A CPPE interactive PDF learning programme. New medicine service. asthma and COPD

Transcription

1 A CPPE interactive PDF learning programme New medicine service asthma and COPD Updated November 2016

2 2 Welcome to New medicine service asthma and COPD CONTENTS This programme contains the following sections: 3 How to use this learning programme 5 About New medicine service asthma and COPD 7 The NMS Thank you for downloading this CPPE interactive learning programme. We hope that you will find it a fun and informative way to help you learn about the key points for conducting new medicine service (NMS) consultations with patients taking medicines for asthma and COPD. Learning with CPPE The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learning opportunities in a variety of formats for pharmacy professionals from all sectors of practice. We are funded by Health Education England to offer continuing professional development for all pharmacists and pharmacy technicians providing NHS services in England. For further information about our learning portfolio, visit: This document uses interactive features that may not be supported if you are using it on a mobile device. For the best results, please access it on your PC or laptop, using an up-to-date version of Adobe Reader Your NMS consultations Learning objectives Reflection point Questions about respiratory medicines Respiratory medicines Case studies Next steps Programme credits Click on a title to go directly to that section.

3 3 How to use this learning programme This programme uses an interactive PDF format. You can navigate your way through by using the arrows in the bottom right corner of each page. Where directed, you can also navigate to sections by clicking on text or images. The programme uses case studies and web links to help you explore this topic. You will need to be connected to the internet to access the web links. Text which links to to the internet will be in blue.

4 4 The programme contains two case studies to highlight significant counselling points in patients who are taking new medicines for asthma or chronic obstructive pulmonary disease (COPD) for the first time. You will be able to type, save and reveal answers to some activities. We would recommend that you keep notes as you go along as these could be ideal to generate evidence for your CPD record. If you are using a printed version of this programme, you will not be able to view our suggested answers. To see these, either open this document on your computer or download the separate answers document from the CPPE website.

5 5 About New medicine service asthma and COPD NHS services are increasingly focused on delivering the best possible outcomes for patients the NMS was set up with this in mind. Adherence to medicines has been linked with better patient outcomes. 1,2 In delivering the NMS you will be supporting patients in managing their newly prescribed medicines. As well as helping them to optimise their medicines use, the aim is to improve adherence by engaging patients in shared decision making, providing them with the knowledge needed to make informed choices about treatment and self-management. You will also be contributing to the NHS aim of providing highquality healthcare for everyone, a key cornerstone of the NHS constitution. 1. DiMatteo MR et al. Patient adherence and medical outcomes: a meta-analysis. Medical Care 2002;40(9): Haynes RB et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008;2: CD000011

6 6 This programme will provide and signpost you to key learning to help you conduct effective NMS consultations. It will provide a record of your learning of the key points to consider and share with patients taking drugs for asthma and COPD as new medicines. We estimate that the whole programme will take you three to four hours to complete. The first few pages will provide you with learning to ensure that you can provide an NMS consultation. After that, we will focus on respiratory medicines for people with asthma and COPD, one of the medicine groups for which a first prescription qualifies a patient for an NMS consultation. This programme is the fourth in a series of interactive PDF learning for the NMS, following New medicine service - anticoagulants and antiplatelets, New medicine service - antihypertensives and New medicine service - type 2 diabetes.

7 7 The NMS Before you start, make sure that you have completed enough learning to allow you to complete the Pharmaceutical Services Negotiating Committee (PSNC) and NHS Employers self-assessment form to assure yourself, your employer (if appropriate) and the NHS that you are ready to provide the NMS. If you need to access the CPPE learning materials for the NMS and complete the CPPE open learning programme, you can do so by clicking on the images of the learning programmes on the left. The NMS Evaluation (funded by the Department of Health) was published in August The evaluation found that at Week 10 the NMS had increased adherence by about 10 percent and that increased numbers of medicines problems had been identified and dealt with compared with standard current practice. The case studies on pages assume that you know what questions are included in the intervention stage of the NMS. If you re not sure what these are, view them on the PSNC website.

8 8 Your NMS consultations If you have already worked through this exercise in other programmes in this NMS interactive PDF series, then move on to the next section. Now that the NMS is up and running, what is stopping you conducting more new medicine service consultations? Type your answer in the box below.

