Scottish Pharmacist Volume 8 Issue 4

CASE STUDY his oxygen saturation levels

• He was reviewed once a month and the consultation would take up to 30 minutes to complete all the measurements

GOALS OF THERAPY AND WHAT MATTER TO HIM

• To reduce the amount of exacerbations

CASE STUDY COPD

Patient description and past medical history • 72 year old male • Moderate COPD

• Ex smoker. Stopped fifteen years ago

CURRENT THERAPY

• Symbicort 400/12 one puff twice daily

• (Contains ICS Budesonide 400mcg and Long acting Bronchodilator Formoterol 12mcg)

• Theophylline (Uniphyllin 200mg twice daily)

• Carbocysteine (mucodyne liquid) It works by making mucus (phlegm) less sticky. This makes the mucus easier to cough up.

• Salbutamol when required

• Spiriva ( Tiotropium) Long acting antimuscarinic to assist with hyperinflation and allows patient to walk further and achieve more.

CURRENT SYMPTOMS • Shortness of breath even at rest

• Using salbutamol in excess of ten times a day

• Mucous is thick with a chewing gum texture

• Exacerbations more than two per year

• Quality of life very poor and patient showing signs of anxiety

CURRENT CARE AT GP SURGERY

• Sees nurse once a year unless he gets an infection

22 - SCOTTISH PHARMACIST SHARED CARE APPROACH

• Introduced the pharmacy review in 2014

• Agreed with patient and practice to feed back all clinical data and progress from reviews

PHARMACY INTERVENTIONS

• Due to poor inhaler technique and him forgetting on many occasions to take the night time dose of symbicort, stop symibcort.

• Replace with Relvar Fluticasone furoate 92mcg/(ICS)/Vilaneterol trifenatate22mcg( LABA) Take one puff at tea time. Evidence suggests better control if taken at this time of day

• Stop Spiriva

• Start Incruse Umeclidinium Bromide 55mcg ( LAMA)

This was decided upon based on compliance and ease in which he could actually use the Ellipta device.

REVIEW PROCEDURE AND MEASUREMENTS TAKEN.

• He was booked into our spirometry clinic and nurse performed a recent spirometry

• His FEV 65 per cent suggested he did not require a steroid but, due to his past medical history of exacerbations, we decided to keep it in meantime and review again in twelve months

• On each review we did a CAT score to determine how the COPD and symptoms were impacting on his life

• We checked on his use of his salbutamol and his level of activity

• Using pulse oximeter, I would check

• To reduce the steroids if possible • To feel better and not so breathless

• To tend to his garden and have the health to breathe and look after it again

• To reduce the amount of salbutamol needed daily

RESULTS AT SIX MONTHS • CAT score much improved

• Quality of life Improved dramatically with very rarely maximum of twice a week requiring his salbutamol inhaler

• No exacerbations in this six-month period.

• Ongoing follow up and management plan

• We agreed to keep the same regime for a further six months with a monthly review.

TWELVE-MONTH REVIEW

No exacerbations over period of a year.

His sputum no longer a thick chewing gum consistency and no longer using the carbocysteine on a regular basis.

PRESCRIBING DECISIONS AT THIS STAGE

• Stop Mucodyne. GP practice agreed to take off repeats

• Stop Uniphyllin for a trial of three months. This was back to weekly reviews to ensure this was the right decision to stop and he experienced no deterioration in symptoms.

After regular reviews for a further three months we asked for Uniphyllin to be taken off his repeat records.

• Stop Relvar. The patient had no exacerbations in the last twelve months. His symptoms were such

that he had very little shortness of breath and very rarely required his salbutamol. His exercise tolerance has markedly improved and he can now manage his garden every day and can lift heavy bags of soil and walk into a wind now and not get breathless.

• Start Anoro Ellipta. (Umeclidinkium bromide 55mcg(LAMA)/Vilenterol trifenatate 22mcg LABA)

It was explained in great detail to the patient why I felt he could manage without the steroid and that it may in fact assist in the long term to prevent exacerbations.

His action plan was updated to reflect his new therapy and he was given a note of the dose of steroids now reduced in line with the new guidelines for COPD to 30mg daily for seven days and Amoxycillin 500mg three times a day for seven days.

OUTCOMES AT 18 MONTHS

• Huge improvement in his quality of life not just his physical ability to function and achieve doing his garden but also in his mental health.

• He is pleased that he feels better and requires less medicines to achieve this.

• He likes to still come for a smaller review once a month when he picks up his medication and likes to fill me in on how his garden looks as well as taking some measurements.

• He has continued not to have an exacerbation but has his written plan and knows that he has a course of steroids and antibiotics at home just in case.

• He does not require his blue inhaler at all at this present time and keeps it just in case.

HE no longer has to spit up thick mucous daily.

WHAT CAN WE DO AS PHARMACISTS

I hope I have demonstrated that we can do a lot to support our respiratory patients from the community pharmacy setting. We are ideally placed to see them more regularly and even if not a prescriber a regular review of their inhaler technique can prove significant for many patients. •

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