What is the Challenge?

Transcription

1 Respiratory Inhaler Check-up Service What is the Challenge? Dr Toby Capstick Lead Respiratory Pharmacist Leeds Teaching Hospitals NHS Trust 25 th September 2018 The Burden of Disease in the UK ASTHMA 8 million people in the UK diagnosed with asthma million asthmatics in UK 1-2 (1.1 million children) 2 There were 65,623 UK Hospital admissions in 2015/ % of admissions are avoidable 2 Asthma was responsible for 1,468 deaths in /3 of deaths are preventable 2 COPD 1.2 million people in the UK diagnosed with COPD. 1 2/3 of people with COPD thought to remain undiagnosed. 1 There were 140,000 UK Hospital admissions each year. 1 COPD was responsible for 25,000 30,000 deaths annually. 1,4 Patients in Leeds: 50% have not had inhaler technique checked & recorded in the last 15 months. 1,400 receive 6 SABA inhalers in the past year & not on asthma/copd register. 1. British Lung Foundation. The Battle for breath Asthma UK (2014) 3. Asthma UK. The Asthma UK Data Portal. (accessed 27/10/17) 4. DH (2011). An outcomes strategy for COPD and Asthma in England 5. Public Health England. Inhale - INteractive Health Atlas of Lung conditions in England. 2015/16 data. Prescription Cost Analysis - England, 2017 Drug No. Items Supplied Expenditure 1 Rivaroxaban 20mg tabs. 2,465, ,150,612 2 Fostair 100/6 MDI 3,086, ,563,396 3 Spiriva 18mcg refills 2,503,359 99,989,225 4 Apixaban 5mg tabs. 1,900,432 98,633,014 5 Sitagliptin 100mg tabs. 2,082,265 77, Drug Overall, 987 million spent on inhalers in England in 2017 BUT, are we getting value for money? NHS Digital. Prescription Cost Analysis, England Available at: Publication date: 15 th March 2018 Expenditure 1 Tiotropium DPI 141,711,339 2 Fostair 100/6 MDI 106,563,396 3 Budesonide/formoterol 200/6 DPI 4 Fluticasone propionate /salmeterol 250/25 MDI 5 Budesonide/formoterol 400/12 DPI 94,356,310 91,968,124 61,413,934 Asthma & COPD: Inhalers in 2010 Bronchodilators SABAs Salbutamol (7+ devices) Terbutaline (1 device) SAMAs Ipratropium (2 devices) LABAs Formoterol (2 devices) Salmeterol (2 devices) LAMAs Tiotropium (2 devices) Corticosteroids ICS Beclometasone (4 devices) Beclometasone extra-fine (3 devices) Budesonide (3 devices) Ciclesonide (1 device) Fluticasone propionate (2 devices) Mometasone (1 device) ICS/LABA Fostair (1 device) (beclometasone/formoterol) Seretide (2 devices) (fluticasone propionate/salmeterol) Symbicort (1 device) (budesonide/formoterol) Asthma & COPD: Inhalers in 2018 Bronchodilators Corticosteroids SABAs ICS Salbutamol (6 devices) Beclometasone (2 devices) Terbutaline (1 device) Beclometasone extra-fine (3 devices) Budesonide (3 devices) SAMAs Ciclesonide (1 device) Ipratropium (1 devices) Fluticasone furoate LABAs Fluticasone propionate (2 devices) Formoterol (4 devices) Mometasone (1 device) Salmeterol (2 devices) ICS/LABA Indacaterol (1 device) Aerivio (fluticasone propionate/salmeterol) (1 device) AirFluSal (fluticasone propionate/salmeterol) (2 devices) Olodaterol (1 device) Aloflute (fluticasone propionate/salmeterol) (1 device) Vilanterol Combisal (fluticasone propionate/salmeterol) (1 device) LAMAs DuoResp (budesonide/formoterol) (1 device) Flutiform (fluticasone propionate/formoterol) (2 devices) Aclidinium (1 devices) Fobumix (budesonide/formoterol) (1 device) Glycopyrronium (1 device) Fostair (beclometasone/formoterol) (2 devices) Tiotropium (3 devices) Relvar (fluticasone fuorate/vilanterol) (1 device) Sereflo (fluticasone propionate/salmeterol) (1 device) Umeclidinium (1 device) Seretide (fluticasone propionate/salmeterol) (2 devices) LABA/LAMAs Sirdupla (fluticasone propionate/salmeterol) (1 device) Anoro (vilanterol/umeclidinium (1 device) Symbicort (budesonide/formoterol) (1 device) Duaklir (formoterol/aclidinium) (1 device) ICS/LABA/LAMA Trelegy (fluticasonefuorate/vilanterol/umeclidinium) (1 device) Spiolto (olodaterol/tiotropium) (1 device) Trimbow (beclometasone/formoterol/glycopyrronium) (1 device) Ultibro (indacaterol/glycopyrronium) (1 device) Not available as monotherapy 1

