Audit and Review of Adults with Asthma on High Dose Inhaled Corticosteroids
Background
Inhaled corticosteroids (ICS) are safe and effective for the prevention of symptoms of
asthma when used regularly at the recommended doses. The British Thoracic
Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) asthma
guidelines recommend that regular inhaled corticosteroids are introduced if a patient
requires short acting bronchodilator therapy more than twice a week, or if there are
night-time symptoms more than once a week, or if there has been as exacerbation in
the last 2 years. Regular use of inhaled corticosteroids reduces the risk of
exacerbation of asthma.
However, prolonged treatment with ICS at high doses carries a risk of systemic side
effects such as adrenal suppression and a reduced bone mineral density
predisposing patients to osteoporosis. There have been reports of a small risk of
glaucoma and cataracts with prolonged high doses of inhaled corticosteroids,
together with an increased risk of developing diabetes. Hoarseness, dysphonia,
throat irritation, and candidiasis of the mouth or throat may occur. Paradoxical
bronchospasm has been reported very rarely. Anxiety, depression, sleep
disturbances, behavioural changes including hyperactivity, irritability, and aggression
(particularly in children) have been reported; hyperglycaemia (usually only with high
doses), cataracts, skin thinning and bruising have also been reported.
High dose inhaled corticosteroids are introduced at step four of the BTS/ SIGN
guidelines and are defined in the guidelines (given through metered dose inhaler)
as: > 800micrograms beclometasone (Clenil Modulite®)
 > 400 micrograms beclometasone (Qvar®)
 > 800 micrograms budesonide
 > 400 micrograms fluticasone
The BTS / SIGN asthma guidelines recommend stepping treatment down when
asthma control is stable for at least 3 months to prevent over treating and to find and
maintain at the lowest controlling step. The lowest possible dose of ICS which
controls the symptoms of asthma should be used, where the dose should be
reduced slowly, (consider a reduction every 3 months, decreasing the dose by 25 to
50% each time).
Aim
To optimise the use of high dose inhaled corticosteroids for asthma in adults and
ensure that patients can use their device correctly and that they are being prescribed
safely and effectively.
Written by: Karen Homan, Sally-Jane Hamilton 2014, BCCG MMT
Audit Objectives
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Patients with a repeat prescription for high dose inhaled corticosteroid have a
documented indication for prescribing it.
Patients have had an asthma review within the last year.
Patients are able to use their inhalers correctly.
Patients requiring high dose inhaled corticosteroid treatment are prescribed
the lowest dose that controls their symptoms.
Patients requiring high dose inhaled corticosteroid treatment are reviewed
after three months of therapy.
Patients using more than 12 short-acting relievers in the previous 12 months
have an urgent review of their asthma control.
Patients prescribed an ICS inhaler and a LABA inhaler separately should
preferably be prescribed this as a combination inhaler.
Patients requiring more than two courses of systemic steroids (oral or iv) in
the previous 12 months or who require management using British Thoracic
Society (BTS) stepwise treatment 4 or 5 to achieve control are identified and
referred to a specialist asthma service.
Patient Identification
Search for all adult patients (over 12 years old) on a repeat prescription for high dose
inhaled corticosteroid, including those on compound preparations such as
Symbicort® and Seretide® (see Appendix 1 for SystmOne® search procedure).
Data Collection
See Appendix 2 for data collection spread sheet.
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Correct diagnosis recorded – Yes or No
Asthma review within the last 12 months – Yes or No
Inhaler technique check documented in the last 12 months
Documented evidence of step down attempted in last 3 months- Yes or No
Any evidence of symptoms of systemic side effects such as adrenal
suppression, evidence of decreased bone mineral density (fractures) or
glaucoma.
Number of ICS inhalers (including ICS/LABA inhalers) issued in the past 12
months.
Number of SABA inhalers issued in the past 12 months.
ICS inhaler and LABA inhaler prescribed separately – Yes or No
More than 2 courses of systemic steroids in previous 12 months
Patients on step 4 or 5 of BTS who have not been referred to a specialist
asthma service.
