UK asthma mortality is too high, but pharmacy can help

Asthma may be a treatable disease, but it can be a killer. The UK has the fourth worst asthma mortality rate in Europe^[1]
. Around 5.4 million people (1.1 million children and 4.3 million adults) receive treatment for asthma in the UK, but 1,434 people died from an asthma attack in the UK in 2015 — up by more than 20% since 2011^[2]
.

The National Review of Asthma Deaths (NRAD), ‘Why asthma still kills’, looked into the circumstances surrounding 195 deaths from asthma recorded between 1 February 2012 and 30 January 2013. It was published in August 2015 and suggests that more than 60% of the asthma deaths it reported could have been prevented. The results of the review showed some uncomfortable findings^[3]
:

• 10% of these patients died within 28 days of discharge from hospital after being treated for asthma;
• Only 23% of these patients had been provided with personal asthma action plans (PAAPs), which are acknowledged to improve asthma care;
• 43% of these patients had not received an asthma review in the last year of their life;
• 50% of these patients did not have triggers or exacerbating factors documented;
• 39% of the patients who were on short-acting bronchodilator agonists (SABAs) at the time of death had been prescribed more than 12 short-acting reliever inhalers in the year before they died, indicating that their asthma was poorly controlled;
• 38% of patients on preventer inhalers at the time of death were issued with fewer than four prescriptions for inhaled corticosteroids (ICSs) per year (patients should receive at least 12 preventer prescriptions per year);
• For 46% of the deaths, factors were identified that could have prevented death in relation to healthcare professionals’ implementation of asthma guidelines.

The NRAD report also provided recommendations for clinicians caring for people with asthma to improve care and, ultimately, reduce deaths; it is important that pharmacists are included in this drive.

Quality asthma interventions by pharmacists

Pharmacists are vital in efforts to address NRAD’s findings^[4]
 and this is reflected in subsequent national policy. The Community Pharmacy Quality Payments Scheme rewards community pharmacists for ensuring children who are prescribed ICSs have a spacer device. It also rewards pharmacists who refer asthma patients who have been given more than six SABA inhalers without any ICSs within a six-month period to another healthcare professional^{[5]
‚[6]}
.

The ‘NHS Long-Term Plan’, published on 7 January 2019, also highlights the role of pharmacists in ensuring that patients with asthma receive the right medicines. It proposes that pharmacists in primary care networks should undertake medication reviews in asthma patients and encourage them to reduce their use of SABA inhalers and “support uptake of new smart inhalers, as clinically appropriate”.

Community pharmacists should see themselves as ‘SABA guardians’ who can help patients understand that SABAs are not the ‘core treatment’ and do not necessarily keep asthma symptoms at bay. Most SABA inhalers contain 200 puffs so, in theory, less than 1.5 SABA canisters per year should be sufficient for a patient who has well-controlled asthma. Patients may also need around two extra inhalers; for example, for use at school or in the car.

Use of more than 1.5 canisters per year is excessive for a well-controlled patient. Guidance from the National Institute for Health and Care Excellence states that “three or more days a week with required use of a SABA for symptomatic relief” constitutes uncontrolled asthma^[7]
. Medicines optimisation pharmacists (GP-based pharmacists and medicines management pharmacists working directly with clinical commissioning groups) can support GPs to identify patients with asthma who are taking more than three doses (while one dose equates to 1–2 puffs) of SABA per week (i.e. those prescribed more than two reliever inhalers per year) or collecting fewer than 80% of their required ICS inhalers.

Managing puffs can be confusing for patients, particularly as most inhalers containing SABA do not have a dose counter. In order to alleviate this confusion, the Primary Care Respiratory Society, in partnership with the International Primary Care Respiratory Society, has produced resources such as the ‘Asthma Right Care SABA slide rule’ to help healthcare professionals and patients understand that SABAs are not the core treatment for asthma (except in rare circumstances for patients who have infrequent, short-lived wheeze)^[8]
. The tool — which pharmacists can download or order — uses a ‘traffic light’ system to highlight levels of SABA use that are considered too high, and the readiness ruler on the reverse should create a sense of urgency to shift patient and clinician behaviours away from over-reliance on SABAs.

Pharmacists can play an integral part in shifting the average ratio of reliever to ICS inhalers prescribed in a year; the ideal ratio is 1:6, but it is currently likely to stand at 2:1^[9]
. Using medication records to identify patients, pharmacists can initiate conversations about SABA over-reliance and ICS underuse, and how this can lead to worsening symptoms and poor asthma control. They can spend time educating, answering questions and checking the PAAP is up to date.

Of course, this is all with the caveat that pharmacists should be cautious about changing an inhaler device to one that the patient is unfamiliar with^[10]
. It is important to prescribe by brand so that the patient receives a familiar device each time; unfamiliar devices may result in poor technique and poor adherence.

Improving adherence and using action plans

In clinical trials, ICS treatment has been shown to be effective by reducing asthma attacks by 55% compared with placebo or SABA alone^[11]
. Adherence to ICS treatment is a critical factor in maintaining good asthma control, but fewer than 50% of children and 30–70% of adults (depending on country, age, sex and ethnicity) are adherent^[12]
. Incorrect inhaler technique, which is unacceptably frequent, is also an issue.

Pharmacists should familiarise themselves with good inhaler technique so they can coach patients on using inhaler devices and spacers. The free RightBreathe
^[13]
app — for clinicians and patients alike — is a useful resource for pharmacists. It provides videos demonstrating good inhaler technique for the available devices (including spacers), evaluated against UK Inhaler Group standards^[14]
. The app also allows patients to set reminders of when they need to inhale their next dose.

Pharmacists should also remind patients of the importance of using a PAAP to identify when their symptoms are worsening and how they should respond. Asthma UK has produced a template that clinicians can fill out with patients^[15]
. The PAAP can include details of preventer dose, reliever use, spacer use, peak flow readings (and the patient’s personal best peak flow), the patient’s triggers, a reminder of when to make an appointment and advice on what to do in the event of an asthma attack.

Developing respiratory services in community pharmacy

Patients can also take advantage of other services provided by community pharmacy, such as the medicines use review and the new medicines service, including an assessment of inhaler technique. As people with asthma are a defined patient cohort for vaccination, they should be encouraged by pharmacists to receive a flu vaccination, which they can do in the pharmacy. Stop smoking services can also provide support for patients who smoke or live with a smoker. If warning signs are noticed, pharmacists can refer the patient to an asthma specialist when warning signs are flagged.

Pharmacists can contribute to improved care at the patient level but, with their expert medicines knowledge, they are also valuable collaborators in local initiatives. The Business Services Authority has produced respiratory dashboards^[16]
that pharmacists can use to make local practices aware of prescribing patterns and unwarranted variation in prescribing. For local areas that are considering making improvements, NHS Rightcare^[17]
has produced long-term condition packs and good-practice case studies that pharmacists can refer to.

Doing more for asthma

Patients with asthma deserve better care. Mortality rates are stubbornly high, despite many deaths that could potentially be preventable with the correct treatment. The pharmacist’s role in asthma care is sometimes overlooked — this urgently needs to change to prevent further disease, disability and death. As pharmacists, we can do more.