Pharmaceutical Care in Respirtory Disease Flashcards
What is the aim of pharmaceutical care in respiratory disease
Our aim is to help patients with respiratory disease to:
• obtain most effective therapy
• understand their disease
• use their medicines appropriately (medicines optimisation)
• experience improved QoL
We can do this by preventing disease, identifying disease and managing diagnosed conditions.
How do we try to prevent asthma and copd in the first instance
Asthma: Encourage breast feeding - protective effect Allergen detection and avoidance Smoking COPD: Prevent smoking
How do we identify underlying disease
If a patient presents with the following, pharmacists may be in a position to identify respiratory diseases Asthma: Frequent ‘chest infections’ Persistent cough Children: Recurrent ‘wheezy bronchitis’ Chest tightness or shortness of breath COPD: Current or ex-smoker Persistent cough Recurrent ‘bronchitis’ in winter Breathlessness on exertion Wheezing
For both, we must be mindful of regular OTC sales/Rx’s for cough medicines and antibiotics
What links can be made between smoking and respiratory disease
Smoking causes 35% of respiratory related deaths each year
COPD is the fourth most common cause of death worldwide
Second hand smoke is related to asthma in both children and adults
What support must pharmacists offer to people with newly diagnosed respiratory disease
Newly diagnosed patients need support: • Ensure understanding of disease, education • Assess prescriptions: o appropriate doses o interactions o sensitivities o Contraindications • Most important - check patients have been shown how to use inhalers/take medicines
Why do we need to councel patients on the correct way to use inhalers
The device is as important as the drug itself!
Device must be:
• Able to effectively deliver drug to the site of action
• Suitable for individual patients to be able to use
What factors must we consider when deciding on the best device for the patient
There are lots of devices available, but there a few factors to consider when making a choice:
• Aerosol or dry powder
• Breath actuated?
• Manipulation of it – is the patient able to (cognitively or physically) use the device?
• Taste
• Is there a dose counter?
What factors influence the prescribing choice of inhaler
• Cost • Patient preference • Assessment of correct use o Consider: - manual dexterity - age - portability - choice of drug may determine inhaler
There is no evidence for using one type of inhaler over another (when the dose and drug is the same)
What are some common errors patients make when using MDIs
Problems commonly occur with:
• Not shaking inhaler before use (drug isn’t well dispersed)
• Inhaling too sharply or at the wrong time (breath doesnt have to be overstated)
• Not holding breathe for long enough after inhaling
What is the difference in drug delivery in patients with good inhaler technique vs poor inhaler technique
With GOOD technique, the patient will get 20% lung disposition.
With BAD technique it can be as little as 5% disposition of drug at the target site.
90% of patients have the wrong technique.
Health professionals have also been shown to have a poor technique, therefore they train patients incorrectly.
What is important to remember when using MDIs and DPIs
MDI – slow and gentle inhalation (normal breath)
DPI – Fast and quick
Both = deep inhalation
What are spacers and what do they help with?
Spacers can help patients get a better outcome from their MDIs e.g. aerochamber, nebuhaler, volumatic
• Avoid need for coordination with MDI
• Increase lung deposition
• decrease deposition in mouth/throat
• Caution! Dry in air after washing with soap and water – don’t towel dry, wash the spacer monthly (no dishwasher due to static electricity)
• Replace every 6-12 months
What are the cautions around nebulisers
- Caution - over reliance (asthma)
- Mixing drugs, compatibility
- Increased side effects compared with inhalers
- Servicing once per year
How are patients supplied with oxygen therapy are what are the cautions
Oxygen cylinders are supplied by commercial company for different parts of England, e.g. Air Products for NW
• GP/hospital uses Home Oxygen Order Form (HOOF) to order
• Provision of advice for patient &/or carer
• Smoking!
What are the general monitoring requirements for patients with respiratory disease
• Changes in prescriptions (escalating/de-escalating therapy)
• Symptoms, including exercise limitation
• Inhaler technique
• Adherence
• Drug/disease interactions e.g. beta-blockers, NSAIDS (negative impact)
• Adverse effects, e.g.
o Beta agonists – tremor
o ICS - thrush, hoarse voice
What are the monitoring requirements for patients with asthma
Asthma • PEF • Self-management plan/Action plan • Use of bronchodilators • Annual flu vaccine • Weight loss
What are the monitoring requirements for patients with COPD
COPD • Sputum – increased production? • Annual flu vaccine • Annual Pneumococcal vaccine • Worsening symptoms • Osteoporosis
What are the monitoring requirements for patients with respiratory disease by hospital pharmacists
In hospital • Blood gases • Theophylline levels (methylxanthine) • U&Es (e.g. K+ - salbutamol) • HR/RR • O2 saturation • Temperature (suspected chest infaction) • C&S
Why might treatments fail?