9 9 How are you going to overcome these barriers? Complete the table below by adding the barriers you identified in the left-hand column and typing in possible solutions in the right-hand column. There is more space on the next page. Barriers to NMS Solutions Barriers to NMS Solutions No consultation area Discuss with the pharmacy manager/owner the benefits of having a consultation area. Have one built or installed. Improvise to create a private area. No medicines use review (MUR) accreditation Get MUR accreditation with CPPE or another HEI provider. Too few patients Not enough experience Try advertising or mobilising staff to recognise new medicines at prescription receipt. Contact your local hospital/gp practices to discuss how they can refer patients to community pharmacy. You ve got to start somewhere! Do this CPPE learning programme to help build your knowledge base. A bit scared to approach patients Set up a system so that new medicines are recognised by you or a member of staff and automate it as far as possible. Then talk to your patients.

10 10 Barriers to NMS Solutions Barriers to NMS Solutions GPs are against the idea Set up a meeting and convince them of the benefits. View the resources on PSNC and CPPE websites, such as the GP detailing card. Another pharmacist nearby does them all There is plenty of opportunity if you get a system set up to recognise new medicines. I m a locum Then you have more time available to offer these services than employed pharmacists who are concerned with staff and management issues. Help them out and get invited back! I don t know the patients I see You can soon establish a relationship if you sell patients the benefits of the NMS, even if you don t personally complete the three interviews. I don t have time Pharmacy staff can do more to free you up to do the services that matter to patients. Mobilise them to do this. Undertake CPPE s Skill mix e-learning programme. Complicated and confusing payment system This has been simplified: you will now receive payment for every NMS conducted. The payment system is explained on the PSNC website.

11 11 Now that we have looked at the new medicine service in general, we are ready to move on to the respiratory medicines specifically.

12 12 Learning objectives The overall aim of this learning programme is to provide you with, and signpost you to, key learning resources to support you in providing effective, outcomes-focused consultations for people prescribed new medicines for asthma and COPD. By the end of this learning programme, you should be able to: l identify the key issues for patients taking a new respiratory medicine l provide advice to patients to enable them to manage their condition effectively l find key resources to help you plan and deliver effective new medicine service consultations for people with respiratory disease l provide advice to people using a new inhaler and support them in ensuring they have an effective inhaler technique.

13 13 Reflection point Before you look at the learning materials, work through the questions to see what you already know. This programme covers both asthma and COPD. Complete the table to refresh your knowledge of the differences between the two. COPD Asthma COPD Asthma Airway obstruction Airway obstruction Permanently damaged and narrowed Inflammation causes constriction; usually reversible Cough symptoms Cough symptoms Chronic cough often with sputum Irritating cough, often at night, and there can be some mucus plugging Breathlessness Breathlessness Persistent and progressive Variable Significant diurnal or day-to-day variability of symptoms Significant diurnal or day-to-day variability of symptoms Uncommon Common Night-time symptoms that keep patient awake Night-time symptoms that keep patient awake Not common Common but variable Main age group affected Main age group affected Over 35 years Any age Smoker or ex-smoker Smoker or ex-smoker Nearly always Possibly

14 14 Questions about respiratory medicines Which classes of drugs might you expect to see on prescriptions for people with respiratory disease? Your answer may have included: l beta 2 adrenoceptor agonists/sympathomimetics l antimuscarinic bronchodilators l antibiotics l corticosteroids: inhaled and oral l leukotriene receptor antagonists l mucolytics l nedocromil l oxygen l sodium cromoglicate l theophylline/aminophylline. Which of those listed are eligible for the NMS and which are not? Patients must be taking a medicine listed in one of the following British National Formulary (BNF) sub-sections: Adrenoceptor agonists Antimuscarinic bronchodilators Theophylline/aminophylline Compound bronchodilator preparations 3.2 Corticosteroids 3.3 Cromoglicate and related therapy, leukotriene receptor antagonists. (Legally, the new medicine service could be undertaken for patients for prescribed phosphodiesterase type-4 inhibitors for the treatment of asthma or COPD. However, the phosphodiesterase type-4 inhibitors are not indicated for the treatment of asthma. These are recommended only in the context of research as part of a clinical trial, in certain circumstances, in adults with severe COPD.) New prescriptions for antibiotics, mucolytics and oxygen cannot trigger an NMS intervention but you may well need to provide information on them in a discussion with a patient.

15 15 Well, how well did you do? You can find more learning resources with detailed information about respiratory medicines by clicking on the topics on the following page.

