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

2. Summary of Prescribing Recommendations

For all people with respiratory conditions:

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

Asthma

• clinical recommendations are to review patients that are taking three or more reliever inhalers annually. However, the clinical and patient consensus was to prioritise those prescribed six or more reliever inhalers annually. This 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 to 50% each time and arranging regular review as treatment is reduced
• issue a steroid treatment card to patients on high dose inhaled corticosteroids – a steroid emergency card may also be required
• review montelukast at four to eight weeks following initiation to ensure a response and review continued need at regular intervals

In severe asthma

• identify patients at risk of severe asthma and where modifiable risk factors are addressed and asthma control remains suboptimal, refer to secondary care for treatment optimisation

In children with asthma

This guidance is not for children, therefore prescribers should refer to guidance on asthma management in children, however, 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

• ICS (licensed only as part of combination therapy with LABA and/or LAMA) are prescribed for people with COPD who have a severe exacerbation, more than two exacerbations in one year or if there are features of asthma
• review patients with COPD following initiation of ICS as part of combination therapy after three months. Stop ICS if there is insufficient response or if there are adverse effects that outweigh benefits
• 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
• review of mucolytic therapy during the annual COPD review should be undertaken and may be stopped if 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
• repeated use of 'rescue medication' (steroid and/or antibiotic) (two or more per year) should trigger a review to optimise long-term management

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 should only be prescribed 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 regular reviews to optimise disease control and reduce inappropriate prescribing of inhalers
• prioritise review of people with asthma who are over-reliant on SABA inhalers, defined as ordering more than three inhalers per year (see asthma chapter). Those on six or more should be targeted first
• streamline inhaler devices, 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 appropriate treatment, and if appropriate consider a low GWP inhaler
• update local formularies to highlight and promote inhalers with lower CO2 emissions
• use ScriptSwitch to promote key messages e.g.
  • to highlight SABA overuse
  • prescribe low volume pMDI with lower global warming potential (GWP)
• raise public awareness to promote improvements in asthma care and 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 where 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 or SMI if appropriate, following a person-centred review - we do not recommend a blanket switch
  • consider switch to DPI for individuals with asthma who have an adequate inspiratory flow. If there is concern regarding inspiratory ability due to age or frailty, it can be checked using an inspiratory flow device, such as placebo whistles or In-check device®