Document name:
Guidelines for the recommendation of
inhaled medication changes for
COPD
Document type:
Guideline
Staff group to whom it
applies:
Registered Nurses whether they are
prescribers or not who are
recommending changes to inhaled
therapy for COPD
Distribution:
The whole of the Trust
How to access:
Intranet and internet / ward folder
Issue date:
June 2015
Next review:
June 2017
Approved by:
Executive Management Team
Developed by:
Practice Governance Coach
Director leads:
Director of Nursing, Clinical
Governance and Safety
Contact for advice:
Kath Hemming Practice Governance
coach
Julie Booker Lead Nurse for COPD
Sarah Hudson Lead pharmacist
Barnsley BDU
Contents
Content
Introduction and Purpose
Page Number
3
Scope
3
Definitions
3
Duties and Responsibilities
3
Process
4
Training
4
Appendices
1. Algorithm for inhaled therapies
5
2. Notification of Change of
Medication
8
2
Introduction and Purpose
South West Yorkshire Partnership Foundation Trust employs a number of Registered
Nurses who work in specialist or clinically advanced roles who are not registered with the
Nursing and Midwifery Council, (NMC) as a nurse independent prescriber or a nurse
supplementary prescriber. An example of this is COPD Specialist Nurse and Assistant
Community Matrons. These nurses will review and assess on a regular basis patients with a
diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Their assessment, based on
best available evidence and in partnership with the patient, may indicate that a change in
inhaled therapy is recommended.
This guideline has been developed to ensure that Registered Nurses working with patients
with a diagnosis of COPD, who do not hold a nurse independent/supplementary prescribing
qualification and make recommendations to a GP or a nurse independent prescriber based
on their clinical assessment, do so within a framework of best available evidence from NICE
and locally agreed inhaled therapy management algorithm for COPD shown in Appendix 1. It
is recommended as best practice that registered nurses holding an independent prescribing
qualification also prescribe inhaled therapy in line with this algorithm.
Scope
This guideline applies to all Registered Nurses who do not have an independent or
supplementary prescribing qualification, working with patients with a diagnosis of COPD who
have completed a COPD competency assessment framework. This guideline only applies
to inhaled therapies and must be read in conjunction with the Trust Medicines Code.
Definitions
Chronic Obstructive Pulmonary Disease is characterised by airflow obstruction that is not
fully reversible. The airflow obstruction does not change markedly over several months and
is usually progressive in the long term
Nurse Independent Prescriber - Specially trained registered nurses allowed to prescribe
any licensed and unlicensed drugs within their clinical competence.
Nurse Supplementary Prescriber - voluntary prescribing partnership between a doctor
(independent prescriber), a registered nurse (supplementary prescriber) and the patient
where the supplementary nurse prescriber has the ability to prescribe any drug listed in a
patient-specific clinical management plan once the patient has been diagnosed by a doctor
FEV1 – (Forced Expiratory Volume in 1 second) – The amount of air that can be forcibly
expired in the first second of a forced exhalation, it is measured through spirometry.
Duties and Responsibilities
The COPD Lead Nurse is responsible for ensuring appropriate training and supervision is
available for Registered Nurses following this guideline
Registered Nurses reviewing and making recommendations for changes to inhaled therapy
regimes are responsible for ensuring their competencies for the management of patients
with COPD are up to date with current evidence based treatments for the management of
COPD.
Registered Nurses reviewing and recommending changes to inhaled therapy regimes are
responsible for reporting any untoward incident in relation to this guidance in line with the
Trust’s Policy.
3
Process
Following full assessment and in partnership with the patient, recommendation for changes
to inhaled therapy for the management of COPD will be in line with the following algorithms,
(Appendix 1)



Algorithm for inhaled therapies in the management of COPD
Algorithm for inhaled therapies in the management of COPD for patients with
FEV1>50%
Algorithm for inhaled therapies in the management of COPD for patients with FEV1
< 50%
Options for changes to inhaled therapies and recommendations will be discussed and
agreed with the patient. The patient must be made aware that further discussion will be held
with their GP or appropriate nurse independent prescriber.
Recommendations made to the GP or nurse independent prescriber, where possible, must
be made for the inhaled therapy drug group, e.g. long acting beta agonist. However, there
may be times when a particular drug is recommended, for example, where a patient has
been assessed as suitable for a particular inhaler device, and this device is only available for
a particular drug.
Any recommendations for changes in inhaled therapy must have a clear rationale, i.e.
findings of assessment, any changes in observations that is discussed or put in writing to the
GP or independent prescriber and recorded clearly within the patient’s clinical record. A
template letter for recording the rationale and recommendations to changes in inhaled
therapy is available in Appendix 2.
The patient must be informed of the outcome of the recommendation to the GP/ independent
prescriber and be made aware of how they will receive supplies for any changes to the
inhaled therapy.