16 16 Respiratory medicines Click on any of the words below to explore these areas in further depth. You will be able to return to this menu by clicking the link at the bottom of the page at the end of each section. You can also work through the topics in sequence using the navigation tabs at the bottom of the page. outcomes asthma starting point COPD monitoring inhaler technique adherence smoking resources lifestyle

17 17 Starting point Before you get to grips with the key learning and case studies in this e-learning programme, you may feel that you need to refresh your knowledge on the medicines, their uses, appropriate doses, side-effects and interactions. The BNF is a good starting point. Here you will find key information, including a summary of the guidance issued by the National Institute for Health and Care Excellence (NICE) relating to this group of medicines. If you have not already done so, you will need to register with the BNF website to access the information within. Read through sections 3.1 to 3.3 to find out more about the drugs used to treat asthma and COPD.

18 18 Outcomes In 2012, the Department of Health published An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England to improve outcomes for people with COPD and asthma through high-quality prevention, detection, treatment and care. The full strategy document is very lengthy; however, there is a short summary to the companion document which outlines the role we have to play in improving outcomes for people with COPD and asthma across the five domains of the NHS outcomes framework. Take a few minutes to read through the document and identify areas where you are performing well and where you might be able to further develop your services to improve outcomes for people with asthma or COPD.

19 19 Asthma The UK has one of the highest rates of self-reported asthma in the world. In 2012, an estimated 5.4 million people in the UK were receiving treatment for asthma. Book 1 of the CPPE focal point on asthma will help you consider how best to apply the evidence base for the treatment of people with asthma and how you can deliver an outcomes-focused service for them. Click on the image to read the September 2012 revised edition of our Asthma focal point, which provides the most up-to-date guidance on the management of this long-term condition. In February 2013, NICE published quality standard QS25 Asthma. The summary page has a useful list of implementation tools and resources that you might want to take a look at.

20 20 COPD The management of COPD is covered extensively by NICE in its COPD pathway. It includes the COPD clinical guideline CG101 and the quality standard QS10. There is further information in the Global Initiative for Chronic Obstructive Lung Disease publication, Global strategy for the diagnosis, management and prevention of COPD. Take some time to read through these to refresh your knowledge of the current treatment pathways and the medicines used at each stage. How does the use of long-acting beta 2 agonists (LABAs) differ in asthma and COPD? The long acting beta 2 agonists formoterol and salmeterol both have a role in the control of chronic asthma, but to ensure safe use they must only be used by people who are taking regular inhaled corticosteroids (ICS). In COPD they can be used safely without the need for an ICS, as can indacaterol and olodaterol, LABAs licensed for maintenance treatment of COPD.

21 21 Inhaler technique A major cause for concern when treating respiratory disease is poor inhaler technique. This leads to poor drug delivery, decreased disease control, increased inhaler use and waste. The inhaler technique improvement project, carried out across the south central NHS region in 2011/2012 and involving more than 5000 people, showed, in relative terms, a 40 percent improvement in asthma control. Meanwhile, 55 percent of COPD patients showed an improvement in symptom management after intervention by a pharmacist. What percentage of people who have had an inhaler for an average of two to three years report that they can use it correctly? 75 percent What percentage of these people can actually demonstrate correct use? 10 percent Appropriate use of inhalers can make a huge difference to people in allowing them to take part in normal activities, improving sleep and also keeping them out of hospital.

22 22 How good is your technique? For a handy portable resource that can be used with patients, University Hospitals of Leicester NHS Trust offers its 7 steps to success cards. Click on the image below to find out more about how you can purchase and use the cards. The figures on the previous page illustrate that there is a huge way to go to ensure people can use their inhalers effectively. With so many inhalers now available, are you confident that you know how to assess and demonstrate inhaler techniques appropriately? What percentage of healthcare professionals who demonstrate inhaler technique can do so correctly? An article in Thorax medical journal in 2010 reported that 91 percent could not demonstrate correct inhaler use. 3 There is a large number of video resources available to support both healthcare professionals and patients in correct inhaler technique, such as the videos from Wessex innovation resources and the interactive videos on the Asthma UK website. 3. Baverstock M, Woodhall N and Maarman V. Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? Thorax 2010; 65 (Suppl 4): A117-A118

23 23 Monitoring While peak flow readings in asthma and spirometry in COPD will give us a quantitative measure of lung function, they are not necessarily representative of the actual effect on quality of life. An NMS consultation provides an ideal opportunity to monitor both the effectiveness of the treatment and any concerns the patient might have. What could you do during an intervention or follow-up consultation to establish if a new medicine is having a positive effect? Monitoring for symptom control can be done simply and easily in the pharmacy by asking questions. This will give a good picture of whether the patient is managing their disease and whether their medication is working. What standard questions could you ask to check symptom control in people with asthma? Royal College of Physicians three questions Answering yes to any one of these three questions would indicate uncontrolled asthma: Have you had difficulty sleeping because of your asthma symptoms (including cough)? Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? Has your asthma interfered with your usual activities (housework, work, school)?