Written by: Karen Homan, Sally-Jane Hamilton 2014, BCCG MMT
Analysis
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Percentage of patients with correct diagnosis recorded.
Percentage of patients with an asthma review within the last 12 months.
Percentage of patients that have had their inhaler technique checked and
documented.
Percentage of patients on high dose inhaled corticosteroid with documented
evidence of step down attempted in last three months.
Percentage of patients with symptoms of ICS adverse effects such as low
bone mineral density, diabetes, glaucoma or adrenal suppression.
Percentage of patients with less than 12 ICS or ICS/LABA inhalers in the last
12 months.
Percentage of patients using less than 4 SABA inhalers in past 12 months.
Percentage of patients using more than 12 SABA inhalers in past 12 months.
Percentage of patients prescribed an ICS inhaler and a LABA inhaler as
separate inhalers.
Percentage of patients prescribed more than 2 courses of systemic steroids
(oral or iv) in the previous 12 months.
Percentage of patients on step 4 or 5 of BTS who have not been referred to a
specialist asthma service.
Possible Action Plan
For each patient, record what action is required. Some suggested actions include:
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If incorrect diagnosis recorded, then read code diagnosis.
If no review within the last 12 months, review patient.
If inhaler technique has not been checked, review patient.
If patient on high dose inhaled corticosteroid with no documented evidence of
step down attempted in last three months, review patient and step down if
clinically appropriate.
If patient using less than 12 ICS or ICS/LABA inhalers in the last 12 months,
review patient and consider suitability for stepping down ICS or whether they
are adhering to their preventer therapy.
If patient not using SABA, consider suitability for stepping down inhaled
corticosteroid if patient is on one.
If patient has used more than 12 SABA inhalers in the past 12 months,
urgently review patient as asthma may not be controlled.
If patient is on a separate ICS inhaler and LABA inhaler, review patient and
prescribed ICS / LABA combination inhaler if both components are required.
If patient is experiencing side effects, review treatment.
If patient has required more than 2 courses of steroids in the previous 12
months or at step 4 or 5 of BTS and NOT been referred to a specialist asthma
service, make referral.
Written by: Karen Homan, Sally-Jane Hamilton 2014, BCCG MMT
References
 BNF May 2014 accessed on-line at www.medicinescomplete.com user
registration required.
 British Guideline on the Management of Asthma. The British Thoracic Society
and Scottish Intercollegiate Guidelines network. May 2008, revised May 2011.
Accessed via www.brit-thoracic.org.uk
 Why asthma still kills. The National Review of Asthma Deaths (NRAD). Royal
College of Physicians. May 2014.
Written by: Karen Homan, Sally-Jane Hamilton 2014, BCCG MMT
Appendix 1
Running the SystmOne® Search
1. In SystmOne enter Clinical Reporting
Clinical Reporting)
(in the top toolbar select Reporting 
Searching for the high dose inhalers:
2. Click ‘New’ to open a new search. Give the search a name.
3. From the left hand menu select Demographics  Age
4. Tick the box ‘Current age’ and enter Over 12 Years
5. From the left hand menu select Clinical  Repeat Templates
Written by: Karen Homan, Sally-Jane Hamilton 2014, BCCG MMT
6. Then select Exact drugs, and click on the brown bottle icon
7. The ‘Select Multiple Drugs or Appliances’ window opens. In the search box type
the first few letters of the drug name you are searching for and press Enter
8. Click on the drug you want to select to highlight it and click on the black arrow to
move it into the right hand pane
9. Continue to select all the drugs and move them into the right hand pane. Make
sure you search both brand and generic:
 Beclometasone 250mcg inhalers
 Asmabec Clickhaler 250mcg
 Clenil 250mcg
 Beclometasone 400mcg inhalers
 Pulvinal 400mcg
 Becodisks 400mcg
 Budesonide 400mcg inhalers
 Pulmicort 400mcg
 Easyhaler budesonide 400mcg
 Budesonide/Formoterol Inhaler 400/12
 Symbicort® Turbohaler 400mcg/12mcg
 Fluticasone 125mcg inhalers
 Fluticasone 250mcg inhalers
 Fluticasone 500mcg inhalers
 Flixotide 125mcg Evohaler
 Flixotide 250mcg Evohaler
 Flixotide 250mcg Accuhaler
 Flixotide 500mcg Accuhaler
 Fluticasone/Formoterol Inhaler 250/10mcg
 Flutiform® Inhaler 250/10mcg
 Fluticasone/Salmetrol Inhaler 125/25mcg
 Fluticasone/Salmeterol Inhaler 250/25mcg
 Fluticasone/Salmeterol Inhaler 500/50mcg
 Fluticasone/Salmeterol Inhaler 250/50mcg
 Seretide® 125 Evohaler 125mcg/25mcg
 Seretide® 250 Evohaler 250mcg/25mcg
 Seretide® 500 Accuhaler 500mcg/50mcg
Written by: Karen Homan, Sally-Jane
Hamilton 2014,
MMT
 Seretide®
250BCCG
Accuhaler
250mcg/50mcg
 Fluticasone /Vilanterol Inhaler 92µg/22µg
 Relvar® Ellipta® 92µg/22µg
 Fluticasone /Vilanterol Inhaler 184µg/22µg
 Relvar® Ellipta® 184µg/22µg
10. When you have selected all the drugs click OK to close the Selection window
11. Click OK to complete & close the search
To join the search to the Asthma Register:
12. Click ‘New’ to open a new search. Give the search a name
13. In the left hand pane select Report Joining  Join to two reports
14. Click on ‘Select report one’
15. Locate your search run above, and double click on it to select it
16. Click on ‘Select report two’
17. Locate the Asthma register (System Wide  QOF  Asthma  AST001
Register) and double click on it to select it
Written by: Karen Homan, Sally-Jane Hamilton 2014, BCCG MMT
18. Back in the search window select the first join type:
(This will search for patients on the selected drugs
AND on the Asthma register)
19. Click OK to complete & close the search
20. Finally, click on the green triangle to run the search
to view the patients
Written by: Karen Homan, Sally-Jane Hamilton 2014, BCCG MMT
, and the magnifying glass
Appendix 2
Data Collection Template - High Dose Inhaled Corticosteroids in Adult Asthmatics Audit
Practice ………………… Number of patients reviewed…………Audit carried out between …/…/2014 and …/…/2014 Audit lead ………………………
Patient
ID
Medication
details
Indication
for ICS
inhaler in
patient
notes?
Asthma
review in
the last
12
months
Inhaler
technique
check
documented?
Yes or No
Step
down
attempted
in the
past 3
months?
ICS
inhaler
Yes
Yes
Yes
Yes
Dose
No
No
No
No
Any side
effects
reported (e.g.
symptoms of
adrenal
suppression,
low bone
mineral
density,
glaucoma,
diabetes)
Number of
ICS inhalers
(include
ICS/LABA
combinations)
issued in past
12 months?
Number
of SABA
inhalers
issued in
past 12
months?
Are LABA
and ICS
inhaler
prescribed
separately?
Yes or No
More than
2 courses
of
systemic
steroids
(oral or iv)
in previous
12
months?
Yes or No
If patient
Action
on step 4 Required
or 5 of
BTS, have
they been
referred to
a specialist
asthma
service?
Yes or No
Yes
Yes
Yes
No
No
No
Appendix 3
Example Patient Information Letter
Practice
Address
Tel:
Fax:
Date
~[Title/Initial/Surname]
~[Patient Address Block]
Dear ~[Title]~[Surname],
We would like to invite you to come for an asthma review as we are currently looking
at the medication we use to treat asthma where a high dose inhaled corticosteroid
preventer inhaler has been prescribed. National recommendations advise us to
review asthma patients regularly to check such things as how well the asthma is
controlled, inhaler technique, how often inhalers are used, any side effects
experienced, whether treatment can be stepped down.
Please book an appointment to see the asthma nurse at your earliest convenience.
Yours sincerely
Practice Nurse