Respiratory Prescribing in Tower

HamletsBill Sandhu

Head of Medicines Management, Tower HamletsMedicines Management Team

Prescribing Expenditure April-November 13-14• Cost of Inhalers for all

indications is £2.6 Million• This is 9% of the total budget

for prescribing• We are spending around

£280K a quarter on fluticasone alone

Change in Prescribing Spend Versus Prevalence

Background – Uncontrolled Asthma is a European Issue

Patients withcontrolled asthma

• Comprises 51% of ICS users across Europe1

• Fewer symptoms and less need for SABAs than patients with uncontrolled asthma2

• No emergency visits2

• Ability to take part in everyday activities2

Patients withuncontrolled asthma

• Comprises 49% of ICS users across Europe1

• Asthma attacks3

• Increased symptoms versus patients with controlled asthma3

• Sleep disturbances3

• Unscheduled healthcare visits: hospitalisations; GP visits3

• Major limitations on activities3

1. Cazzoletti L, et al. J Allergy Clin Immunol 2007;120:1360–7 2. Bateman ED, et al. Eur Respir J 2008;31:143–78

3. Rabe K, et al. Eur Respir J 2000;16: 802–7

ICS = inhaled corticosteroidsSABA = short-acting β2-agonists

Mortality rates for asthma in adults in the UK and Europe

1. Loddenkemper R, ed. European Lung White Book. Part 2, Major Respiratory Diseases, 20032. Asthma UK. http://www.asthma.org.uk/asthma-facts-and-statistics; accessed May 2013

In the UK:• >1,143 deaths from asthma in 2010 • On average three people die from

asthma/day• 90% of these are preventable2

Mortality due to asthma in Europe (per 100,000 population)1

<2 2–4 4–8 >8PortugalGermany

BelgiumRussia

FranceDenmarkSwedenAustria

LithuaniaPoland

UK Spain

IrelandFinland

The NetherlandsGreece

SlovakiaCzech Republic

UkraineSlovenia

What’s the Issue?

Fostair_Inh 100mcg/6mcg (120D) CFF

Seretide 100_Accuhaler 100mcg/50mcg(60D)

Seretide 125_Evohaler 125mcg/25mcg(120D)

Seretide 250_Accuhaler 250mcg/50mcg(60D)

Seretide 250_Evohaler 250mcg/25mcg(120D)

Seretide 50_Evohaler 50mcg/25mcg (120 D)

Seretide 500_Accuhaler 500mcg/50mcg(60D)

Symbicort_Turbohaler 100mcg/6mcg (120 D)

Symbicort_Turbohaler 200mcg/6mcg (120 D)

Symbicort_Turbohaler 400mcg/12mcg (60 D)

£0.00 £10.00 £20.00 £30.00 £40.00 £50.00 £60.00 £70.00 £80.00 £90.00

Cost per Prescription

Inhaler Use

• With the correct technique, only 1/3 of the drug reaches the lungs,

• What happens if inhaler is used incorrectly?• NICE :

– recognises inhaler technique is often neglected– recommends it should be regularly reassessed and re-

taught

• Where more than 1 type of inhalers is used, further problems can occur– studies have found an association with increased errors in

the use of inhalers when different types of inhalers were used

Healthcare professionals have sufficient knowledge of inhaler technique?

• 150 Healthcare professionals (from 74 PCTs and 76 Acute Trusts) asked to demonstrate how to administer a pMDI

• Included hospital doctors, hospital nurses, GPs, practice nurses, hospital and community pharmacy staff

• Of 150 HCPs assessed:• Only 7% could demonstrate all the recognised steps• 75% of HCPs said they were involved in the teaching of inhaler

technique• 48% were prescribers or involved in prescribing• 63% had received some training on inhaler technique in the past

of which 67% said took place > a year agoRef: Thorax Dec 2010 Vol 65 Suppl 4

Requirements for an optimal device

• Simple handling

• Device should facilitate– optimal respiratory flow of drug when device is used

– correct inhalation technique

– patient to verify medication inhalation has been successful

• Dosage and deposition of active ingredient in the lungs must be sufficiently high and reproducible

• Dose counter – so they know how much is left

• Require minimal maintenance itself

• Be acceptable to the patient so they will use it

Virchow JC, et al. Respir Med 2007;102:10–9

What do experts say about the importance of inhaler device selection?

“When prescribing a new inhaler, or reviewing patients’ progress,

inhaler technique should be demonstrated by the clinician, followed

by the patient. Many people forget how to use their inhaler devices,

and this is likely to affect clinical outcomes”

“The least cost effective inhaler device is the one that patients

cannot use. In deciding which device and drug formulation to

prescribe determine the patients ability to use the prescribed device

correctly”

General Practice Airways Group (GPIAG) Opinion Sheet on Inhaler Devices No.20; 2008

BTS recommends the “THREE CHECKS”

• Before initiating or adjusting a new therapy, practitioners should always re-check:– 1. Adherence with existing therapy– 2. Inhaler technique– 3. Eliminate trigger factors

BTS recommends:

1. Prescribe inhalers only after patients have received training in the use of the device by a competent healthcare professional and have demonstrated satisfactory technique

2. Reassess technique as part of the clinical review