Steps to take when you suspect a patient is under-using ICS
Pharmacist and Primary Care Respiratory Society (PCRS) executive committee member Darush Attar-Zadeh gives advice for asthma-related pharmacy queries during the coronavirus pandemic.
As Professor Anna Murphy, consultant respiratory pharmacist at University Hospitals of Leicester NHS Trust, says of ICS in asthma, this is: ‘The Inhaler to Control Symptoms’.
Asthma is an inflammation of the airway, and treatment fundamentally needs to target this. However, we know there is current underuse of ICS and over reliance on short acting beta agonists (SABA). The first step for pharmacists when doing searches on GP practice or community pharmacy records should be to attend to these patients as all guidelines recommend that they should be on ICS.
PRIMIS has developed some stand-alone system searches to help practices identify and target higher risk patient groups in relation to Covid-19. One of the searches includes identifying asthma patients with 3+ issues of SABA in last six months with no corresponding issue of ICS inhaler (review to consider ICS inhaler use). Access the PRIMIS search via guidance on shielding, as well as other Covid-19 resources, through the PCRS website.
High dose ICS > 1000mcg BDP equivalent in asthma. Can step down be considered?
Any prescribing of high dose ICS in people with asthma for the prevention of exacerbations has always needed to be clearly justified and the current situation should concentrate our minds further.
It is important to consider:
- Are they controlled or uncontrolled? If uncontrolled, is it definitely asthma causing the symptoms (consider whether other multi-morbid conditions may be contributing)?
- Was the step up to above BDP equivalent 1000mcg daily justified when it happened and did the step up align with guidance or exceed this? Have they been reviewed subsequently with a view to stepping back down?
- Are they using the inhaler, including their spacer if applicable, effectively and as prescribed such that they are receiving this high dose?
- Has anything changed since the last review, for example, have they stopped smoking, has their device been changed without their having received support to use the new device correctly?
- Is the patient using an up to date PAAP that they’ve co-created with their designated respiratory clinician?
High dose ICS prescribing compared with prescribing of all ICS can be viewed at a practice level and CCG level freely on open prescribing. Reduction of ICS should be considered for well controlled patient every three months after a clinical assessment.
Increasing ICS in case of asthma attack with suspected Covid-19
Current evidence supports up to quadrupling of ICS from standard doses until symptoms improve in adults. Evidence does not support increasing ICS in children in asthma to improve asthma attack outcomes.
OCS in case of severe asthma attack with suspected Covid-19
Oral corticosteroids (OCS) should be used in people with asthma attacks according to current UK guidelines. There is no evidence to suggest appropriate use of OCS in asthma attacks will cause a worse outcome if Covid-19 or similar viruses is suspected to be the trigger. The PCRS provides additional information.