Asthma Management Protocol

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1 Asthma Management Protocol USC School of Pharmacy Updated October /24/18 USC School of Pharmacy 1

2 I. Goals and Objectives The goal of the pharmacist-managed Asthma Management Program (AMP) is to partner with primary care physicians in helping patients achieve optimal control of their asthma. The objectives of the AMP are as follows: A. Following educational sessions with pharmacists, patients will be able to: 1. Explain, in lay terms, the pathophysiology of asthma and symptoms of worsening of asthma control 2. Identify and manage patient-specific triggers of asthma exacerbations 3. Identify each asthma medication as a preventer or rescuer 4. Demonstrate proper use of drug delivery devices including metered-dose inhalers, spacer devices, and home nebulizer education. 5. Demonstrate proper use of peak flow meters to establish personal best peak flow rates and daily variability 6. Incorporate peak flow testing into a personalized Asthma Action Plan that includes guidelines for the use of bronchodilators and burst oral corticosteroid therapy B. Ensure that asthma patients are receiving the appropriate long-term control medications, if indicated, at sufficient doses to maintain peak expiratory flow > 80% of personal best and minimize the use of short-acting beta-2-agonist inhalers. C. Keep asthma control within the Rules of 2, e.g., limit daily asthma exacerbations to <2 per week and nocturnal exacerbations to <2 per month. D. Screen IT-based triggers on a routine basis to identify asthma patients who maybe poorly controlled and intervene as appropriate (e.g. hospitalization or ER visit due to an asthma exacerbation, asthmatic on LABA and not ICS, patients with asthma and GERD). E. Continually update physicians on new asthma medications, evidence, and guidelines II. Protocol A. Eligibility / Recruitment 1. Eligible patients are those diagnosed with asthma who receive medical care on a regular basis at the clinic. 2. Patients may be recruited by the following methods: Referral from primary care physicians (PCPs), nurses, or other members of the healthcare team including health educators Referral from information technology (IT) via established triggers such as: a. Persistent asthma patients not receiving an inhaled corticosteroid (ICS) b. Asthma-related hospitalization or ER visit, patient not on ICS c. Asthma patient receiving LABA and not receiving ICS Identification of patients who appear to frequently utilize rescue medication (beta-2 agonists, burst corticosteroid) and / or frequently utilize acute care resources (e.g., > 2 hospitalizations per year, > 3 emergency room visits per year) for asthma exacerbations B. Staffing and Duties / Responsibilities 08/24/18 USC School of Pharmacy 2

3 The AMP will be managed by a clinical pharmacist. Other pharmacy-related personnel may include pharmacy residents, clinical pharmacy technicians, and student pharmacists. Primary care providers will be updated and consulted as outlined below. The expertise of all allied health will be utilized, including but not limited to nurses, nutritionists/dieticians, and case managers. The clinical pharmacist is responsible for ensuring that the elements of care described in this protocol are accurately provided by all pharmacy-related personnel. C. Clinical Privileges (in accordance with California State Pharmacy Law, Section ) 1. Treatment: The clinical pharmacist may initiate, discontinue, and adjust doses of asthma medications as needed to reach treatment goals per NHLBI-NIH EPR 3 Guidelines. The clinical pharmacist may also initiate, discontinue, and adjust doses of other medications for medical conditions that, when poorly-controlled, impair asthma symptom control such as COPD (e.g. anticholinergics, PDE-4 inhibitors), allergic rhinitis (e.g. nasal corticosteroids, antihistamines), and/or GERD medications (e.g. proton pump inhibitors and H2 receptor antagonists). 2. Monitoring: The clinical pharmacist may order laboratory tests necessary for monitoring the safety and efficacy of medications for asthma. Examples of these tests include: general chemistry, liver function tests. D. Technician duties and responsibilities (In accordance with California State Pharmacy Law, Section 4115): The clinical technician will function under the direct supervision of the pharmacist in performing duties and responsibilities that does not require the professional judgment of a pharmacist, which may include, but not limited to: 1. Administrative and clerical duties a. Assist in front end activities pertaining to the patient work flow as necessary b. Prepare and gather relevant information that the pharmacist may need during the patient visit c. Schedule the patients for appointments d. Perform other related duties as assigned 2. Clinical duties a. Assist in back end activities such as vital sign measurement, weight and height b. Gather patient s prescriptions (if available) and pharmacy information c. Follow-up with patients via telephone to collect information about medication use, monitoring, symptom frequency, peak flow testing and values, etc. d. Perform other related duties as assigned E. Clinic Supervision The medical director, designee, or any medical staff member will serve as supervisor for the AMP, and will be available for consultation. F. Description of Asthma Management Services Provided by the Clinical Pharmacist 1. Initial visits (generally visits 1 through 3) a. Explain the pathophysiology of asthma with emphasis on the importance of controlling inflammation. b. Explain the role of each medication available for asthma management including proper monitoring for therapeutic and adverse effects. Differentiate between rescue or reliever vs. preventer or controller medications. 08/24/18 USC School of Pharmacy 3