2 MDI Inhalers are not all the same Small Vol. Spacer Large Vol. Spacer Aerosol Soft Mist Inhaler Autohaler Easi-Breathe K-haler Generic Prescribing Budesonide/formoterol Beclometasone/formoterol Single dose DPI - Blister Dry Powder Inhaler (DPI) Single dose DPI - Capsule Symbicort DuoResp Fobumix Turbohaler Spiromax Easyhaler Fluticasone/salmeterol pmdi NEXThaler Accuhaler Ellipta Forspiro Aeroliser Breezhaler HandiHaler Zonda Seretide Accuhaler AirFluSal Forspiro Aerivio Spiromax Formoterol Reservoir Multidose DPI Easyhaler Genuair NEXThaler Novolizer Spiromax Turbohaler Twisthaler Atimos Modulite pmdi Formoterol Easyhaler Foradil Aeroliser BTS/SIGN Asthma Guidelines 2016 Oxis Turbohaler NICE COPD Guidelines (DRAFT) 2018 Switching Inhaler Devices: Effect of unconsented switch (Asthma) Why is Inhaler Technique Important? Treatment Success OR: 0.29 [95% CI: 0.19, 0.44; p<0.001) Thomas et al. BMC Pulmonary Medicine 2009;9:1-10 The Good Old days How Frequently do COPD Patients make Errors Using Inhaler Devices? Accuhaler (n=452) Breezhaler (n=876) HandiHaler (n=598) pmdi (n=422) Respimat (n=625) Turbohaler (n=420) Total (n=3,393) 50-75% of patients make errors using common inhaler devices (Accuhaler, pmdi, Turbohaler). 1 Between 1:3 and 1:10 patients make critical (serious) errors using these inhalers. 1 8% of healthcare professionals can use a pmdi correctly. 2 No error At least one critical error 29.2 [ ] 21.2 [ ] All data presented as % [95% CI] 36.5 [ ] 15.4 [ ] 10.7 [ ] 29.3 [ ] 16.4 [ ] 43.8 [ ] 23.0 [ ] 46.9 [ ] 30.5 [ ] 32.1 [ ] Rate of hospitalisation or ER visit in the previous 3 months was: No error: 3.3% (95% CI ) At least 1 critical error: 6.9% (95% CI ) OR 1.86 [95% CI ], p< [ ] 30.0 [ ] 1. MolimardM et al. Journal of Aerosol Medicine 2003;16: Baverstock M et al. Thorax 2010;65(Suppl4): A117-A118 NB. Sponsored by Novartis Molimard M et al. Eur Respir J 2017; 49:

3 Inhaler Technique: Has it Improved Over 40 Years? Systematic review. 144 studies, 54,354 patients Sanchis et al. Chest 2016; 150(2): Association Between Inhaler Technique and COPD exacerbations % of patients exacerbating OR 1.47; p=0.001 OR 1.62; p<0.001 OR 1.50; p<0.001 OR 1.54; p< Hospital admissions Emergency dept visits At least 1 Critical Error Antibiotic courses No Errors Corticosteroid courses Melani et al. Resp Med 2011;105:930-8 Misuse of Inhalers is Associated with Decreased Asthma Stability AIS = Asthma Instability Score 0: best asthma stability 9: worst asthma stability Frequency distribution of the number of errors in inhalation technique (left axis) Asthma Instability Score (right axis) What do Guidelines Recommend? BTS/SIGN Asthma Guidelines 2016 Prescribe inhalers only after patients have: Received training in the use of the device, and Have demonstrated satisfactory technique Before initiating a new drug therapy practitioners should check: Adherence with existing therapies Inhaler technique, and Eliminate trigger factors NICE COPD Guidelines 2010 Inhalers should be prescribed only after patients have received training in the use of the device, and have demonstrated satisfactory technique Patients should have their ability to use an inhaler device regularly assessed by a competent healthcare professional and, if necessary, should be re-taught the correct technique BTS/SIGN Asthma Guidelines 2016 NICE clinical guideline 101: Chronic obstructive pulmonary disease Giraud V. Eur Respir J 2002;19: The Service Service Outline Eligible Patients Diagnosis of asthma / COPD, on inhaled therapy Registered with Leeds GP Speak & understand English (or translated by pharmacy team) Able to attend both consultations Service allowed once per patient Pharmacy requirements Use consultation room Provided by Pharmacist or Registered Pharmacy Technician, Must have completed CPPE Declaration of Competence for Improving Inhaler Technique. Must use In Check DIAL G16 with 1-way inspiratory mouthpieces, & placebos. Initial supply provided. It is your responsibility to obtain more. London Medicines Evaluation Network. Availability and supply of respiratory support devices to healthcare professionals. 13_LMEN.pdf 3

4 Consultation Format Two appointments: baseline & 6-8 weeks later Take telephone no. and/or to use as a reminder Patient education: 1. Assessment of Asthma Control (ACT) or COPD health status (CAT) 2. Inhaler technique: Measure inspiratory flow using In-Check DIAL G16 Assess, teach and optimise inhaler technique 3. Medicines use 4. Adherence 5. Smoking cessation 6. Data recorded on Pharmoutcomes within 48 hours 7. GP referral: e.g. if alternative device needed NB. If patient has (1) good control (ACT 20 or CAT<10), (2) good inhaler technique and (3) good inspiratory flow DO NOT invite back for 2 nd consultation. You can also carry out an MUR in addition to this inhaler service, if patient is eligible. The Consultation Patient education: 1. Assessment of Asthma Control (ACT) or COPD health status (CAT) 2. Inhaler technique: Measure inspiratory flow using In-Check DIAL G16 Assess, teach and optimise inhaler technique 3. Medicines use 4. Adherence 5. Smoking cessation 6. Data recorded on Pharmoutcomes within 48 hours 7. GP referral: e.g. if alternative device needed Consultation 1 Consultation 2 What is COPD? A common, preventable and treatable disease characterised by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. What is Asthma? Asthma is a chronic inflammatory disorder of the airways Involves a variety of cells and cellular mediators Airflow limitation is widespread, variable, and often reversible Chronic inflammation leads to an increase in airway hyperresponsiveness with recurrent episodes of wheezing, coughing, and shortness of breath Chronic Inflammation: Parenchymal destruction Breakdown of alveolar attachments Loss of bronchiole elasticity Chronic irritation by tobacco smoke / noxious agents: Increased Narrowing no. of goblet of cells airways & enlarged submucosal glands Impaired mucociliary clearance Mucous plugging Normal airway Asthmatic airway 4 Basement membrane Epithelium Mucus plug Smooth muscle Resulting Symptoms: Wheeze Breathlessness at rest & during activities Chest tightness Cough Increased mucous & phlegm Mucous glands Adapted from Jeffery PK. Am J Respir Crit Care Med. 2001;164:S28-S38. 4

5 1. Assessment of Asthma Control (ACT) or COPD Health Status (CAT) COPD Assessment Test (CAT) ( 8 Questions (max score 40) Score 5: normal healthy non-smokers <10: low impact of COPD on health status 10-20: medium impact >20: high impact >30: very high impact A change of 2 is clinically meaningful. Vaccination Influenza vaccination can reduce hospital admissions for both pneumonia and influenza, and reduce mortality risk. ACTION Ask whether patient had a flu vaccination during the most recent winter If patient did not have their most recent vaccination when due Advise of the benefits and encourage to have it annually During flu season : offer annual flu vaccination From community pharmacy or GP How Should We Teach Inhaler Technique? 2. Inhaler Technique Turbohaler Technique Score 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pre n=8 Post n=7 Pre n=9 Post n=8 Pre n=9 Post n=9 Unsatisfactory Satisfactory Optimal Verbal Augmented Verbal Augmented Verbal + Physical Basheti IA et al. Respir Care 2005;50:

6 Impact of Show and Tell Inhaler Technique Counselling Service Assess Technique using Placebos Show and Tell training method Re-assess technique Complete Inhaler Technique Labels Repeat at frequent intervals Community Pharmacy Service: Teaching Inhaler Technique Improves Asthma Outcomes Inhaler Technique Asthma Severity Basheti IA et al. Patient Education and counseling 2008;72:26-33 Basheti IA et al. Patient Education and counseling 2008;72:26-33 Inhaler Technique Assessment Written Resources Videos Inhaler Technique Assessment ACTION: Assess & improve inhaler technique Step 1 - Check inspiratory flow Use In-Check DIAL G16 inspiratory flow meter to measure inspiratory flow through the inhaler device(s). Step 2 - Check inhaler technique Patient should demonstrate how they use their own inhaler (unless newly prescribed). Assess Inhaler technique as Optimal (all steps completed correctly), Satisfactory (some minor errors, but all critical steps completed correctly), or Unsatisfactory (at least one critical error made). Step 3 - Teach correct inhaler technique Pharmacist/Tech should demonstrate correct inhaler technique to the patient. Issue Aerochamber where appropriate Step 4 Re-check inhaler technique and check understanding After teaching correct technique, the patient should demonstrate how they would use it again. This allows Pharmacist/Technician to check understanding & reinforce any difficulties. Categorising Inhaler Devices MDI MDI + Spacer Aerosol Soft Mist Inhaler Autohaler Easi-Breathe Measuring Inspiratory Flow: In-Check DIAL Dry Powder Inhaler (DPI) Single dose DPI - Blister Single dose DPI - Capsule Accuhaler Ellipta Forspiro Aeroliser Breezhaler HandiHaler Zonda Reservoir Multidose DPI Easyhaler Genuair NEXThaler Novolizer Spiromax Turbohaler Twisthaler 6

7 Comparison of Inspiratory Resistance & Inspiratory Flow Kruger P et al. on behalf of Almirall. ERS Poster 2014 Inhaler Technique: 7 Steps to Success 1. Preparation Check dose counter Shake inhaler (where applicable) 2. Priming Before first use (where applicable) Open inhaler / remove cap 3. Exhaling Fully and away from mouthpiece 4. Mouth Tilt head so that chin is lightly upwards Place mouthpiece in mouth & close lips for tight seal 5. Inhalation DPI: quick and deep inhalation (within 2 3 seconds) pmdi/smi: slow and steady inhalation (over 4 5 seconds) 6. Breath holding Remove from mouth, hold breath for 5 seconds 7. Closing and repeating Close inhaler / replace cap Repeat as necessary For individual devices patients should refer to the Patient Information Leaflet that accompanies the inhaler Usmani, Capstick, Chowhan & Scullion. Choosing an appropriate inhaler device for the treatment of adults with asthma or COPD. Guidelines.co.uk. In Press. (adapted from Anna Murphy (simplestepseducation) Seven Step approach) Aerosol Inhalers Range of MDI Wide range of drugs/classes Compatibility with Spacer (needed for many) Low IFR needed Many inhale too fast Ease of Use Moderate dexterity Coordination required Many use incorrectly Haleraid available counter: ICS/LABA (not SABA or ICS) SMI Respimat Long-acting bronchodilators Low IFR needed Efficient dose delivery High dexterity Complex loading/priming Locks when empty BA-MDI Autohaler/Easi-Breathe ICS and SABA only Low IFR needed Low dexterity indicator None Feedback Taste / sound Taste / click Taste / click Single DPI - Blisters Range of Accuhaler Ellipta Forspiro SABA LABA ICS; ICS/LABA Medium-low airflow across IFR 30-90L/min Ease of Use Low-moderate dexterity Gritty if not used correctly ICS/LABA LAMA LAMA/LABA Medium-low airflow Consistentacross IFR L/min Low dexterity Simple device FP/Salm only (1 strength) Medium-low airflow across IFR 30-90L/min Moderate-high