Asthma and COPD Inhaled
Therapy Resource Kit
Can they use it?
Do they use it?
Medicines Management Team
July 2014
Medicines Management Team
Suite 2, Capability House, Wrest Park, Silsoe, Bedfordshire, MK45 4HR
Tel: 01525 864430 ext. 5903
Asthma and COPD Inhaled Therapy
Resource Kit- Contents
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



Introduction and acknowledgements
BCCG Medicines Formulary – Updated monthly, check website for
most recent edition.
Bedfordshire and Luton Joint Prescribing Committee (JPC) Bulletins
How to use your inhaler leaflets
Information on expected number of inhalers used annually at stated
doses
ASTHMA






Quick reference guide for the management of chronic asthma in adults
Asthma Control Test and checklist
Check list for asthma review
Audit Project: Audit and Review of Adults with Asthma on High Dose
Inhaled Corticosteroids
Why asthma still kills- the national Review of Asthma Deaths (NRAD)
May 2014 - Executive Summary
Breathing Well Patient information pack
COPD




BCCG COPD guidelines
Checklist for COPD review
BCCG COPD 2013 audit action points
Audit Project: Review the need for ICS/LABA inhaler in COPD
patients with an FEV1≥50
DEVICES
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
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In-Check Dial
Peak flow meter
Placebo inhaler devices
Introduction and acknowledgements
This asthma and COPD resource kit has been put together by the
Bedfordshire Clinical Commissioning Group (BCCG) Medicines Management
Team (MMT) to support you in your work with patients assisting them to
optimise the use of their inhalers for their asthma or COPD.
This resource kit aims to supplement information contained in national
guidelines such as the BTS/SIGN British Guideline on the Management of
Asthma and the local COPD Guidelines.
Many thanks to Luton CCG for sharing their asthma resource pack with us,
some of which has been reproduced within this resource kit. We would also
like to thank Chiesi Ltd. for donating the Breathing Well patient packs and
demonstration inhaler, AstraZeneca, Boehringer Ingelheim, GSK and Teva
UK for providing placebo inhaler devices.
We hope you find this resource kit useful in your healthcare setting.
We welcome any comments you may have, please contact the editor, Karen
Homan, Commissioning Pharmacist, BCCG MMT, Suite 2, Capability House,
Wrest Park, Silsoe, Bedfordshire, MK454HR. email:
Karen.homan@bedfordshireccg.nhs.uk .
These materials are based on the best available evidence but their application
can always be modified by professional judgement.
BCCG Medicines Formulary - Inhalers
3: RESPIRATORY SYSTEM
3.1.1.1 Selective
beta2 agonists
3.1.2
Antimuscarinic
bronchodilators
3.1.3
Theophylline
BNF Section
3.2
Corticosteroids
Compound
preparations
Short acting
Salbutamol
100micrograms/dose inhaler
CFC free
Longer acting
Easyhaler formoterol
12microgram/dose
Ipratropium bromide
20micrograms/dose inhaler
CFC free
Tiotropium bromide
18microgram inhalation
powder, hard capsule
Phyllocontin Continus ® tablets
225mg
Preparations
Comments
Clenil modulite® cfc-free
aerosol inhaler 50, 100, 200 &
250 micrograms per dose
Asthma
Fostair ® cfc free inhaler
100microgram/6microgram
Adult over 18 years
NB extra fine particles and has 5
months shelf life when dispensed
(100microgram extra-fine
beclometasone dipropionate is
equivalent to 250microgram CFCfree beclometasone dipropionate)
Symbicort ® 100/6 turbohaler
Child 6-12 years
Symbicort ® 200/6 turbohaler
Child 12-17 years
COPD
Fostair ® cfc free inhaler
100microgram/6microgram
Symbicort ® 400/12 turbohaler
The latest version of the formulary is available at:
http://www.gpref.bedfordshire.nhs.uk/referrals/bccg-primary-careformulary.aspx (user registration required.)
Appendix 1: Comparison of the ICS/LABA combination products
Trade name
Flutiform®
Fostair®
Device
Pressurised metered dose
inhaler (MDI)
Pressurised MDI
Strengths
available
Fluticasone/formoterol
50 / 5 microgram
125 / 5 microgram
250 / 10 microgram
Beclometasone/formoterol