Treatment may fail for many reasons. Consider:
• Failure to take medicines as prescribed
• Failure to use devices correctly
• Failure to use peak flow meter regularly
• No Action Plan
- drug causes, adrs
- worsening of underlying disease or acute condition
- others (depression)
What are the general councelling points for asthma
- Smoking cessation
- Allergens avoidance
- Avoid NSAIDs, (ᵝ-blockers)
- PEF + diary
What are the general councelling points for COPD
- Smoking
- Nutrition and keeping a healthy BMI
- Drugs as above + sedatives
What are the general councelling points for the use of Beta agonists
- Time to effect
* ADRs – tremor
What are the general councelling points for the use of short acting beta agonists
- ‘Reliever’
- Use prn or regularly
- Usually Blue
What are the general councelling points for the use of long acting beta agonists
- ‘Controller’
- Usually Green
- Regular use
What are the councelling points for corticosteroids
- ‘Preventers’
- For inflammation
- Use regularly, even if the patient feels well
- Rinse mouth after use to prevent oral thrush etc
- ADRs
- Brown, orange lots of colours available
What are the councelling points for oral steroids
- Usually short course
- 5 days’ asthma, 7 days COPD
- Carry steroid card if maintenance Rx
- Continue with inhaled steroids
- Take all tablets in morning
- With/after food
- ADRs - increased appetite, acne, sleep disturbance
- Long-term ADRs – osteoporosis (consider prophylaxis), diabetes etc
What are the councelling points for theophylline
• Same brand due to its narrow theraputic drug index
• Take regularly but don’t increase dose if breathing worsens
• Avoid OTC preps including theophylline
• ADRs – headache, irritability, nausea – seek advice as its a sign of toxicity
• THINK INTERACTIONS AND ADRs
o Smoke, Abx
What are the councelling points for antibiotics
- Complete course
- Take regularly
- Drink plenty of fluids
What are the councelling points for leukotriene antagonists
Leukotriene antagonists
• Take regularly
• Thirst and bedwetting if child
What must we educate and support our patients with
All patients must have an Asthma Action Plan (PERSONALISED): - Inhaler/PEF training - Knowledge of drug types - Support self-care Recognition of worsening asthma/COPD – Action points e.g. when to • increased inhaled steroids • start oral steroid and/or antibiotics (COPD) • seek medical attention COPD self-care - home antibiotics and steroids
What do personal asthma action plans include
They are written and personalised to the individual patient
Moderate – severe disease, i.e. BTS Step 3 or above &/or previous admission - CRITICAL these patients have an AAP
Describes PEF at which to:
• Double dose of inhaled steroid
• Start oral steroids
• Telephone GP or call ambulance
Evidence of improved health outcomes and reduced hospital admissions
Can link to MUR/NMS which are respiratory specific
What are the key values of PEF in asthma
Peak Expiratory Flow rate (PEF) – allows patient and/or HCP to monitor asthma control by keeping a PEF diary - effort dependent - best of 3 - available on FP10 - dependent on sex, age, height - % predicted normal or best: – Aim >70% or 0.7 (if FEV1/FEV) – “Normal” > 80% – <50% acute severe asthma Allows patient/HCP to monitor control in conjunction with the AAP
How do we monitor asthma using a patients personal asthma action plan
Monitoring the patient against their action plan – are they achieving the treatment aims?
- PEF (> 80% FEV1 or PEF predicted?) for asthma or FEV1% decline or stable for COPD
- b-agonist use in asthma (does prescribing need to escalate)
- Symptoms
- ADRs
- Holistic: depression, effect on daily life
- Smoking
• Inhaler technique - repeat advice wherever possible
• Review 3 monthly: step down if possible – ASTHMA
• Review at least annually - COPD
• Asthma MUR(medicines use review)/NMS (new meds service) and Asthma Control Test (ACT)