4 c. Evaluate use of inhalation devices (metered-dose inhalers [MDIs], spacers, nebulizers, etc.) and make corrections as needed. Written instructions will be provided (Appendix A). Provide a spacer device if the patient does not have one, if applicable. d. Screen for triggers of asthma exacerbations (Appendix B) and provide written and verbal information on how to control these (Appendix C). Suggest support for smoking cessation if needed (e.g., NO-BUTTS or NO-FUME for Spanish speakers). e. Fill out the Asthma Control Test (ACT) Questionnaire (Appendix H). Document spirometry test results if available. f. Provide a peak flow meter and instruct patients on how to use it to establish a personal best peak flow and measure daily variability during a 2-week period of good asthma control (Appendix D). g. Classify asthma severity based on asthma symptoms and peak flow results based on NHLBI-NIH guidelines (Appendix E). h. Consider therapy adjustment if any of the following apply. Consult with primary care physician if needed(appendix E). Use of >2 canisters short-acting beta2-agonist per year Experiencing asthma sx s >2x/week OR nighttime sx s > 2x/month Peak expiratory flow <80% of predicted normal 2. Subsequent visits- Establish personal best peak flow and personalized Asthma Action Plan if not already determined, evaluate treatment efficacy and reinforce education a. Review peak flow diary to determine personal best peak flow and daily variability. i. If peak flow results appear to reflect a period of good asthma control (e.g., >80% of predicted personal best), then instructions for self-management of exacerbations will be provided based on a personalized Asthma Action Plan [AAP] (Appendix F). The AAP will include a prescription for oral steroid for emergency use, with specific instructions for use provided in the AAP. ii. If peak flow results are likely not reflective of a period of good asthma control (e.g., <80% of predicted personal best, asthma symptoms), a medication adjustment or a short course of oral corticosteroid may be needed. Following attainment of good asthma control, the patient will be instructed to determine personal best peak flow and daily variability for another 2-week period. b. Screen for asthma symptoms / control and evaluate drug therapy for efficacy and toxicity (Appendix G). Consult with PCP as needed. c. Re-evaluate use of inhalation devices (metered-dose inhalers [MDIs], spacers, nebulizers, etc.) and peak flow meter; make corrections as needed d. Evaluate peak flow test results and use of personalized AAP e. Consider step-up (if treatment goals have not been met) or step-down (if no exacerbations or peak flow reductions < 80% of personal best x 3-6 months) drug therapy if indicated. Consider discharging stable patients (see section 2.J.). G. Patient Education Materials and Supplies 1. Education materials (others will be provided as needed) Appendix A: Appendix C: Appendix D: Appendix F: Instructions for inhaler / spacer use Asthma trigger management Instructions for peak flow meter use Asthma Action Plan 2. Supplies 08/24/18 USC School of Pharmacy 4

5 H. Documentation a. Spacer device b. Peak flow meter with diary All information related to each patient care encounter will be entered into the NextGen electronic health record within 24 hours of the encounter. This communication fulfills the legal responsibility that the clinical pharmacist has in regards to conveying treatment changes to the primary care provider and other members of the healthcare team (California State Pharmacy Law, Section ) I. Performance Data Reporting Quality improvement reports will be generated at least quarterly or other specified frequency focusing on metrics aligned with national standards (NQF, NCQA) such as use of controller medications for patients with persistent asthma, frequency of beta2-agonist use, use of peak flow meters and provision of asthma action plans, etc. J. Suspension of patient care Since the purpose of the AMP is to work with the most challenging patients, all efforts will be made to retain patients in the program. Patients who miss appointments will be contacted by a clinical pharmacy technician and/or other clinic personnel involved in rescheduling missed appointments for rescheduling. As an alternative to in-clinic visits, follow-up with patients may be conducted by phone or through selective home visits depending on each patient s circumstances. In rare cases, patients may be suspended from the AMP, e.g., behavior that is threatening to the safety of the clinical pharmacy team members. K. Exit Criteria Patients who meet asthma treatment goals (e.g., appropriate medications based on asthma severity / control, PEF > 80% of personal best, <2 exacerbations per week, <2 nighttime exacerbations per month, little to no need for short-acting beta2-agonist inhaler, completion of Asthma Action Plan) may be exited from the AMP and continue with ongoing care from the medical home. Patients who may remain in the AMP, in agreement with the primary care team, despite meeting treatment goals include: 1. Patients undergoing major medication changes 2. Patients requiring frequent follow-up to ensure adherence with prescribed treatment 3. Patients with a history of frequent asthma exacerbations leading to hospitalizations or ER visits 08/24/18 USC School of Pharmacy 5