100 / 6 microgram
Seretide®
Symbicort®
Accuhaler (dry powder, breath
actuated inhaler)
Evohaler (Pressurised MDI)
Fluticasone/salmeterol Accuhaler
100 / 50 microgram
250 / 50 microgram
Turbohaler (dry powder, breath
actuated inhaler)
Budesonide/formoterol
100 / 6 microgram
200 / 6 microgram
400 / 12 microgram
500 / 50 microgram
Adult asthma
prophylaxis /
maintenance
dose
Adult asthma
single
maintenance and
reliever therapy
(SMART)
2 puffs BD with all strengths
Not licensed
1-2 puffs BD (maximum 4 puffs
daily)
1 puff BD for maintenance.
Patients should take 1
additional puff PRN in
response to symptoms and an
additional puff if symptoms
persist after a few minutes.
Maximum daily dose is 8
puffs/day.
Fluticasone/salmeterol Evohaler
50 / 25 microgram
125 / 25 microgram
250 / 25 microgram
 100/50: 1 puff BD, reduce to 1 puff
OD if controlled
 250/50 and 500/50: 1 puff BD
 50/25: 2 puffs BD, reduce to 2 puffs
OD if controlled
 125/25 and 250/25: 2 puffs BD
Not licensed
 100/6 and 200/6: 1-2 puffs BD
(maximum 4 puffs BD, reduce to 1
puff OD if controlled)
 400/12: 1 puff BD (maximum 2
puffs BD, reduce to 1 puff OD if
controlled)
 100/6: 2 puffs daily in 1-2 divided
doses, for relief of symptoms use
1 puff PRN up to max 6 puffs,
maximum 8 puffs/day (up to 12
puffs daily can be used for a
limited time)
 200/6: 2 puffs daily in 1-2 divided
doses, up to 2 puffs BD; for relief
of symptoms use 1 puff PRN up to
max 6 puffs, maximum 8 puffs/day
(up to 12 puffs daily can be used
for a limited time)
Child asthma
prophylaxis /
maintenance
dose
2 puffs BD with 50/5 and
125/5 inhalers only in
patients aged 12 yrs and
over
Not licensed
COPD dose
Not licensed
Not licensed
Price per unit
~30 days supply
(see appendix 1
for price per
dose)
120 actuations inhaler
50/5: £18
125/5: £29.26
250/10: £45.56
120 actuations inhaler
100/6: £29.32
Miscellaneous
information
Compatible with generic
spacers: A2A Spacer, Able
Spacer, Optichamber
Diamond, Pocket Chamber,
Vortex
 Fridge storage required
 The 100mcg dose of
beclometasone in Fostair® is
not bioequivalent to a
100mcg dose of
beclometasone in other
inhalers.
 Compatible with
Aerochamber Plus spacer
(and generic spacers)
 100/50: 1 puff BD, reduce to 1 puff
OD if controlled in children aged 4
yrs and over
 250/50 and 500/50: 1 puff BD in
children over 12 yrs old
 50/25: 2 puffs BD, reduce to 2 puffs
OD if controlled in children aged 4
yrs and over
 125/25 and 250/25: 2 puffs BD in
children over 12 yrs old
500/50: 1 puff BD
60 actuations Accuhaler
100/50: £18
250/50: £35
500/50: £40.92
120 actuations Evohaler
50/25: £18
125/25: £35
250/25: £59.48
 Accuhaler preloaded, primed by
opening. Easy to use, requires
minimal manual dexterity to prime.
Red warning seen with last 5
doses. Humidity protected.
 Evohaler compatible with Volumatic
and Aerochamber Plus spacers
(and generic spacers)
 100/6: 1-2 puffs BD, reduce to 1
puff OD if controlled in children
aged 6-17 yrs
 200/6 and 400/12: 1-2 puffs BD,
reduce to 1 puff OD if controlled in
children 12-17 yrs
200/6: 2 puffs BD
400/12: 1 puff BD
120 actuations Turbohaler
100/6: £33
200/6: £38
60 actuations Turbohaler
400/12: £38
Turbohaler preloaded, primed by
twisting. Easy to use, requires
minimal dexterity. Cog wheel dose
indicator with last 20 doses marked
in red. Separate cap. Humidity
protected.
References/ Sources of Review
1. Bedfordshire and Luton Joint Prescribing Committee, Bulletin 137 Fostair® (beclometasone
dipropionate (BDP)100mcg and formoterol fumarate dihydrate 6mcg metered dose
inhaler) for asthma
2. British National Formulary No 65. London: British Medical Association and The Royal
Pharmaceutical Society of Great Britain; March- September 2013.
3. Smith,K, Suffolk PCT Drug and Therapeutics committee ICS/LABA review, October 2012
4. British Guideline on the management of asthma. Produced jointly by SIGN and the British
Thoracic Society (BTS) since 2003, sections of the guideline are updated annually. Guideline
101. May 2008, Revised May 2011, Section 4.3.4 revised Sept 2011, Section 1 revised Jan
