The financial squeeze on NHS resources has resulted in generic inhalers becoming an attractive option – but is generic substitution the best option?
As pharmacists, we encourage the use of the cheapest therapeutic agents where there is clear equivalence. What makes active switching to generic inhalers more tricky is being able to ensure that the inhaler provided can be used effectively by patients to maintain their asthma or COPD control.
According to the NHS Business Services Authority, inhaled medications should be prescribed by brand name, while the current NHS COPD guidelines and BTS/SIGN asthma guidelines both recommend that inhalers must not be issued without first teaching and assessing inhaler technique.
Problems that have been occurring include the provision of a DuoResp Spiromax against a generically prescribed formoterol/budesonide dry powder inhaler (DPI), when the intended device was a Symbicort Turbohaler device.
The Spiromax and Turbohaler devices are both DPIs with slightly different delivery methods so, if patients are not informed of the switch and inhaler technique not assessed, they may not be able to use this new device. Additionally, there may be a risk of therapy duplication if patients do not realise that Symbicort and DuoResp contain the same ingredients. The most suitable inhaler device can only be determined when assessed with the patient.
More recently, AirFluSal Forspiro has been launched as a DPI that could be badged as a new generic Seretide, but requires a totally different inhaler technique from the Accuhaler DPI, and so should not be used interchangeably. It is also only licensed for use in COPD (not asthma).
Similar concerns may also arise with pMDIs, despite identical inhaler technique. For example, Sirdupla pMDI was launched in 2015 at an approximate 25 per cent cost saving compared to Seretide pMDI – but there are differences that need to be considered, so patients should be advised of any switch and their agreement sought.
Although there is a cost saving to the dispensing pharmacy by providing a cheaper branded generic inhaler against a generic prescription (e.g. DuoResp Spiromax against a prescription for budesonide/ formoterol), this cost saving is not passed to the NHS, as the pharmacy is still paid for the brand leader. Cost savings to the NHS are only made through branded prescribing and teaching correct inhaler technique.
In summary, prescribers should be encouraged to prescribe inhalers by brand name. Where this has not occurred, pharmacists should check with the patient which device they are expecting to receive.
Before supplying any different device, it is also important to check that the patient has had a structured review to assess inhaler technique. Opportunities to check inhaler technique include the NMS and MUR services.