saba guardians - creating the followers saba over-reliance ...€¦ · pharmacy pmr saba & ics...

PCRS Respiratory Conference20th and 21st September 2019

SABA Guardians - creating the followers

SABA over-reliance - the bottom up approach

Katherine Hickman GP Low Moor Medical Practice

Darush Attar-Zadeh Pharmacist – Barnet CCG

IPCRG & PCRS received funding from AstraZeneca

to develop the Asthma Right Care Initiative

2019 PCRS Respiratory Conference

What does Asthma Right Care (ARC) mean to you?


What does basic care look like?

https://www.asthma.org.uk/globalassets/get-involved/external-affairs-campaigns/publications/annual-

asthma-care-survey/annual-asthma-survey-2018/asthmauk-annual-asthma-survey-2018-v7.pdf


Asthma Right Care – starting with SABA (one of the

NRAD recommendations)

• Use of SABA in asthma in need of major improvement

• Over-reliance, but how to define?

• Note choice of language: not ”use” but “reliance” = type of dependency

• 1st conversations about SABAs may effect future use

• Occur in many places eg community pharmacies, EDs, GP/FP

• We need to know more about these

• Asthma is low priority for change in general HCP despite evidence of

• unwarranted variation in outcomes

• avoidable mortality, morbidity and healthcare utilisation

• education programmesUK data: Variation in proportion of patients receiving 6+

short-acting beta2 agonist (SABA) inhalers for asthma

Respiratory Dashboard, published June 2018 NHS Business Services Authority https://www.nhsbsa.nhs.uk/epact2/epact2-dashboardsspecifications/respiratory-

dashboard. “CCG” is clinical commissioning group – a population of between 250-500,000

https://www.nhsbsa.nhs.uk/epact2/epact2-dashboardsspecifications/respiratory-dashboard


How can we create less comfort

with current asthma care?

Is there enough noise about

asthma?

Does it get the coverage that

Diabetes, CVD gets?

NHS LTP opportunities

2/3rds deaths are preventable, is

there more we can do? How?

Affects young & old, rich & poor,

rural/urban, all ethnicities


SABA overuse: An indicator of poor control (2)

● “There is a progressive risk of hospital admission associated with the prescription of more than three SABA inhalers a year”

Hull SA, et al. NPJ Prim Care Respir Med. 2016;26:16049.

Healthcare resource use 1-3 inhalersN=5888

4-12 inhalersN=2054

>13 inhalersN=285

Inpatient episodes 20 33 2

Crude inpatient episode rate per 100 population

0.34 1.61 0.70


• We are passionately, frustrated with current asthma care in the UK

• Dr Noel Baxter GP South London, PCRS Policy Lead

Doing things


SABA Confusion/Paradox

● Is it important to draw clinician's attention to the inconsistencies and paradoxes that exist in current national and international recommendations on asthma management?

● On the one hand, the bronchodilating inhalers -- known as "relievers" -- are a good temporary measure

● But patients often are so impressed by the rapid response of the inhalers that they don't use the anti-inflammation inhalers -- known as "controllers"

● As the inflammation on the walls of the airway gets worse, the reliever inhalers fail to work properly as they become overwhelmed


The resources

What does good asthma control look like?

What does bad asthma control look like?


What conversation do you have about asthma and SABA use?

1. I follow asthma guidelines, so I tell patients to use SABA’s for asthma treatment in step 1 (for infrequent, intermittent wheeze).

2. SABA’s should only be used for a short time; if you need it a lot contact your physician.

3. I seldom talk to my patients about SABA use as it’s a common, low cost medicine

4. I seldom see the patient and lose track of the excess prescriptions or sales

5. SABA’s only relieve your symptoms, they don’t treat your asthma.

IPCRG 2019 Jaime Correia de Sousa, MD, PhD, on behalf of the Asthma Right Care Team


Identifying some Asthma RISKS(S)

Ratio of ICS/SABA

ICS appropriate use – non-adherence and over

prescribing

SABA – over-reliance/dependency in asthma

Knowledge – Asthma Reviews, PAAP, Inhaler

technique

Smoking cessation offered and 2nd hand smoke,

environmental exposure

Spacer use


Pharmacy PMR

SABA & ICS ratio

Oral steroids, hospital discharge

Co-morbidities e.g. hayfever,

reflux (GORD)

Medicine interactions e.g.

smoking

Sense check of diagnosis

Pharmacy label:

PAAP

Only use for cough, wheeze,

breathlessness, tight chest

Seek urgent medical help if not

lasting 4 hours

Inhaler SLOW & STEADY (pMDI)

Health promotion

zone – making

more noise about

Pharmacy

AsthmaRightCare

Creating followers –

patients and peers

Management & Treatment

Discussion aids (ICE)

Slide Rule, Select Q&C cards, Lung tubes

Reframing ICS – Natural Balance

ACT & SABA questionnaires – monitoring asthma control

Diagnostic tools - PEFR, micro-spirometry, CO

Medicines optimisation – including inhaler technique

OTC sales, excess

Rx’s, non-

adherence to ICS

(not collecting?)