For situations where the patient requires immediate treatment for an acute exacerbation, the
registered nurse can administer the patient’s own salbutamol via the usual method of
delivery in the following way:


For moderate exacerbations, give 2 – 10 puffs of salbutamol each inhaled separately
and repeated after 10- 20 minutes as necessary. If there is a poor clinical response
after 30 minutes, arrange immediate transfer to hospital.
For acute exacerbations, start treatment as described above and arrange immediate
transfer to hospital.
Training
All Registered Nurses using this guideline must be trained and assessed as competent in
the management of COPD, using an appropriate framework and attend regular updates as
required.
All new staff meeting the above criteria who work with patients with a diagnosis of COPD will
be made aware of these guidelines at local induction.
References
1. NICE Clinical Guideline 101 (2010) Chronic Obstructive Pulmonary Disease
2. Algorithm for Inhaled Therapies in the Management of COPD, (2014) Adapted from
Barnsley Guidance on the Management of COPD
4
Appendix 1
Adapted from Barnsley guidance on the management of COPD and based on NICE Clinical
Guideline 101 – Chronic Obstructive Pulmonary Disease June 2010
Algorithm for inhaled therapies in the management of COPD
For patients with an FEV1<50%
Breathlessness or
Exercise limitation
Exacerbations or
persistent
breathlessness
Use SABA (Salbutamol or Terbutaline) or SAMA (Ipratropium) 2 puffs QDS PRN
Per device: Salbutamol inhaler £1.50, Salbutamol Easyhaler £3.31, Salbutamol
Easibreathe inhaler £6.30, Salbutamol Accuhaler £4.85, Terbutaline turbohaler £6.92,
Ipratropium inhaler £5.56
LABA+ICS in combination inhaler
Fostair (100 micrograms extra-fine beclometasone +
6 mcg formoterol) 2 puffs BD
£29.32
Or
Symbicort 400/12 Turbohaler (400mcg
budesonide + 12 mcg formoterol) 1 puff BD £38.00
Or
Seretide 500 Accuhaler (500mcg fluticasone +
50 mcg salmeterol) 1 puff BD
£40.92
LAMA (in place of SAMA)
st
1 line Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler
device, £33.50 refill pack
nd
2 line Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
Consider using either Salmeterol or
Formoterol, plus Tiotropium or Aclidinium if
inhaled steroid declined or not tolerated.
Persistent
Exacerbations or
breathlessness
LAMA+LABA+ICS
Fostair (100 micrograms extra-fine beclometasone + 6 mcg formoterol)
2 puffs BD
£29.32
Or
Symbicort 400/12 Turbohaler (400mcg budesonide + 12 mcg formoterol)
1 puff BD
£38.00
Or
Seretide 500 Accuhaler (500mcg fluticasone + 50 mcg salmeterol)
1 puff BD
£40.92
Plus
Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler device, £33.50 refill pack
Or
Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
SABA – Short acting beta
agonist
SAMA – Short acting
antimuscarinic
LABA – Long acting beta
Offer therapy
Consider therapy
5
Adapted from Barnsley guidance on the management of COPD and based on NICE Clinical Guideline
101 – Chronic Obstructive Pulmonary Disease June 2010
Algorithm for inhaled therapies in the management of COPD
For patients with an FEV1>50%
Breathlessness or
Exercise limitation
Use SABA (Salbutamol or Terbutaline) or SAMA (Ipratropium) 2 puffs QDS PRN
Per device: Salbutamol inhaler £1.50, Salbutamol Easyhaler £3.31, Salbutamol
Easibreathe inhaler £6.30, Salbutamol Accuhaler £4.85, Terbutaline turbohaler £6.92,
Ipratropium inhaler £5.56
LABA
Exacerbations or
persistent
breathlessness
LAMA (in place of SAMA)
st
1 line Formoterol 12mcg BD
nd
2 line Salmeterol 50mcg BD
Reserve Indacaterol▼ for patients who
require a once daily preparation
Formoterol easyhaler £11.88
Formoterol mdi inhaler £18.04
Formoterol dry powder-Foradil £23.38,
Formoterol turbohaler (Oxis) £24.80
Salmeterol Accuhaler and Evohaler £29.26;
Indacaterol breezhaler £29.26
Persistent
Exacerbations or
breathlessness
st
1 line Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler
device, £33.50 refill pack
nd
2 line Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
LABA+ICS in combination inhaler*
Fostair (100 micrograms extra-fine beclometasone
+ 6 mcg formoterol) 2 puffs BD
£29.32
*Please note: LABA+ICS
combination inhalers are
licensed for patients with
an FEV1<50% (Fostair and
Symbicort) or FEV1<60%
(Seretide). However, can
be considered in patients
who remain symptomatic
despite regular treatment
with a long acting beta
agonist.