2012. http://www.sign.ac.uk/pdf/sign101.pdf
5. NICE TA 138. Corticosteroids for the treatment of chronic asthma in adults and children aged
12 years and over. March 2008. http://guidance.nice.org.uk/TA138
6. MIMS October 2012
7. Anon. Single maintenance and reliever therapy (SMART) for asthma. Drug & Therapeutics
Bulletin 2011; 49 (11): 126-9
8. NICE Clinical Guideline 101. Management of chronic obstructive pulmonary disease in adults in
primary and secondary care (partial update). June 2010 http://guidance.nice.org.uk/CG101
9. Global strategy for the diagnosis, management and prevention of chronic obstructive
pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Revised
2011 http://www.goldcopd.org/uploads/users/files/GOLD_Report_2011_Feb21.pdf
10. Cates CJ, Oleszczuk M, Stovold E, Wieland LS. Safety of regular formoterol or salmeterol in
children with asthma: an overview of Cochrane reviews. Cochrane Database of Systematic
Reviews 2012, Issue 10. Art. No.: CD010005. DOI: 10.1002/14651858.CD010005.pub2.
11. Bodzenta-Lukaszyk A et al. Fluticasone/formoterol combination therapy is as effective as
fluticasone/salmeterol in the treatment of asthma, but has more rapid onset of action: an open
label, randomised study. BMC Pulm Med 2011;11:28. Epub 2011 May 23
12. NICE. ESNM3: Asthma: fluticasone/formoterol (Flutiform®) combination inhaler. October 2012
http://www.nice.org.uk/mpc/evidencesummariesnewmedicines/ESNM3.jsp
13. Bodzenta‐Lukaszyk A, Buhl R, Balint B, et al. Fluticasone/formoterol combined in a single
aerosol inhaler vs. budesonide/formoterol for the treatment of asthma: a non‐inferiority trial.
Abstract presented at the European Respiratory Society Annual Congress; 2011 Sep 24 ‐ 28;
Amsterdam, Netherlands.
14. Papi A, Paggiaro PL, Nicolini G, Vignola AM, Fabbri LM. Inhaled Combination Asthma
Treatment versus Symbicort® (ICAT SY) Study Group. Beclomethasone/formoterol versus
budesonide/formoterol combination therapy in asthma. Eur Respir J 2007; 29: 682-9.
15. Papi A, Paggiaro P, Nicolini G, Vignola AM, Fabbri LM. ICAT SE study group.
Beclomethasone/formoterol vs. fluticasone/salmeterol inhaled combination in moderate to
severe asthma. Allergy 2007; 62: 1182-8.
16. NICE TA 138. Corticosteroids for the treatment of chronic asthma in adults and children aged
12 years and over. March 2008. http://guidance.nice.org.uk/TA138
17. Shepherd J, Rogers G et al on behalf of the Peninsula Technology Assessment Group
(PenTAG), Peninsula Medical School and Southampton Health Technology Assessments
Centre (SHTAC),Wessex Institute for Health Research and Development (WIHRD), University
of Southampton. NICE Assessment Report - ICS and LABAs for the treatment of chronic
asthma in adults and children aged 12 years and over: Systematic review and economic
analysis. December 2006. http://www.nice.org.uk/nicemedia/live/11705/35060/35060.pdf
18. FitzGerald JM, Boulet LP, Follows RMA. The CONCEPT trial: A 1-year, multicenter,
randomized, double-blind, double-dummy comparison of a stable dosing regimen of
salmeterol/fluticasone propionate with an adjustable maintenance dosing regimen of
formoterol/ budesonide in adults with persistent asthma. Clin Ther 2005; 27(4):393-406.
19. Vogelmeier C, D'Urzo A, Pauwels R, Merino JM, Jaspal M, Boutet S et al.
Budesonide/formoterol maintenance and reliever therapy: An effective asthma treatment
option? Eur Respir J 2005; 26(5):819-828.
20. Aalbers R, Backer V, Kava TTK, Omenaas ER, Sandstrom T, Jorup C et al. Adjustable
maintenance dosing with budesonide/formoterol compared with fixed-dose
salmeterol/fluticasone in moderate to severe asthma. Current Medical Research & Opinion
2004; 20(2):225-240.
21. Cates CJ, Lasserson TJ. Regular treatment with formoterol and an inhaled corticosteroid
versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma:
serious adverse events. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.:
CD007694. DOI: 10.1002/14651858.CD007694.pub2.
22. Lasserson TJ, Ferrara G, Casali L. Combination fluticasone and salmeterol versus fixed dose