SABA

Cough mixture

Hayfever treatments

Antibiotics

Prevention &

Treatment

Flu-vaccination

Weight

management

Physical activity

Smoking cessation

Trigger

management

(know your CO?)

Opportunities in the pharmacy


Pharmacy Module on

Asthma Right Care


Barnet – North London

Follower


Patient Case – 10 year old Raj

● A 10 year old boy diagnosed with asthma at 5, co-existing eczema, hayfever

● Attended an ARC group education workshop (1 hour session)

● First SABA experience - Pre-school, viral induced acute wheeze (SABA through a large volume spacer @ ED)

● On beclometasone (clenil®) and salbutamol/albuterol (12 SABA and 2 ICS shown on records – last year), spacer and mask

● Father has asthma and a smoker (CO reading 12ppm, Raj = 4ppm), smokes outside kitchen window.

VBA offered – PCRS Become a Quit Catalysthttps://www.pcrs-uk.org/resource/tobacco-dependency-pragmatic-guide

https://www.pcrs-uk.org/resource/tobacco-dependency-pragmatic-guide


Patient Case – 10 year old Raj

● ACT score of 14, episodes of wheeze (heard on auscultation), SOB, night time awakening > twice a week.

● Avoids exercise at school as symptoms get worse, (He wishes he was like other kids – ICE).

● PEFR 212 l/min – best = 254 l/min (6 months ago) – 83% of capacity

● Triggers – Pollen, flu, cold weather, laughter, smoke, perfume, worse when going back to school (psychosocial?), exercise (likely to be due to poorly controlled asthma)

● Receives annual flu vaccine

ICE = Ideas, concerns, expectations




Given Raj’s situation, what are the clinician’s main tasks at this point?

(there may be more than one right answer)

1. Confirm the diagnosis of asthma & other causes of symptoms

2. Review the medical history

3. Request a new spirometry &/or peak flow at home monitoring

4. Inhaler technique, consistency of device where possible (DPI, pMDI)

5. CO reading for exposure

6. Review the medication with the patient, adherence, ICS concerns?

7. Address SABA dependency as a matter of urgency as there’s an increased morbidity/mortality risk

8. Order allergy skin (prick) tests

9. Work more collaboratively with other clinicians e.g. community pharmacist

10. All of the above

IPCRG 2019 Jaime Correia de Sousa, MD, PhD, on behalf of the Asthma Right Care Team


Patient Case – Raj’s Journey

● What is asthma?

● Asthma control

● Trigger avoidance

● Inhaler technique with spacer and without mask

● Understanding the numbers – potential breathless moments


Co-creation

12 canister = 2400 puffs = 1-2 puffs = 1 dose

1200-2400 breathless moments in the last 12 months



Patient Case – Raj’s Journey

● Addressing ICS non-adherence (Concerns of side effects? Cost? Beliefs?)

● Airway lung models, importance of ICS and how it can help recover any loss of lung openness. Salbutamol only used to help with the outside of the lungs and as an emergency treatment.

Natural steroids

Our lungs are reacting too strongly to triggers

Natural steroids in the body are needed to address the

imbalance

Low dose ICS will help maintain the natural balance.

Inhaled medicines (with good technique) go directly to the

site it’s needed at far lower strengths than tablets.

With thanks to Prof Rob Horne (Psychologist - UCL London)

www.rightbreathe.com

http://www.rightbreathe.com/


Behaviour change tools and arrange follow up

4 week follow up.2 puffs in the last 4 weeks and regular low dose beclometasone inhaler use –amazing! Look where you are nowSABA Guardian


Using the resources

● Lets get practicing


In the Community Pharmacy

● Making Every Contact Count (MECC) – what does this brief conversation look like?

● 1) Patient 2) Peer/clinician

Pharmacy PMR

SABA & ICS ratio

Recent asthma attack, oral steroids

Co-morbidities

Medicines interactions e.g. smoking

How different will this

conversation look:

(12 month period)

1st ever issue of SABA?

3rd issue of SABA?

6th Issue of SABA?

What matters to the patient?


● Records flag up that the 3rd SABA is being issued in the first 3 months, after a patient request.

● Records flag up that 6 or more SABA have been issued in the last 12 months, patient request.

● Records flag up that ICS prescriptions are not being requested or being collected from the pharmacy

In the GP surgery

Making Every Contact Count (MECC) –

what does this conversation look like?

1) Patient 2) Peer/clinic

How different will this

conversation look:

(12 month period)

1st ever issue of SABA?

3rd issue of SABA?

6th Issue of SABA?

What matters to the patient?


Question cards


Patients &

Clinicians


Pharmacists Health Care

Professionals


Conclusion

PCRS Respiratory Conference20th and 21st September 2019

SABA Guardians - creating the followers

SABA over-reliance - the bottom up approach

What is your pledge?

IPCRG & PCRS received funding from AstraZeneca

to develop the Asthma Right Care Initiative


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saba guardians - creating the followers saba over-reliance ...€¦ · pharmacy pmr saba & ics...

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