Inappropriate prescribing putting asthma patients’ lives at risk, warns charity

Thousands of patients with asthma in the UK are not being prescribed the right medication to keep their condition under control, finds an audit^[1]
of GP practice records by the charity Asthma UK.

The National Review of Asthma Deaths^[2]
, published in May 2014, investigated the deaths of 195 people who died from asthma in 2012 and 2013. It highlighted prescribing errors in nearly half of the asthma deaths in primary care (47%), and the two most common were use of long-acting reliever inhalers alone and excessive use of short-acting relievers.

To identify how often these two prescribing errors occurred in routine care, Asthma UK analysed 94,955 patient records from over 500 UK GP practices between 2010 and 2013. The results of the audit show that 5,032 patients had been prescribed more than 12 reliever inhalers over a 12-month period, 1,965 of them without being reviewed by a nurse or doctor. A further 402 patients had been prescribed long-acting reliever medicines without a corticosteroid preventer, or not as a combination inhaler. Long-acting relievers are not licensed to be used in this way for asthma.

When applied to the UK population, this indicates that around 106,742 people with asthma may have been prescribed excessive amounts of reliever medication without being reviewed. This includes more than 10,000 children. In the audit, the number of reliever inhalers prescribed over 12 months varied from 13 to 80. A maximum of 12 reliever inhalers should be prescribed per person per year, with more than six giving a warning sign of poor asthma control.

Across the UK, a further 22,840 people with asthma, including 1,903 children, “may have been prescribed unlicensed medicine which puts them at a higher risk of death”, the report says. Long-acting reliever inhalers open up the airways so that people are less likely to experience an asthma attack if they are exposed to triggers. However, they do not treat the underlying inflammation, so using them alone leaves the airways of people with asthma inflamed and more likely to react to triggers such as pollen or pollution.

“It is simply unacceptable that the lives of people with asthma are being put at risk because of unsafe prescribing,” says Kay Boycott, chief executive of Asthma UK. “The UK has some of the highest mortality rates for asthma in western Europe and the levels of unsafe prescribing identified in our report must be stopped.”

Boycott says it is crucial that healthcare professionals review their systems and urgently recall patients who have been prescribed long-acting reliever inhalers on their own without a steroid preventer, or not as a combination inhaler.

Anna Murphy, consultant respiratory pharmacist at University Hospitals of Leicester NHS Trust, says the recommendations in the National Review of Asthma Deaths hadn’t been implemented a year on, but pointed out that some patients did not understand that asthma is a chronic inflammatory disease that needs treatment with inhaled corticosteroids, and for relievers to be used as back up only.

“So it’s not just about bad prescribing, it is also about the challenge of making sure patients understand how to manage asthma,” she says. “If we can’t get patients to understand that, it is no wonder that we can’t get them to come in for asthma reviews.”

The review process is often “the lever” for changing medication, but at the moment only around 45% of people with asthma attend their annual review, she adds.

Alastair Buxton, director of NHS services at the Pharmaceutical Services Negotiating Committee (PSNC), says: “Community pharmacy is well placed to offer services to help people with asthma better manage their condition and its associated medicines and, with general practice currently facing immense pressure, community pharmacy can also offer access to services over longer opening hours often with no appointment needed.”

After the National Review of Asthma Deaths was published, the PSNC published a report^[3]
in June 2014 highlighting the contribution that community pharmacy could make to improving asthma care.