In asthma, prevention is vital to successful management of the condition. Preventer inhalers should be the mainstay of treatment and relievers should only be used if the patient is suffering symptoms. To health professionals this simple point is the basic principle for treating many patients with asthma. This is so simple but often missed.
The evidence-based guidelines support this principle. Inhaled steroids are used in all steps of asthma treatment in the UK except step 1 (British Guideline on the Management of Asthma SIGN 141). Beta-2 agonists, such as salbutamol, are reliever inhalers. Salbutamol is useful because it causes rapid bronchodilation and hence eases the symptoms of asthma. For example, a Ventolin Evohaler will cause rapid bronchodilation (onset within five minutes) in reversible airway diseases such as asthma. The effect will last for four to six hours. This is, of course, useful in acute situations or pre-exercise but is rarely the answer to managing asthma on a long-term basis.
The preventer inhaler (usually an inhaled steroid alone or in combination with a long-acting beta-2 agonist inhaler) has been shown to be effective at reducing and often reversing the inflammatory response.
Addressing how preventer inhalers were being used by patients who died, the National Review of Asthma Deaths said: “There was evidence of widespread underuse of preventer medication. Overall compliance with preventer inhaled corticosteroids (ICS) was poor, with low repeat prescription fill rates both for patients treated with ICS alone and for those treated with ICS in combination with a long-acting beta agonist (LABA).
“Non-adherence to preventer inhaled corticosteroids is associated with increased risk of poor asthma control and should be continually monitored.”
The management of asthma is complex, and successful treatment depends on factors beyond the compliant use of preventative inhalers. That said, community pharmacists should be monitoring compliance of patients using preventer inhalers as part of the clinical check. If a patient is overusing a beta-2 agonist inhaler, it is not unlikely that they are underusing the inhaled steroid preparation.
Spotting this as part of the clinical check in the dispensing process and then engaging with the patient (in England through a medicines use review or in Scotland through the chronic medication service) could help the prescriber manage the patient and lower the risk of asthma exacerbation.
For community pharmacists, there is no better time to have this chat than when dispensing the inhaler. This type of intervention is simple, requires no access to the patient record, does not depend on the pharmacist being a prescriber, and also can easily be completed in a busy community pharmacy.