24 24 What standard questions could you ask to check symptom control in people with asthma? (continued) Asthma control test (ACT) The ACT asks five questions related to a patient s asthma control over the previous four weeks: 1. During the past four weeks, how often did your asthma prevent you from getting as much done at work, school or home as you would normally do? 2. During the past four weeks, how often have you had shortness of breath? 3. During the past four weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? 4. During the past four weeks, how often have you used your reliever inhaler (usually blue)? 5. How would you rate your asthma control during the past four weeks? Each question enables a score from one to five in terms of control. The total score therefore has a range from 5 to 25, with higher scores indicating better control. If someone scores 19 or less, then it is considered that their asthma is not being well controlled. You can find out more on the Asthma UK website.

25 25 What questions would you use to check COPD control? As with asthma, you need to find out the patient s symptoms and the effect that COPD is having on their day-to-day life. The COPD Assessment Test (CAT) The CAT, available online in many languages, is a way to measure the overall impact of COPD on a person s life. It is made up of eight statements regarding cough, mucus, chest tightness and breathlessness, as well as impact on sleep and day-to-day activity. Each statement is scored on a scale of zero (no impact) to five (very severe impact), giving a range of CAT scores from 0 to 40. A higher CAT score indicates a more severe impact of COPD. You can find out more at: In addition to symptom control what else might you want to monitor during the consultation? The limited time you have will influence what you can monitor but other things to consider asking about include: side effects, (especially for those on inhaled corticosteroids), smoking, status, inhaler technique, adherence to their medicines and check their vaccination status.

26 26 Adherence One of the key aims of NMS interventions is to reduce non-adherence. What can you do to support those who are unintentionally non-adherent? Unintentional non-adherence for people with COPD or asthma may be due to a number of factors, including forgetfulness, inability to use their device correctly or complex dosing regimens. For those who forget to use their ICS, one of the things you could advise them to do is to pick a task that they do regularly and always use their inhaler just before, such as cleaning their teeth (and with inhaled steroids this has the added advantage of reducing the risk of oral thrush). Combination inhalers may help those who are struggling to cope with the dose regimen, while ongoing checks on inhaler technique will pick up those who cannot use their inhalers correctly. If the problem is co-ordination or dexterity, then there are various aids available to use with the prescribed inhalers, or an alternative type of inhaler might be an option. If the problem is inspiratory effort, then swapping to another device might be the most appropriate course of action.

27 27 What support can you provide to those who are intentionally not taking their medicines as prescribed? A patient-centred approach is needed here. The more you can understand their reasons for not taking their medication, the more likely it is that you will be able to work with them to find a solution that has maximum benefits to their health. By establishing their ideas, concerns and expectations regarding their health and medicines, you can identify and then help to minimise the barriers to adherence. Reasons will vary. Some, such as concern about side-effects or not understanding the necessity of taking the medication, are relatively easy to overcome with education. Others, such as their personal health beliefs, may be more difficult to address. Handling intentional non-adherence may be challenging as the patient has made a conscious decision not to take their medicine. However, by inviting someone for an NMS consultation, you are opening up the dialogue and allowing them the opportunity to ask any questions they might have.

28 28 Smoking The single most important thing you can do for someone with respiratory disease is to support them to quit smoking. Smoking is the biggest risk factor for the development and progression of COPD and is a trigger factor for asthma. The risk of developing COPD is directly related to the total number of pack years smoked, with anything over 15 pack years considered significant. How are pack years calculated? Evidence shows that quitting at any point in life will slow the progression of COPD. Therefore any patient, regardless of age, should be encouraged to stop smoking. The Fletcher Peto diagram can be used to provide a visual illustration of the benefits of smoking cessation to patients. 4 Do you offer a smoking cessation service in your pharmacy? If not, are you confident that you know who you can refer people to, locally? Pack years are calculated as follows: number of cigarettes x number of years patient smoked per day has smoked Parkes G et al. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008;336: 598.