6 Appendix A: Patient Instructions for Proper Inhaler Use (for standard metered-dose inhalers) 1. Remove cap and hold inhaler upright 2. Shake the inhaler 3. Tilt head back slightly (to straighten your airway) and breathe out 4. Position the inhaler in one of the following manners: 5. Press down on the inhaler to release medication as you breath in slowly 6. Breathe in slowly, generally over 3 to 5 seconds. (Note: Most spacer devices include a flow rate signal that alerts you when breathing in too quickly.) 7. Hold your breath for at least 10 seconds, if possible, to allow the medication to reach deeply into your lungs 8. Repeat above for each prescribed puff. When using beta2-agonists or quick relief inhalers, wait 1 minute in between each puff. If using multiple inhalers, wait 5 to 10 minutes between each DIFFERENT TYPE of inhaled medication of possible. 9. If using more than 1 inhaler, use your quick-relief (beta2-agonist) inhaler (for example, albuterol [Ventolin, Proventil, ProAir] first. Beta2-agonist inhalers work quickly to widen your airways, which helps your other inhaled medications reach deeper into your lungs. To avoid common errors, check to be sure that you are doing the following correctly: 1. Breath out BEFORE pressing the inhaler 2. Inhale SLOWLY 3. Breathe in through your mouth, not your nose 4. Press down on your inhaler at the START of inhalation (or within the first second of inhalation) 5. Keep inhaling as you press down on the inhaler 6. Press your inhaler once ONLY while you are inhaling. Remember: 1 breath for 1 puff. 7. Make sure you breathe in evenly and deeply Cleaning your inhaler as needed Look at the hole where the medicine sprays out from you inhaler. If you see powder in or around the hole, clean the inhaler. Remove the metal canister from the L-shaped plastic mouthpiece. Rinse only the mouthpiece and cap in warm water, let them dry overnight. In the morning, put the canister back inside and put the cap back on. Know when to replace your inhaler For medicine you take every day- An example: Say your new canister has 200 puffs (number of puffs is listed on canister) and you are told to take 8 puffs a day. 200 puffs per canister 8 puffs per day = 25 days supply So this canister will last 25 days. If you started using this inhaler on May 1, replace it on or before May 25. For quick-relief / rescue medicine- Take doses as needed and count each puff. Do not put your canister in water to see if it is empty. This does not work. 08/24/18 USC School of Pharmacy 6

7 Appendix B: Patient Self-Assessment Form for Environmental and Other Factors that Can Make Asthma Worse (Asthma Triggers ) Patient Name: Date: Do you cough, wheeze, have chest tightness, or feel short of breath year-round? (If no, go to next question) If yes: Are there pets or animals in your home, school, or day care? Is there moisture or dampness in any room of your home? Have you seen mold or smelled musty odors any place in your home? Have you seen cockroaches in your home? Do you use a humidifier or swamp cooler in your home? Does your coughing, wheezing, chest tightness, or shortness of breath get worse at certain times of the year? (If no, go to next question) If yes: Do your symptoms get worse in the: Early spring? (Trees) Late spring? (Grasses) Late summer to autumn? (Weeds) Summer and fall? (Alternaria, Cladosporium) Do you smoke? Does anyone smoke at home, work, or day care? Is a wood-burning stove or fireplace used in your home? Are kerosene, oil, or gas stoves or heaters used without vents in your home? Are you exposed to fumes or odors from cleaning agents, sprays, or other chemicals? Do you cough or wheeze during the week, but not on weekends when away from work or school? Do your eyes and nose get irritated soon after you get to work or school? Do your coworkers or classmates have symptoms like yours? Are isocyanates, plant or animal products, smoke, gases, or fumes used where you work? Is it cold, hot, dusty, or humid where you work? Do you have a stuffy nose or postnasal drip, either at certain times of the year or year-round? Do you sneeze often or have itchy, watery eyes? Do you have heartburn? Does food sometimes come up into your throat? Have you had coughing, wheezing, or shortness of breath at night in the past 4 weeks? Does your infant vomit then cough or have wheezy cough at night? Are these symptoms worse after feeding? Have you had wheezing, coughing, or shortness of breath after eating shrimp, dried fruit, or canned or processed potatoes? After drinking beer or wine? Are you taking any prescription medicines or over-the-counter medicines? If yes, which ones? Do you use eye drops? Do you use any medicines that contain beta-blockers (e.g., blood pressure medicine)? Do you ever take aspirin or other nonsteroidal anti-inflammatory drugs (like ibuprofen)? Have you ever had coughing, wheezing, chest tightness, or shortness of breath after taking any medication? Do you cough, wheeze, have chest tightness, or feel short of breath during or after exercising? _ 08/24/18 USC School of Pharmacy 7