combination budesonide and formoterol for chronic asthma in adults and children. Cochrane
Database of Systematic Reviews 2011, Issue 12. Art. No.: CD004106. DOI:
10.1002/14651858.CD004106.pub4.
23. Australian Public Assessment Report for Budesonide/eformoterol fumarate dehydrate. Oct
2010 http://www.tga.gov.au/pdf/auspar/auspar-Symbicort®.pdf
24. NICE website, accessed 24/10/12 http://www.nice.org.uk
25. National Prescribing Centre, Key therapeutic topics- medicines management options for local
implementation, April 2012 Version 4.2
26. Drug Tariff August 2013
27. SMC. Beclometasone 100mcg, formoterol 6mcg metered dose inhaler (Fostair®). 373/07,
January 2008.
http://www.scottishmedicines.org.uk/files/beclometasone%20dipropionate%20%20Fostair®%2
0Abbreviated%20FINAL%20April%202007%20amended%20February%202008%20for%20we
bsite.pdf
28. SMC. fluticasone/formoterol (Flutiform®). 736/11, October 2012.
http://www.scottishmedicines.org.uk/files/advice/fluticasone_Flutiform®.pdf
29. lipworth BJ, Systemic adverse effects of inhaled corticosteroid therapy: A systematic review and
meta-analysis. Arch Intern Med. 1999 May 10;159(9):941-55.
30. ESNM22: Asthma: beclometasone/formoterol (Fostair®) for maintenance and reliever treatment,
National Institute for Health and Care Excellence, 25 June 2013.
31. Electronic Medicines Compendium (http://www.medicines.org.uk/emc/), accessed 20/8/13 for the
Summary of Product Characteristics of Seretide 100,250, 500 Accuhaler; Seretide 50, 125, 250
Evohaler; Fostair 100/6 inhalation solution; Symbicort Turbohaler 400/12 inhalation powder;
Symbicort Turbohaler 200/6 inhalation powder; Symbicort Turbohaler 100/6 inhalation powder.
32. Primary Care Switch Protocol – Low and Moderate Dose ICS/LABA Combination Inhalers Switch to
Fostair® 100/6 Inhaler, PrescQipp (East of England) Bulletin 5, issued June 2011, reviewed July
2011
33. Low, Moderate and High dose ICS/LABA Combination Inhalers Switch to Flutiform® Inhaler,
PrescQipp (East of England) Bulletin 23, issued December 2012.
N:\Medicines Management\JPC from Aug 13\Approved Bulletins and Papers\Sept 13\Bulletin 176 Choice of ICS
LABA Updated Sept 13.docx
Information on expected number of
inhalers used annually at stated doses
ICS/LABA Combination
Inhaler
Dose
Seretide® 250 Evohaler
Seretide® 250 Evohaler
Seretide® 125 Evohaler
Seretide® 125 Evohaler
Seretide® 50 Evohaler
Seretide® 50 Evohaler
Seretide® 500 Accuhaler
Seretide® 250 Accuhaler
Symbicort® 400/12
Turbohaler
Symbicort® 200/6
Turbohaler
Symbicort® 100/6
Turbohaler
Symbicort® 100/6
Turbohaler
Fostair® 100/6 Inhaler
Fostair® 100/6 Inhaler
2 puffs bd
1 puff bd
2 puffs bd
1 puff bd
2 puffs bd
1 puff bd
1 puff bd
1 puff bd
1 puff bd
Approximate number to
be prescribed in 12
months
12
6
12
6
12
6
12
12
12
1 puff bd
6
2 puffs bd
12
1 puff bd
6
2 puffs bd
1 puff bd
12
6
Can they use it? Do they use it?
Under use of ICS / LABA combination inhalers in asthma may lead to poor control
and frequent exacerbations, and in some cases, patients may rely on
bronchodilators.
Under use of ICS / LABA combination inhalers may indicate that an attempt can be
made to step down treatment in line with BTS/SIGN asthma guidance.
Over-ordering of ICS / LABA combination inhalers could indicate that the patient is
taking a higher ICS dose than prescribed.
Over use of short-acting β2 agonist (SABA) inhalers, e.g. salbutamol- Good asthma
control is associated with little or no need for using a SABA. Therefore a marker of
poorly controlled asthma is using 2 or more SABA inhalers per month or more than
10-12 puffs per day. These patients should be excluded from stepping down therapy
and should have their asthma management reviewed.
Where a LABA inhaler and ICS inhaler are prescribed separately, they should be
issued in similar quantities. Where this is not the case, consider prescribing an ICS /
LABA combination inhaler.
BCCG Quick Reference Guide for Management of Chronic Asthma in Adults June 2013
The AIM OF ASTHMA TREATMENT is maximum control of the disease with minimal side-effects. This is defined as




