CASE STUDY
AS SCOTTISH PHARMACY CONTINUES TO OPERATE IN THE WAKE OF THE 2014 NATIONAL REVIEW OF ASTHMA DEATHS, BERNADETTE BROWN FROM CADHAM PHARMACY TELLS SP ABOUT TWO CASE STUDIES, WHICH HAVE GREATLY IMPROVED PATIENT OUTCOMES....
A BREATH OF FRESH AIR...
by Bernadette Brown, Cadham Pharmacy D
uring the course of my daily prescribing, I had noticed more elderly COPD patients
struggling to breathe and wanted to have more coming to my clinics for respiratory reviews. In order to get this initiative up and running, my local GP practice gave me a list of asthma patients who were using more than twelve inhalers a year as this was a good starting point to start my prescribing journey.
CASE STUDY ASTHMA
Patient description and past medical history • Male aged 67 years • PMH asthma all his life. • Osteoarthritis and hypertension. • Non smoker
The patient was using more than twelve salbutamol inhalers a year and his ACT score was poor. His asthma was controlling his life and he could not walk from the pharmacy to his car without getting breathless. I started seeing him in 2014.
CURRENT THERAPY
• Accuhaler and high dose steroid with inhaled long acting bronchodilator.
• Each single inhalation provides a delivered dose (the dose leaving the mouthpiece) of 47 micrograms of salmeterol (as salmeterol xinafoate), 460 micrograms of fl uticasone propionate. This corresponds to a pre-dispensed dose of 50 micrograms of salmeterol (as salmeterol xinafoate) and 500 micrograms fl uticasone propionate.
WHAT MATTERS TO HIM? He had not long retired and was upset
20 - SCOTTISH PHARMACIST
that he could not spend quality time outdoors with his grandson, family and friends. He could not walk any distance at all without his salbutamol inhaler and was using this up to eight times a day.
INHALER TECHNIQUE
Due to poor inhaler technique, I was able to fi nd a way of getting the medicine delivered to the lungs by a teach approach and spending time on this part of the consultation.
I stopped the Accuhaler device and prescribed the same steroid andlong acting beta agonist in an MDI DEVICE and aerochamber with mask. This small change in his device and regular reviews to reinforce technique.
In line with the Asthma UK guidelines I saw him regularly to check technique and as he was on a high dose of corticosteroid it was important to give the advice to prevent oral thrush or sore throat:
• Brush your teeth, rinse out your mouth or gargle and spit out, after using your preventer inhaler
• Use a spacer with your preventer inhaler
GOALS OF THERAPY
• To avoid, where possible, the patient’s asthma triggers - in his case sudden changes in temperature or cats.
• To use the inhalers as prescribed regularly for the preventer combination inhaler and when needed for the salbutamol and aim to gradually see a reduction in the need for the salbutamol regularly.
• To reduce the high dose steroid at a suitable point in the future to reduce long-term risks of pneumonia.
REVIEW PROCESS
• 20-minute appointments every fortnight for the fi rst six months.
• Each review complete an ACT score
• Record day and night time symptoms
• Record peak Flow reading and compare to last review.
• Record triggers and progress on achieving his goals and what matters to him.
This regular review was motivational for this patient and he felt that the care and compassion to help him to achieve his goals was a different approach that he liked and responded well.
RESULTS AT MONTH SIX
• Peak Flow improved from a baseline of 250 to 550.
• He could cycle ten miles with his grandchild
• His quality of life had improved. ONGOING REVIEW
• His mental health had also improved and he was more positive about life. ACTION PLAN
• I stopped the high dose combination inhaler and reduced it to STEP 2 Asthma Guidelines
• Monthly reviews 10-20 minutes • Continued to monitor technique
• I see him monthly when he collects his medication for a quick review and we have agreed a formal six monthly check up.
• He has an asthma plan and is clear when to come and see me should his peak fl ow and symptoms deteriorate and this plan has been agreed by his practice.
and symptoms at all reviews.
OUTCOME AFTER TWELVE MONTHS
• Peak fl ow despite being on the lower dose on ICS/LABA stabilized around 550-600
• He rarely uses his reliever inhaler and can now cycle fi fteen miles with his grandchild and regularly hill walks with his friends.
• He has had no asthma exacerbations in twelve months
He has now rented a holiday home in Cyprus and he and his family regularly visit enjoying his health and life to the full.
Throughout this ‘journey’, the patient’s GP was informed and his medical records updated to refl ect the changes in his prescribed medication. All of the results were also fed back to the practice and the practice staff updated all the relevant clinical fi elds in their personal records.
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