dexterity Small dose counter Large dose counter counter Feedback Taste Taste Taste Visual: loading of doses & used blisters Single DPI - Capsule Range of Breezhaler HandiHaler Zonda LABA LAMA LAMA/LABA Low airflow across IFR L/min Risk of inhaling capsule fragments Ease of Use High dexterity Redesigned blisters easier to open Feedback Taste Visual: transparent caps LAMA LAMA High airflow across IFR 28-60L/min Risk of inhaling capsule fragments High dexterity Blisters difficult to open Taste Visual: open caps High airflow No data on drug delivery?? Risk of inhaling capsule fragments? High dexterity Capsules in bottle Taste Visual: transparent caps Single DPI - Capsule Range of Breezhaler HandiHaler Zonda LABA LAMA LAMA/LABA Low airflow across IFR L/min Risk of inhaling capsule fragments Ease of Use High dexterity Redesigned blisters easier to open Feedback Taste Visual: transparent caps LAMA LAMA High airflow across IFR 28-60L/min Risk of inhaling capsule fragments High dexterity Blisters difficult to open Taste Visual: open caps High airflow No data on drug delivery?? Risk of inhaling capsule fragments? High dexterity Capsules in bottle Taste Visual: transparent caps 7

8 Range of Reservoir Multidose DPI (1) Easyhaler Spiromax Turbohaler SABA LABA ICS ICS/LABA (due 2017) High airflow Consistent across IFR 30-60L/min Ease of Use Low dexterity Prime in vertical position counter (steps of 10) Feedback Taste Window shows unused doses ICS/LABA SABA LABA ICS ICS/LABA Medium airflow Higher dose delivery at faster IFRs (90 vs 40 L/min) Low dexterity Simple device Prime in verticalhorizontal position counter (steps of 2) Medium-high airflow Higher dose delivery at faster IFRs (90 vs 40 L/min) Moderate dexterity Prime in vertical position Turn aid available counter (Symbicort steps of 20) or indicator Taste Generally no taste Reservoir Multidose DPI (2) Range of Genuair LAMA LAMA/LABA Medium airflow Consistent No delivery <35L/min Ease of Use Low dexterity Prime in vertical position Locks when empty counter (steps of 10) Feedback Taste Click Window Green -> Red NEXThaler ICS/LABA Medium-high airflow across IFR 30-90L/min No delivery <30L/min Low dexterity Simple device Prime in vertical position counter (steps of 1) Taste Click 3. Education on Medicines Education on COPD Medicines Drug Role in Treatment Common side effects Short-acting beta 2-agonist (SABA) Salbutamol, terbutaline Long-acting muscarinic antagonists (LAMA) Braltus, Eklira, Incruse, Seebri, Spiriva Long-acting beta 2-agonist (LABA) e.g. Onbrez, Oxis, Serevent, Striverdi PRN use for fast-acting relief of breathlessness and wheezing. Onset within 5 mins; duration: 4-6 hours. All Asthma & COPD patients should have a SABA inhaler. Regular OD or BD use (aclidinium/eklira only). More effective than short-acting relievers, Larger improvements in lung function, breathlessness and quality of life, and reductions in hospitalisations. COPD: Recommended for patients with more significant COPD symptoms (CAT score 10; MRC 3). Asthma: Spiriva Respimat recommended as add on therapy to ICS/LABA to improve lung function & prevent exacerbations Regular OD (Onbrez and Striverdi ) or BD use. More effective than short-acting relievers, Larger improvements in lung function, breathlessness and quality of life, and reductions in hospitalisations. COPD: Recommended for patients with more significant COPD symptoms (CAT score 10; MRC 3). Asthma: Not recommended as single inhaler. Must be taken with ICS (ideally as combination inhaler) Tremor, palpitations, headache. Tend to occur with high use, or larger doses given as a nebuliser. Dry mouth is the most common side effect. This may be managed by rinsing mouth after use, or may require switch to an alternative within this