No daytime symptoms
No need for rescue medication
No limitations on activity including exercise
FEV1 and/or PEF>80% predicted or best




No night time awakening due to asthma
No exacerbations
Normal lung function (in practical terms)
Minimal side effects from medication
REGULAR PATIENT REVIEW AND FOLLOW-UP requires routine clinical review with the patient on at least an annual basis. Symptomatic
asthma control is best monitored using validated tools such as the Asthma Control Questionnaire, the Asthma Control Test or the RCP ‘3
Questions’ (QOF 2012/13 id ASTHMA 9)1, as follows: In the last week (RCP 3 questions) or month (ACT):
1. Have you had difficulty sleeping because of your asthma symptoms? (including cough)
2. Have you had your usual asthma symptoms during the day? (breathlessness, wheeze, cough, chest tightness)
3. Has your asthma interfered with your usual activities? (housework, school/work, etc.)
THE STEPWISE APPROACH
1. Start treatment at the step most appropriate to initial severity
2. Achieve early control
3. Maintain control by stepping UP treatment as necessary, stepping DOWN when control is good
Review every 3 months -If stable, decrease inhaled steroid dose (by approx. 25-50% each time). Always assess diagnosis, assess
adherence/compliance, inhaler technique, smoking status and reduce existing or new triggers prior to stepping up. ENSURE ANNUAL
INFLUENZA VACCINATION as per DH guidance.
PERSONALISED ACTION PLANS
Patients with asthma should receive education and a written action plan. Those admitted with severe asthma should receive a personalised
action plan on discharge from a clinician with expertise in asthma management
1
The percentage of patients with asthma who have had an asthma review in the preceding 15 months that includes an assessment of asthma control using the 3 RCP questions
http://www.nhsemployers.org/Aboutus/Publications/Documents/QOF_2012-13.pdf
BCCG Quick Reference Guide for Management of Chronic Asthma in Adults June 2013
STEP 1*
Mild intermittent
asthma
STEP 2
Regular preventer therapy
STEP 3
Initial add on therapy
STEP 4
Persistent poor control
STEP 5
Continuous or frequent use of
oral steroids
Review treatment every 3 months: Step up to improve control as needed and Step down to maintain lowest controlling step
Inhaled short acting
Add inhaled corticosteroids (ICS) 200Addition of long acting beta2 agonist
If concordance is a potential issue consider
beta2
800mcg*.
(LABA).
Symbicort+ SMART therapy.
Start at dose appropriate to severity.
Good response – continue LABA
If not consider trials of increasing ICS
agonist as required
Some benefit but control still
400mcg* is an appropriate
(including LABA) up to 2000mcg* daily or add
starting dose for many patients
inadequate increase ICS to
montelukast or theophylline MR. Patients using
800mcg* daily
HIGH DOSE ICS should be given a steroid
No response- stop LABA and
card.
Consider referral to
increase ICS to 800mcg* daily.
asthma clinic
If necessary trial montelukast or
branded theophylline
MDI
Salbutamol 100mcg /
Clenil® 100 modulite ± spacer
FIRST LINE is Fostair® inhalation
Seretide® 250 Evohaler + spacer 2p bd
(Metered
dose inhaler cfc-free ±
2p bd (£7.42)2
100/6 ±aerochamber Plus 1p bd to
(£59.48)4
Dose
spacer 1-2 puffs prn
2p bd
inhaler)
(£1.50/inhaler)
(£14.66-29.32)4
Refer to asthma
Seretide® Evohaler 50/25 2p bd
specialist
(£18)4
increasing to Seretide Evohaler ±
spacer 125/25 2p bd (£35)4
Breath
Salamol easi-breathe®
QVAR® 50 easibreathe (£7.74)4 or
actuated
1-2 puffs/prn
autohaler 50mcg 2p bd (£7.87)4
inhaler
(£6.30/inhaler)
QVAR may be substituted for cfc BDP
Or
MDI at 1:2 dosing.
Airomir autohaler®
1.If control is good on beclometasone1-2 puffs prn
CFC, change to half the dose of Qvar®
(£6.02/inhaler)
2.If control is not good on
beclometasone-CFC, change to Qvar®
at the same daily dose
Dry
SECOND LINE is Symbicort®
Salbutamol Easyhaler
Beclometasone 100 Easyhaler 1p bd
Seretide® 500 Accuhaler
powder
200/6 Turbohaler 2p BD (£38)4
100mcg (£3.31/inhaler)
(£5.36)4 or
1 blister bd (£40.92)4
inhaler
Terbutaline 500mcg
Budesonide 100 Easyhaler 1p bd
+SMART > 18yrs = 1p bd and prn
Symbicort® 400/12
Turbohaler 1 puff prn up
(£8.86)4 or
(12p max/day)
Turbohaler 2p bd (£76)
to qds (£6.92/inhaler)
Budesonide 100 Turbohaler 1p bd
Seretide® 100 to 250 Accuhaler, 1p
bd (£18 - £35)4
(£11/inhaler)4
Always review diagnosis (consider COPD or dysfunctional breathing), encourage smoking cessation and consider treating rhinitis before stepping up.
CHECK INHALER TECHNIQUE, EXPOSURE TO NEW OR EXISTING TRIGGERS and CONCORDANCE AT EACH REVIEW AND PRIOR TO STEPPING UP
Use inhaler-training tool e.g. InCHECK Dial to check correct inspiratory flow rates
NOTES
*Beclometasone diproprionate equivalent
*Move up to step 2 if:
1. Inhaled short acting β2 agonist needed three times a week or more.
2.Night time symptoms more than once per week
3.Symptomatic 3 times per week or more
4.Has had an exacerbation in last 2 years
2
All prices are approximate for a 30 day supply based on May 2013 Drug Tariff and BNF 65 for a sample of commonly prescribed items. The most cost-effective option has been highlighted. Other inhaler devices are
available, however details of every inhaler cannot be included for practical reasons.
Asthma Control Test7
Asthma Control Test™ is a simple five-point questionnaire, which is self-completed
by patients. Each item is scored from one (poor control) to five (good control) and the
scores added to give a final score with a maximum of 25.
The Asthma Control Test Five Questions are:
1. During the past 4 weeks, how often did your asthma prevent you from
getting as much done at work, school or home?
2. During the past 4 weeks, how often have you had shortness of breath?
3. During the past 4 weeks, how often did your asthma symptoms
(wheezing, coughing, chest tightness, shortness of breath) wake you up
at night or earlier than usual in the morning?
4. During the past 4 weeks, how often have you used your reliever inhaler
(usually blue)?
5. How would you rate your asthma control during the past 4 weeks?
The QOF now explicitly requires that the following three RCP questions are used as
an effective way of assessing symptoms 8:
In the last month:
 Have you had difficulty sleeping because of your asthma symptoms (including
cough)?