29 29 Lifestyle As well as providing lifestyle advice on areas such as smoking, healthy eating, keeping active, managing exacerbations and inhaler technique, you can signpost patients to a wealth of great websites for finding out more about managing their conditions and supporting them in altering their lifestyles to minimise symptoms. List any patient-friendly websites of which you are aware that have a focus on respiratory disease. Some particularly useful websites for people with respiratory disease are listed below. They offer lifestyle advice as well as leaflets to download and print. Asthma UK Asthma UK is the UK s leading asthma charity. British Lung Foundation Regional teams offer Breathe Easy support groups throughout the UK for people with respiratory disease. NHS choices Patient UK

30 30 Resources In addition to the resources already signposted throughout the programme, the following may be of interest for further information. Asthma The British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network s British guideline on the management of asthma. The Global Initiative for Asthma works with international experts to produce guidelines, reports and other resources about asthma. Adviceline, Asthma UK s telephone advice service, is available Monday-Friday, 9:00am-5:00pm on COPD A number of new inhalers for the treatment of COPD have been launched recently. If you are unfamiliar with these, have a look at section 3 of the BNF. The Global Initiative for Chronic Obstructive Lung Disease has guidelines on the management of COPD and some useful resources for healthcare professionals. Devon Local Pharmaceutical Committee has done extensive work with community pharmacists around providing services to people with COPD. Visit their website to download many useful resources, including presentations on COPD, British Medical Journal articles, factsheets and checklists.

31 31 Case studies This programme contains two case studies. In these, there will be space for you to type answers to the questions. You can save your answers by saving this document to your computer and you can view our suggested answers, which are hidden behind the Reveal answer text, by holding your mouse over the area. Click on an image below to go straight to that case. You will be able to return to this menu by clicking the link at the bottom of the page at the end of each case study.

32 32 Asthma Emma Emma Shawstone is a 19-year-old student who has recently left home and moved into university accommodation. Just before leaving home, she noticed that she had an irritating cough that wouldn t go away. Emma visited her GP who diagnosed mild asthma and prescribed a salbutamol inhaler which she was using occasionally. Since being at university she has needed to use her inhaler much more frequently so she has visited the university health centre. She has come in today with the following prescription: l Salbutamol 100 micrograms metered-dose inhaler, two puffs when required l Clenil Modulite100 micrograms metered-dose inhaler, two puffs twice daily l Large volume spacer device l Standard range peak flow meter

33 33 You provide Emma with some information on the new inhaler she has been prescribed and explain how it differs from the salbutamol inhaler. After confirming she understands about her peak flow meter and showing her how to use the spacer device you tell her about the NMS. Emma says she is confident that she knows how to use the inhaler but is feeling quite overwhelmed by the need to take regular medication. She happily agrees to come back for an NMS intervention consultation in a week.

34 34 1. Emma returns for the intervention consultation. Given that you have limited time for the consultation, what are the key priorities to cover with Emma? The first step is to ask the questions in the PSNC and NHS Employers interview schedule. A key point to consider is whether or not Emma has been using the ICS for a long enough period of time to start to feel the benefit. She may have noticed an improvement in the cough but one week is not long enough to see full effects. She should therefore be encouraged to continue to use it twice a day. Her peak flow readings may also give her an indication of any improvement in diurnal variation of symptoms. It would also be prudent to check if she is experiencing any mouth discomfort, as this could indicate oral thrush from the ICS. This is usually avoided by using a spacer and rinsing the mouth with water after inhaler use will help. Checking inhaler technique at this point is key as many patients, while confident they are using the inhalers correctly, may have already developed their own method which is incorrect. Use of the spacer device should also be checked, as well as advising her on care of the spacer (this needs to be cleaned with warm soapy water and air-dried once a month). Don t forget to save your answers

35 35 2. What lifestyle advice would you offer to Emma? Given that her symptoms have increased since being at university, you might want to check whether her lifestyle has changed significantly and whether she is exposing herself to any additional triggers. She may be exercising differently, eating differently, smoking (or exposing herself to smoke from others), or be in a dustier or damp environment or around different animals. Another consideration is that Emma may have been experiencing some stress with the transition to university life. You should make Emma aware that if she is on regular ICS, she is eligible for an annual flu vaccination. Healthy eating advice and smoking cessation support, in the form of leaflets, are useful at this stage, as she can take them away and mull them over before the follow-up consultation. This would avoid information overload at this stage. Don t forget to save your answers

36 36 Emma has returned to see you for her follow-up appointment. She has brought along her inhalers and says she is getting on OK with them. She says she needs to use far less salbutamol now, only one or two puffs a week, and doesn t always need to use the brown inhaler, which she says is great because carrying around the spacer is very inconvenient, especially if she is going out with friends in the evening.

