long term oral corticosteroids are not recommended for people with COPD, but short courses may be used to treat exacerbations.

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 data indicators have been developed, with a multi-professional and patient group including experts by experience. These indicators provide data to enable benchmarking and help drive quality improvement by reducing unwarranted variation in prescribing practice.