class. Tremor, palpitations, headache, muscle cramps. May occur more commonly with high use of SABA. Education on COPD Medicines Drug Role in Treatment Common side effects Combination longacting bronchodilator (LAMA/LABA) Anoro, Duaklir, Spiolto, Ultibro Combination corticosteroid & long-acting beta 2- agonist (ICS/LABA) Aerivio, AirFluSal, Aloflute, Combisal, DuoResp, Flutiform, Fobumix, Fostair, Fusacomb, Relvar, Sereflo, Seretide, Sirdupla, Symbicort Regular OD or BD (Duaklir only) use. Side effects are likely to be similar to Combining two classes of long-acting bronchodilator those observed with each single agent, produces i.e. dry mouth, tremor, palpitations, Greater increases in lung function, breathlessness and headache, muscle cramps. quality of life than using only one LA-bronchodilator. Significant increase in exercise endurance may be seen. Licensed for COPD only. In Leeds, they are recommended as a first-line option for patients with more significant COPD symptoms (CAT score 10; MRC 3), ahead of using single-agent long-acting bronchodilator. Regular OD (Relvar only) or BD use. ICS decrease the number & activity of inflammatory cells that are present in the lungs of people with severe COPD (FEV 1 <50%) who experience frequent exacerbations. NO role in mild-moderate airway obstruction as these inflammatory cells are not present in sig. numbers. NB. Inhaled corticosteroid inhalers are only licensed for use in COPD when used as a combination ICS/LABA inhaler. Local ICS ADRs: oral thrush and dysphonia. Management: rinse mouth after use, spacer with MDI, or switching to an alternative drug/device. Other ADRs include skin thinning and bruising, osteoporosis. Some ICS increase risk of pneumonia, which may require discontinuation. High dose ICS/LABA: issue High Inhaled Steroid Warning Card. Education on COPD Medicines Drug Role in Treatment Common side effects Combination corticosteroid + long-acting beta 2- agonist + longacting muscarinic antagonist (ICS/LABA/LAMA) Trelegy, Trimbow Regular OD (Trelegy ) or BD (Trimbow ) use. Combining an inhaled corticosteroid with two classes of long-acting bronchodilator produces Greater increases in lung function, breathlessness and quality of life than using either dual LA-bronchodilator, or an ICS/LABA Significant reduction in COPD exacerbations may be seen. Licensed for COPD only. In Leeds, they are proposed first-line option for patients with more significant COPD symptoms (CAT score 10; MRC 3) and frequent ( 2 per year) exacerbations despite LABA/LAMA. Local ICS ADRs: oral thrush and dysphonia. Management: rinse mouth after use, spacer with MDI, or switching to an alternative drug/device. Other ADRs include skin thinning and bruising, osteoporosis. Some ICS increase risk of pneumonia, which may require discontinuation. Bronchodilator side effects are likely to be similar to those observed with each single agent, i.e. dry mouth, tremor, palpitations, headache, muscle cramps. NB. Fusacomb Easyhaler is licensed for use in UK, but has not been launched yet NB. Fusacomb Easyhaler is licensed for use in UK, but has not been launched yet 8

9 Evidence for the Side Effects of ICS Risks of High Inhaled Corticosteroids MHRA May 2006: Prolonged use of high doses of ICS carries a risk of systemic side effects... Corticosteroid treatment cards should be routinely provided for high doses of ICS. MHRA, September 2010: Inhaled (and intranasal) corticosteroids... High Inhaled Corticosteroid Warning Cards, 2014 For all patients Rxed high doses of ICS ( 1000mcg BDP/day). Consider for medium doses of ICS (e.g. 800mcg BDP/day) + Intranasal steroids Further information: Price et al. Prim Care Respir J 2013; 22(1): MHRA. Current Problems in Pharmacovigilance 2006 MHRA. Drug Safety Update Adherence Medication