37 37 3. What issues would you want to address with Emma and what solutions could you offer her? Emma is not using her Clenil Modulite appropriately. It could be that she has forgotten the initial information you gave on the differences between the two inhalers. Emma needs to understand the reason for using her beclometasone regularly and how it works. If she is struggling with the spacer when she is out, and is not home in time to use it at the appropriate time, you could suggest she uses the inhaler without it, though this will decrease the amount of lung deposition by 50 percent and may increase the risk of side-effects. This increased risk can be reduced by using the inhaler before cleaning teeth or by rinsing her mouth afterwards. Alternatively, she might prefer to try using a small volume spacer instead, which will be easier to carry. If not, she might be better changing to an alternative device if it will improve her adherence. 4. At what stage of the BTS guidelines is Emma s treatment? If she continues to improve with regular use of Clenil Modulite 200 micrograms twice daily, what would be the next management option? Emma is now at step 2 of the BTS guidelines as she is using regular inhaled preventer therapy. If she continues to achieve good control then the GP may consider stepping down the ICS. This should be done slowly by considering a decreasing dose of up to 50 percent every three months. Don t forget to save your answers

38 38 COPD Clive Clive Haggerty is a 66-year-old man who has been a regular customer of yours for many years. He is a smoker, having smoked around ten cigarettes a day since he was 21 years old. He has a body mass index (BMI) of Today, when he comes into the pharmacy, he looks very concerned. Over the last six months, he has suffered from shortness of breath and an ongoing cough that he cannot shift. After a visit to the GP he was prescribed an ipratropium 20 micrograms inhaler which he was using about three times a week, whenever he felt a little breathless. However, in the last two weeks, he has been coughing more and become very breathless even on short walks. As a result, he has been back to see his GP. Clive s GP ruled out other conditions and diagnosed COPD.

39 39 Clive has been given some information by the GP, including his spirometry results, which show that his FEV 1 is 59 percent of predicted value with an FEV 1 /FVC ratio of 0.62, and a note to explain that he is being referred for pulmonary rehabilitation. He has been told to stop using the ipratropium and has been prescribed tiotropium inhalation capsules with a Spiriva HandiHaler, plus a salbutamol inhaler to use when required. He asks you what pulmonary rehabilitation is, as he says his GP didn t have time to explain.

40 40 1. How would you answer Clive s question on pulmonary rehabilitation? Pulmonary rehabilitation is a multidisciplinary programme of care for patients with COPD that NICE recommends should be offered to all people with functional disability due to COPD (usually stage 3 or above on the Medical Research Council (MRC) dyspnoea scale). In areas where it is offered it usually consists of two to three outpatient sessions a week for around six weeks. The sessions include a mixture of exercise, education, nutritional advice and support to empower people to manage their own condition. It would give Clive the opportunity to build his exercise tolerance, improve his symptoms and meet up with other people with COPD. 2. What severity of COPD does Clive have? Is this a good indicator of his disability? An FEV 1 of 59 percent of predicted value indicates that Clive has moderate (stage 2) COPD. This is not necessarily indicative of the level of disability he is suffering, as some people are very disabled with this amount of airway restriction while others can function quite normally. Other useful indicators include the MRC dyspnoea scale, which is an indicator of breathlessness, or the BODE index, which takes into account the systemic nature of COPD and combines BMI, obstruction (FEV 1 ), dyspnoea and exercise tolerance (the results of a six minute walking test). The higher the score, the greater the risk of mortality. Don t forget to save your answers