8 Asthma Trigger House Dust Mites & Vacuuming Appendix C: Plan for Controlling Asthma Triggers Methods Available to Control Trigger INDOORS Encase mattress, pillow, and comforter in special dust-proof covers Wash sheets, blankets, and pillows each week in hot water (> 130 o F) Reduce indoor humidity to < 50% using a dehumidifier or air conditioner Avoid sleeping or lying on cloth-covered cushions or furniture Keep stuffed toys away from bedding or wash toys weekly in hot water Vacuuming: Vacuum frequently (twice a week), try to have someone else vacuum to avoid exposure to dust Keep out of rooms during vacuuming, remain away for a short while afterwards Use dust mask, double-layered or microfilter vacuum bag, or HEPA filter on vacuum cleaner Animal Dander Keep furred or feathered pets out of the home OR keep pet out of bedroom & keep bedroom door closed Cover air vents in bedroom with heavy material to filter air Remove carpets and furniture covered with cloth Cockroaches Keep all food out of bedroom Keep food and garbage in closed containers Use poison, baits, powders, traps, etc. (If spray is used, keep out of room until odor disappears) Indoor Mold Fix leaky faucets, pipes, or other water sources Clean moldy surfaces with a bleach-containing cleaner Avoid using humidifiers OUTDOORS Colds & Infections Avoid people with colds or the flu Get rest, eat a balanced diet, and exercise regularly Get a flu shot every year unless you have a clear reason for not receiving it (for example, being allergic to the vaccine) Remember that coughing can be a sign of uncontrolled asthma, so if you re not sure if your cough is due to a cold or to asthma, be sure to speak with your doctor. Pollen & Outdoor Mold Keep windows closed Stay indoors with windows closed during midday and afternoon 08/24/18 USC School of Pharmacy 9

9 Appendix D: How to use a peak flow meter 1. To find your personal best peak flow value and daily variability, measure peak flow at least twice daily, preferably in the morning before using your medicines (when breathing is usually poorest) and between noon and 2pm minutes following use of your rescue inhaler such as albuterol (when breathing is usually best). 2. Once your personal best and daily variability have been established, you may need to check your peak flow: Every morning upon awakening, before taking medication. When experiencing asthma symptoms or an attack, and after taking medicine for the attack to find out if the medicine was effective. 08/24/18 11

10 Appendix E: Classification of Asthma Severity / Control and Medication Selection 08/24/18 12

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16 Appendix F: Sample Asthma Action Plan 08/24/18 18

17 Appendix G: Provide follow-up and repeat education A. Screen for asthma symptoms / control (refer to Step 1) and evaluate drug therapy for efficacy and toxicity (refer to Step 2) Patient Self-Assessment Form for Follow-up Visits Patient Name: Date: Please answer the questions below in the space provided on the right. Since your last visit: 1. Has your asthma been any worse? _ 2. Have there been any changes in your home, work, or school environment No (such as a new pet, someone smoking)? Yes 3. Have you had any times when your symptoms were a lot worse than usual? _ 4. Has your asthma caused you to miss work or school or reduce or change No your activities? Yes 5. Have you missed any regular doses of your medicines for any reason? _ 6. Have your medications caused you any problems? (shakiness, nervousness, bad taste, sore throat, cough, upset stomach) _ 7. Have you had any emergency room visits or hospital stays for asthma? _ 8. Has the cost of your asthma treatment kept you from getting the medicine or care you need for your asthma? _ In the past 2 weeks, 9. Have you had a cough, wheezing, shortness of breath, or chest tightness No during: Yes the day _ night _ exercise or play? _ 10. (If you use a peak flow meter) Did your peak flow go below 80 percent of your personal best? _ 11. How many days have you used your inhaled quick-relief medicine? Number of days 12. Have you been satisfied with the way your asthma has been? _ 13. What are some concerns or questions you would like us to address at this visit? For PERSISTENT asthma- Asthma Control Test score: For staff use. Peak Flow Technique MDI Technique Reviewed Action Plan: Daily meds Emergency meds 08/24/18 19

18 Appendix H: Asthma Control Test (ACT) 08/24/18 20

19 General References: 1. EPR-3. Expert panel report 3: guidelines for the diagnosis and management of asthma (EPR ). NIH Publication No Bethesda, MD: U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, Abramowicz M. Drugs for Asthma. Treatment Guidelines from the Medical Letter 2012;114: Clinical Pharmacology on-line, available at Approved: (Physician Name, Title) Date 08/24/18 21

Asthma Triggers. It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them.

Asthma Triggers. It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them. Asthma s It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them. With asthma, your child s airways are very sensitive. Things, called triggers, may