How community pharmacy teams can help

There are four main ways pharmacy teams can help:

• Providing counselling and information for patients with newly diagnosed asthma and prescribed AIR or MART
• Supporting the transition to AIR/MART for patients with existing asthma
• Spotting and referring patients who are over-reliant on SABA use
• Supporting patients who are continuing with existing separate ICS and SABA or LABA inhalers.

Advising on asthma and exercise (see panel below) is also an important healthy living element of consultations, as is smoking cessation advice.

Pharmacies will see patients with new prescriptions for ICS/formoterol combination inhalers. The patient’s asthma might be newly diagnosed or they may have been switched to a combination inhaler. Either could prompt a NMS consultation (in England) or support for a patient who is registered for the Medicines: Care and Review (MCR) service in Scotland.

Using a SABA on three or more days a week for symptomatic relief constitutes a pragmatic threshold for uncontrolled asthma. Overuse of SABAs is higher in the UK than in other European countries and is associated with an increased risk of exacerbations and mortality.

Spotting over-reliance on SABA inhalers should be happening in GP practices but some patients may fall through the net. Community pharmacy teams can conduct a simple PMR check when receiving a SABA prescription by working out the ratio of ICS and SABA usage in the past 12 months (e.g. 2 ICS : 6 SABA = urgent referral).

There is a progressive risk of hospital admission when more than three SABA inhalers are prescribed in a year.

The SABINA study highlighted that there were twice the number of asthma attacks in people using ≥3 SABA canisters a year than patients using fewer than three. Referral for change to the AIR or MART regimens should be considered for patients over-reliant on SABAs, or those who are not using their ICS regularly.

If you and your team are working in a deprived area, your patients are more likely to have poorly controlled asthma and to end up being admitted to hospital.

Most SABA inhalers contain 200 puffs so, in theory, this should mean two SABA inhalers a year should be sufficient for a patient who is well controlled, although they may need a couple of extra inhalers (e.g. to keep at another home). Most people should carry their reliever at all times.

Alarm bells should go off when six SABA prescriptions have been collected by a patient in the past six months without a single ICS prescription being issued. Many respiratory specialists argue this should happen sooner – i.e. when two or three canisters are prescribed in a 12-month period without ICS. Inappropriate prescriptions for LABAs alone in asthma should also raise an alarm.

You can ask the patient:

• “How many puffs of SABA have you taken during the past seven days?”
• “Are any night-time and/or day-time symptoms present?”

Use the ‘asthma slide rule’ to indicate the number of SABA puffs per year and the potential number of breathless moments. For example, six SABA canisters = 1,200 puffs per year, which could mean 600-1,200 breathless moments (1 dose = 1-2 puffs of SABA).

Is the patient on any other medication (e.g. NSAIDs, beta-blockers) or exposed to triggers (e.g. tobacco smoke, damp, pollen), which can make the asthma therapy less effective?