Or
Symbicort 400/12 Turbohaler (400mcg
budesonide + 12 mcg formoterol) 1 puff BD
£38.00
Or
Seretide 500 Accuhaler (500mcg
fluticasone + 50 mcg salmeterol) 1 puff BD
£40.92
Consider using either Salmeterol or
Formoterol, plus Tiotropium or Aclidinium if
inhaled steroid declined or not tolerated.
SABA – Short acting beta
agonist
SAMA – Short acting
antimuscarinic
LABA – Long acting beta
agonist
Offer therapy
LAMA
– Long acting
antimuscarinic
Consider
therapy
ICS
– Inhaled
Corticosteroid
LAMA+LABA+ICS
Fostair (100 micrograms extra-fine beclometasone + 6 mcg formoterol)
2 puffs BD
£29.32
Or
Symbicort 400/12 Turbohaler (400mcg budesonide + 12 mcg formoterol)
1 puff BD
£38.00
Or
Seretide 500 Accuhaler (500mcg fluticasone + 50 mcg salmeterol)
1 puff BD
£40.92
Plus
Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler device, £33.50 refill pack
Or
Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
6
Algorithm for Inhaled therapies in the management of COPD
(adapted from NICE Clinical Guideline 101 – Chronic Obstructive Pulmonary Disease (update) June 2010
Prices taken from Drug Tariff June 2014 (30 day costs unless otherwise stated).
Use SABA (Salbutamol or Terbutaline) or SAMA (Ipratropium) 2 puffs QDS PRN
Breathlessness or Exercise
limitation
Per device: Salbutamol inhaler £1.50, Salbutamol Easyhaler £3.31, Salbutamol Easibreathe inhaler £6.30,
Salbutamol Accuhaler £4.85, Terbutaline turbohaler £6.92, Ipratropium inhaler £5.56
FEV1 > 50%
FEV1 < 50%
Exacerbations or persistent
breathlessness
LABA
LAMA (in place of SAMA)
1st
1st
line Formoterol 12mcg BD
2nd line Salmeterol 50mcg BD
Reserve Indacaterol for patients who require a
once daily preparation
Formoterol easyhaler £11.88
Formoterol mdi inhaler £18.04
Formoterol dry powder-Foradil £23.38,
Formoterol turbohaler (Oxis) £24.80
Salmeterol Accuhaler and Evohaler £29.26;
Indacaterol breezhaler £29.26
Persistent
Exacerbations or
breathlessness
Offer Therapy
Consider therapy
LABA+ICS in combination inhaler
line Tiotropium 18mcg OD
Spiriva handihaler £34.87 with inhaler
device, £33.50 refill pack
2nd line Aclidinium 322mcg BD
Eklira Genuair dry powder £28.60
LABA+ICS in combination inhaler
Fostair 2 puffs BD
Or
Seretide 500 Accuhaler 1 puff BD
Or
Symbicort 400/12 Turbohaler 1 puff BD
Consider using either Salmeterol or
Formoterol, plus Tiotropium or Aclidinium if
inhaled steroid declined or not tolerated.
Fostair 2 puffs BD (Fostair mdi £29.32)
Or
Symbicort 400/12 Turbohaler 1 puff BD
(Symbicort 400/12 turbohaler £38.00)
Or
Seretide 500 Accuhaler 1puff BD (Seretide 500
accuhaler £40.92)
Consider using either Salmeterol or Formoterol,
plus Tiotropium if inhaled steroid declined or not
tolerated.
LAMA+LABA+ICS
Use Fostair, Seretide or Symbicort plus
Tiotropium or Aclidinium
Although not included within the NICE guidance, in patients with severe
disease who remain breathless, at the discretion of the Respiratory
Specialist, Seretide or Symbicort may be replaced by Indacaterol plus an
inhaled corticosteroid plus Tiotropium.
SABA=short acting bronchodilator SAMA=short acting antimuscarinic LABA=long acting bronchodilator LAMA=long acting antimuscarinic
Guideline adapted June 2014 Dr H Mahdi, Respiratory Consultant and COPD Lead; Caron Applebee, Medicines Management Pharmacist, Barnsley CCG
Appendix 2
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
Community COPD Service
Notification of Change of Medication
Date:
GP:
Name:
Patient’s Address:
DOB:
Unit No:
Medication:
Increased:
Daily Dose:
Medication:
Decreased:
Daily Dose:
Rationale:
Signature: ……………………………………….. Print Name:
…………………………………
Respiratory Nurse Specialist / COPD Service Lead
From: Community COPD Service
Apollo Court Medical Centre
High Street
Dodworth
Barnsley
S75 3RF
Tel:
01226 209889
Service Lead – Julie Booker
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