Adherence ACTION: EXPLORE and identify reasons for reported nonadherence (e.g. due to beliefs, device, medicine, or side-effects). ASK the patient how they feel about using their COPD inhalers. Do they have any concerns about using these medicines? DISCUSS and agree strategies and solutions to improve adherence with the patient. A patient-centred approach should be used at all times Possible Causes of Non-Adherence Beliefs Device Medicine Denial of condition Concern about quantity Misunderstand condition Misunderstand treatment Fear of side-effects Embarrassment Dexterity problems Incorrect technique Incorrect cleaning of spacer Frequency of dosing Several different medicines Actual side-effects Forgetfulness Cost of prescription 9

10 Framework for discussions How are you getting on with this medicine / inhaler? An open question to get the patient talking about issues that are important to them When and how often do you use this medicine / inhaler? Are you having any problems with this medicine/ inhaler, or concerns about taking or using it? It may be important to assure the patient that it is normal to have concerns about taking any medicine Do you think this medicine / inhaler is working? (Prompt- is this different from what you were expecting?) Patients should understand their medicines & benefits in COPD Do you think you are getting any side effects or unexpected effects? Consider filling in a Yellow Card if severe or drugs Allows discussion about managing/preventing side effects Adherence Interventions Information and education about COPD & medicines to address beliefs & concerns Set realistic expectations (e.g. ICS do not have an immediate effect on symptoms) Advice on use and care of inhaler devices & spacers Addressing forgetfulness: reminders, location etc. Managing and avoiding ADRs COPD & smoking FEV1 (% of value at age 25) 5. Smoking Cessation Never smoked or not susceptible to smoke Smoked regularly and susceptible to its effects Stopped at Disability Stopped at 65 Death Age (in years) Fletcher CM, Peto R. The natural history of chronic airflow obstruction. BMJ 1977; 1(6077): Smoking History Stopping smoking is the most important & cost-effective intervention in COPD Very Brief Advice ACTION: Give very brief advice (30 seconds) Ask / Advise / Act Refer to local NHS stop smoking service: Web: Do you or anyone else in your household smoke? CPPE/NCSCT Training: Stop smoking NCSCT practitioners assessment: knowledge and skills Learning about stop smoking support 10

11 Very Brief Advice Very Brief Advice Do you know that stopping smoking can improve breathlessness, reduce hospital admissions, help prevent disease progression and increase life expectancy? It s never too late to stop. Have you ever thought of stopping or tried to stop before? I can tell you where to get the best help. The Local NHS Stop Smoking Service can offer you support and advice on quitting. You are up to 4 times more likely to stop with the support from the service The Stop Smoking Service can make this much easier for you. Shall I refer you? It really is the best thing you can do right now. It s a free advice service Further support for patients Signpost patients to patient resources on the internet, e.g. British Lung Foundation ( Asthma UK ( Inhaler technique videos e.g. Asthma UK ( Right Breathe ( BLF Breathe Easy support groups ( Groups in Beeston, Bramley, Gipton, Hunslet, Middleton, Guiseley/Yeadon, Bradford, Dewsbury End of Consultation Summarise key points: Smoking cessation, inhaler technique & adherence, vaccination, healthy lifestyle Confirm issues being referred to their GP And send it to the GP! Ask if they have any final questions. Arrange follow-up appointment. Record consultation on PharmOutcomes within 48hrs 11