Have you had your usual asthma symptoms during the day (cough, wheeze,
chest tightness or breathlessness)?

Has your asthma interfered with your usual activities (for example,
housework, work/school, etc.)?
An answer of no to all three indicates well controlled asthma.
Practices may want to consider carrying out an asthma control test on all patients
suitable to stepping down treatment prior to changing treatment.
Link to asthma control test: www.asthma.org.uk/applications/control_test/
References
1.
2.
3.
4.
5.
6.
7.
8.
British Thoracic Society: British guidelines on the management of asthma. Mar 2008, revised May 2011.
http://www.sign.ac.uk/pdf/qrg101.pdf
New Guidelines for the treatment of asthma. MeReC Bulletin 1997 8(4)
BNF 63 March 2012
NPC. MeReC Extra no.44. ICS plus LABA not recommended in steroid naive patients with persistent asthma.
March 2010.
NPC. MeReC Bulletin Vol 19;2. Current issues in the drug treatment of asthma. Sept 2008.
Drug Tariff. May 2013 http://www.ppa.org.uk
Asthma Control Test www.asthma.org.uk/applications/control_test/
NICE Clinical Indicator Guidance- Asthma http://www.nice.org.uk/nicemedia/live/13546/55627/55627.pdf
Asthma Control Test™ (ACT) is a simple five-point questionnaire, which can be selfcompleted by patients. Each item is scored from one (poor control) to five (good control) and
the scores added to give a final score with a maximum of 25.
Poor
Question
control
1
2
3
4
1
During the past 4 weeks, how often did your asthma prevent you
from getting as much done at work, school or home?
2
During the past 4 weeks, how often have you had shortness of
breath?
3
During the past 4 weeks, how often did your asthma symptoms
(wheezing, coughing, chest tightness, shortness of breath) wake
you up at night or earlier than usual in the morning?
4
During the past 4 weeks, how often have you used your reliever
inhaler (usually blue)?
5
How would you rate your asthma control during the past 4 weeks?
Total ACT score
ACT READ code to add to the clinical system is 38DL.