41 41 3. What are the implications of Clive s BMI on his condition? What other medical problems could this lead to? Clive is underweight, which is an additional risk factor for mortality in COPD. Pulmonary rehabilitation will help him with dietary advice on ways to increase his weight. However, he may also be referred to a dietician for nutritional advice. People with low BMI are also at increased risk of osteoporosis, which may be relevant if Clive needs to take any courses of oral corticosteroids. If he needs more than three courses in a year, he might need osteoporosis prophylaxis too. 4. What lifestyle advice would you give to Clive? The biggest intervention that you could make to help Clive with his COPD would be to support him in giving up smoking. With a diagnosis of COPD, giving up smoking will slow the progression of the disease. You should also advise him to: ensure he uses his inhaler as prescribed and his technique is correct ensure he has a self-management plan and is following it ensure he has pneumococcal and influenza vaccinations to minimise the risk of infection keep active as this will help with both the physical symptoms and to keep his mood positive, as COPD can have effects on mental health too eat healthily and maintain a healthy weight. Don t forget to save your answers

42 42 5. As COPD is a progressive condition, what would be the next step in the management of Clive s COPD should his condition worsen? If Clive continues to experience breathlessness or persistent exacerbations, the next step according to NICE would be to add in a long-acting beta 2 agonist plus an ICS in a combination inhaler. Products currently licensed for COPD are Seretide 500 Accuhaler, Symbicort (200/6 or 400/12), Relvar Ellipta 92/22 micrograms (fluticasone furoate/vilanterol), DuoResp Spiromax (budesonide/formoterol) and Fostair pmdi and NextHaler and AirFluSal Forsteo. If an ICS is not appropriate for Clive, or he chooses not to use it, then a long-acting muscarinic antagonist (LAMA) and long-acting beta 2 agonist (LABA) could be used either as two separate devices or in a combination product, eg, Anoro which contains vilanterol and umeclidinium. There is also Duaklir Genuair (aclidinium/formoterol) and Ultibro Breezhaler (glycopyrronium/indacaterol). Spiolto (olodaterol/tiotropium) Respimat. The NICE algorithm states that if an ICS is declined or not tolerated a LABA/LAMA combination can be used. However, in clinical practice, there has been a move away from introduction of ICS based on the GOLD ABCD algorithm, so for Clive the next appropriate step would be to prescribe a LABA/LAMA combination inhaler. Encouraging Clive to give up smoking and to attend pulmonary rehabilitation may be a challenge but it would provide him with the best chance of delaying the need to add in extra medicines. This will be of benefit both to him and to the NHS due to the large cost of maintaining people on this combination of medicines. If you want to learn more about supporting patients with smoking cessation, have a look at the CPPE guide, Learning about stop smoking support. Don t forget to save your answers

43 43 Next steps Now that you have completed the case studies, what s next? You might like to: return to the start of the case studies revisit the learning objectives. Are you confident that you have achieved these? complete a related CPPE programme complete a CPD record CPPE with any feedback you may have on your learning experience. We hope that you have enjoyed your learning.

44 44 Programme credits CPPE programme manager Karen Wragg, regional manager Reviewers Dr Helen Meynell, consultant pharmacist with an interest in respiratory and palliative medicine, Doncaster and Bassetlaw Hospitals NHS Foundation Trust Anna Murphy, consultant respiratory pharmacist, University of Leicester NHS Trust CPPE reviewers Anne Cole, regional manager Lesley Grimes, regional manager Piloted by Kenneth Omoijate Okoh, community pharmacist Chinjal Patel, community pharmacist Jignna Patel, community pharmacist Viren Solanki, community pharmacist Richard Yeung, community pharmacist CPPE editors Neil Condron, editor Terri Lucas, assistant editor Disclaimer We have developed this learning programme to support your practice in this topic area. We recommend that you use it in combination with other established reference sources. If you are using it significantly after the date of initial publication, then you should refer to current published evidence. CPPE does not accept responsibility for any errors or omissions. External websites CPPE is not responsible for the content of any non-cppe websites mentioned in this programme or for the accuracy of any information to be found there. Brand names and trademarks CPPE acknowledges the following brand names and registered trademarks mentioned throughout this programme: Accuhaler, Anoro, Breezhaler Clenil, Duaklir, DuoResp, Ellipta, Fostair, Genuair, HandiHaler, Modulite Relvar, Seretide, Spiriva, Spiromax, Symbicort and Ultibro. Production Gemini West, 25 Hockeys Lane, Fishponds, Bristol, BS16 3HH T: Published in November 2016 (originally published in May 2013) by the Centre for Pharmacy Postgraduate Education, Manchester Pharmacy School, The University of Manchester, Oxford Road, Manchester, M13 9PT.

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