Changing prescribing habits is easier said than done

When you have been prescribing the same type of drugs for a number of years, it becomes difficult to incorporate newer drugs, formulations or drug combinations into your usual prescribing habit.

In the past, I have always found the respiratory area of medicine relatively easy to prescribe in. There is a definite structure to the various stages of treatment (for example, the SIGN asthma guidelines), depending on the severity of the patient’s condition, and the limited number of drugs used are listed in a logical fashion. The major issue around prescribing nowadays is that often the inhaler type has to be changed because the drugs have changed (eg, an easi-breathe autohaler has to be changed to an aerosol metered dose inhaler or a dry powder turbohaler).

Also prescribing an inhaler becomes more complicated when there is a plethora of different drug combinations presented in different inhaler types. I have used the same drugs and inhalers over a number of years and, like most prescribers, I suspect I have my “favourites”, which I have a lot of experience with and feel confident in recommending to my patients.

I was recently asked to give a short presentation to pharmacists about any “updates” in the respiratory field over the past year or so. The easy bit was talking about updates to the two major guidelines but the changes in the available inhalers and the newer drugs in use turned out to be a minefield. Although the new drugs still belong to the major groups of drugs in use, they now have names I have never heard of and come in “once daily” dosage as opposed to the more usual “twice daily” regimen.

There is always the possibility that some of these newer inhalers offer advantages (financial or medical) over the “older” ones and they may suit specific patient groups better than those previously available. But I find myself with a bit of a problem: I cannot remember them all. Yes, the drug representatives have been to see me over the past 18 months and given me all the necessary information but it seems to go in one ear and out of the other!

Having spent a considerable number of years telling doctors that they should change their prescribing habits, move with the times and possibly save the NHS some money, I have suddenly discovered why this was such an issue for them. It is difficult to change your prescribing habits, honed to perfection over a considerable number of years, and suddenly to make what seem like fairly radical alterations to what you have become comfortable with.

Most GPs have the advantage of prescribing within the surgery so they can use the computer to remind themselves of any newer drugs and any varied combinations. Unfortunately, as a pharmacist I often do not have computer access available in the background and always have to handwrite my prescriptions so this can be a real problem for me. You can imagine my relief when the local “Managed Clinical Network” produced an idiot’s guide to prescribing for asthma and chronic obstructive pulmonary disease, which adheres to the local joint formulary and has been ratified by the health board and local leading clinicians. Putting a laminated copy of this on my desk will enable me to look as though I know what I am talking about when I am sitting in front of a patient — always useful in the clinical setting.

The icing on the cake is that they recommend prescribing by brand name, thus relieving me of having to remember what can be tricky drug names, not to mention how to spell them!

It would appear I am not the only one with problems because a colleague kindly produced a document with the new inhalers listed by name and content plus a coloured picture of each inhaler. I will be framing this and hanging it on my wall for future reference.