A score of less than 20 means the patient’s asthma may not have been controlled during the
past four weeks. You should recommend an asthma action plan to help improve asthma
control.

A score between 20 and 24 mean the patient’s asthma appears to have been reasonably wellcontrolled during the past four weeks. However, the patient may still be experiencing symptoms
you can give advice on.

A score of 25 means the patient’s asthma appears to have been under control over the last four
weeks. However, the patient may still be experiencing symptoms you can give advice on.
Consider stepping down medications if appropriate.

Asthma is a changeable condition and it would be worth repeating the test in the future to
check how well the patient’s asthma is controlled.
1. Peak Flow: Measuring peak flow can give an indication of whether the medication
currently prescribed for the patient is working and it may help to identify problems with
inhaler technique or compliance.
2. Inhaler Technique: A government-commissioned study by the Medicines Partnership has
suggested that poor knowledge of how drugs and inhalers work, coupled with complex
prescribing regimes, are contributory factors in up to half of the 1,400 fatal cases of
asthma in the UK each year.
3. Patient Compliance: The Medicines Partnership also highlights 'non-compliance' as a
huge problem. An estimated 1.5 million people with asthma follow their prescriptions only
a third of the time, with under-16s the least likely to follow treatment instructions. Among
people with asthma the most typical example of non-compliance is under-use of preventer
medication.
4. Medication on patient records is current: It is important to ensure that the medication
section in the patient’s records is correct and up to date. This will help to minimise
medication errors and may help to identify potential compliance issues.
5. Recommendation: Please enter your recommendation from this review. Can the patient
be stepped down? Or should they continue with their current medication and dose?
6. Vaccinations: Patients with asthma should have annual flu and one dose of
pneumococcal vaccination unless asplenic or other risk factors. Colds and flu are triggers
for around 90% of people with asthma and if they catch viruses during the colder months
their asthma can get much worse. This can result in periods of prolonged illness or even
hospital admissions.
7. Smoking Cessation: Smoking is dangerous for everyone, but particularly for people with
asthma. It can irritate the lungs and bring on asthma symptoms. It is important that
patients with asthma who smoke are offered advice on smoking cessation.
8. Review date: Patients with asthma should be reviewed every 6-12 months unless they
have exacerbations, in which case the patient should be reviewed more frequently.
Good
control
5
Audit and Review of Adults with Asthma on High Dose Inhaled Corticosteroids
(ICS) Patient Review Checklist
Patient name
Patient ID number
ICS or ICS / LABA inhaler used
Dose
1
Asthma Control Test completed Y/N
2
Peak Flow
3
Inhaler Technique checked? Y/N
4
Patient Compliance checked? Y/N
5
Medication on prescribing screen is current
Y/N
6
Recommendation:
1. Step down
2. No change
3. Other: (state)
7
Has patient had annual flu vaccination? Y/N
8
Has patient had annual pneumococcal
vaccination? Y/N
9
If smoker, offer smoking cessation advice /
support
10
Agree and set new review date
Each patient should be reviewed every 6-12 months unless the patient has an
exacerbation.
Name of person conducting review________________________________________
Review the need for ICS/LABA inhaler in COPD patients with an FEV1≥50%
Patient name
Review conducted by_________________
Patient ID number
[COPD diagnosed since 1.4.2011 requires post bronchodilator spirometry 3 months before or
up to 12 months after diagnosis; all COPD patients require FEV1 every 12 months.]
BMI
Date:
/
/
CAT Score (www.catestonline.co.uk )
Date:
/
/
FEV1 before bronchodilation
Date:
/
/
FEV1 after bronchodilation
Date:
/
/
FEV1 % predicted
Date:
/
/
Number of COPD exacerbations in past year
Date:
/
/
Inhaler Compliance (Tick one)
Poor compliance with inhaler
Good compliance with inhaler
Inhaler Technique (Tick one)
Inhaler technique - poor
Inhaler technique - moderate
Inhaler technique – good
Declined to perform inhaler technique
Uses spacer device
Rescue medication prescribed (Tick which applies):
Smoking status:
Smoker
Number of pack years:
Ex-smoker
Date:
Flu vaccination given:
Pneumococcal vaccination given:
Referred for pulmonary rehabilitation:
Steroids
/
/
Antibiotics
/
/
Never-smoker
/
/
Yes
Yes
Yes
No
No
No
Date:
/
MRC Breathlessness Scale (Tick which applies):
Grade 1: Not troubled by breathlessness except on strenuous exercise
Grade 2: Short of breath when hurrying or walking up a slight hill
Grade 3: Walks slower than contemporaries on the level because of breathlessness, or has to
stop for breath when walking at own pace
Grade 4: Stops for breath after about 100m or after a few minutes on the level
Grade 5: Too breathless to leave the house or breathless when dressing or undressing
Oxygen saturation at periphery (%)
COPD Review: Comment Note


Stop ICS / LABA and start LAMA
Stop ICS / LABA and start LABA

No change recommended
/
/
/
BCCG Practice Audit of COPD Prescribing 2013: Suggested actions
where problems have been identified
The BCCG COPD audit undertaken by practices in 2013 revealed a number
of suggested actions for practices. These are given in Table 1 below along
with some good practice points. As an aside, the audit did not ask practices to
classify a patient’s COPD into mild, moderate or severe because it was
thought that this would be too time consuming. However, practices may wish
to do this for their patients and re-analyse triple therapy prescribing.
Table 1: Some suggested actions for practices arising from COPD audit
Suggested action
 Ensure the diagnosis of COPD is correct.









Good practice points
 Ensure health care professional has
undertaken spirometry training.
 Refer to ICOPD team where
diagnosis is uncertain or spirometry
interpretation is required.
For patients with a dual diagnosis of asthma and
COPD, confirm correct diagnosis or refer to
Integrated COPD service for confirmation of
diagnosis.
More patients should be prescribed home rescue
packs (steroids and antibiotics) to treat
exacerbations- this has been shown to help
prevent hospital admissions.

Provide the patient leaflet on
exacerbations and ensure patients
understand the symptoms of an
exacerbation. If the patient cannot
swallow a large 500mg capsule of
amoxicillin, prescribe 2 x 250mg
capsules instead.
Administer flu and pneumococcal vaccinations if
these have not been given.
All smokers should be actively encouraged to
stop smoking.

Stopping smoking should be viewed
as part of their treatment for COPD
and not a lifestyle choice.
Follow treatment algorithm on page 7
of the COPD guidelines.
Review the need for an inhaled corticosteroids in
patients with an FEV1≥50% as per the treatment
algorithm as these patients should be on a LAMA
or LABA alone.
Patients who have had asthma and have now
developed COPD, step down asthma treatment
in line with BTS asthma management guidelines
when initiating treatment with a LAMA (this is to
ensure that patients don’t go straight onto triple
therapy)
When prescribing a new medicine do not add it to
the repeat template until you have assessed its
effectiveness after four weeks.
Optimise treatment of patients with COPDdiscontinue ineffective treatments before adding
new ones.
Ensure all patients have their inhaler technique


Follow guidance on page 9 of the
COPD guidelines.

If necessary, the medicine can go on
repeat, but ensure it cannot be reissued until reviewed.

Ask patients to bring all their inhalers








checked and are using their medication as
prescribed (Can they use it? Do they use it?).
Ensure all healthcare professionals checking
inhaler technique are fully aware of how to use
the inhalers and have their inhaler technique
assessed regularly by peers.
Prescribe an aerochamber for patients who have
difficulty using their MDI or who are on high dose
ICS.
For patients prescribed a LAMA plus ICS,
consider stepping down the ICS inhaler as this
treatment option is not part of the NICE treatment
pathway.
If the patient is being prescribed a short acting
muscarinic antagonist (SAMA) as well as a
LAMA, then discontinue SAMA and ensure that
all prn therapy is with a SABA (such as
salbutamol or terbutaline).
Review patients on ICS monotherapy and initiate
LAMA (if at appropriate stage of pathway) then
step down and eventually discontinue the ICS.
Consider whether co-morbidities and interactions
with other drugs may be affecting the patient’s
willingness or ability to use their medicines
correctly.
For patients with co-morbidities, consider
whether treatment is optimal, such as:
o For patient with cardiac rhythm disorders,
do not prescribe tiotropium Respimat®
and for patients on this device, monitor for
the development of new cardiac rhythm
disorders.
o For patients with established diabetes or
osteoporosis consider whether a high
dose ICS is worsening their condition.
For patients suffering adverse effects of high
dose inhaled corticosteroids, consider discussion
about stepping down treatment or refer to the
ICOPD service.
to their review appointment.

Ensure patients know how to use the
spacer and how to clean it.

Page 9 of the COPD guidelines.

Ensure the SAMA is removed from
repeat medication.

Page 9 of the COPD guidelines.

Give patients the information on
adverse effects.

Review whether the patient has had
pneumonia in the past whilst on high
dose steroids.
Karen Homan (on behalf of BCCG Medicine Management Team)
27 January 2014
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COPD Audit Reports\Actions from BCCG Practice Audit of COPD Prescribing 2013 v3.docx