WELL the simple answer is that preventer inhalers should be the mainstay of treatment, and relievers should only be used if the patient is suffering symptoms.
At the moment, this simple point is the basic principle health professionals use to treat many patients with asthma. The evidence based guidelines support this principle: inhaled steroids are used in all steps of asthma treatment in the UK except step 1 [SIGN 141].
Beta 2 agonists like salbutamol are relievers inhalers. Salbutamol is useful, because it causes rapid bronchdilation and so eases the symptoms of asthma. For example, a Ventolin Evohaler will cause rapid bronchodilation (onset within 5 minutes) in reversible airways disease like asthma and the effect will last for 4-6 hours [EMC, 2015]. This is, of course, useful in acute situations or pre-exercise, but it is rarely the answer if we have an interest in managing asthma long term.
The diagram below shows the effect of inflammation on an asthmatic airway. The preventer inhaler (usually an inhaled steroid alone or in combination with long acting beta-2 agonist) has been shown to be effective in reducing, and often reversing this inflammatory response, hence allowing the patient become symptom free.
The National review of asthma deaths [NRAD, 2104] had the following to say about how preventer inhalers were being used by those patients who sadly died:
“There was evidence of widespread underuse of preventer medication. Overall compliance with preventer inhaled corticosteroid (ICS) was poor, with low repeat prescription fill rates both for patients treated with ICS alone and for those treated with ICS in combination with a long-acting beta agonist (LABA).
“Non-adherence to preventer inhaled corticosteroids is associated with increased risk of poor asthma control and should be continually monitored.”
The management of asthma of course is multi-factorial and successful treatment depends on many factors beyond the compliant use of preventative medicine. It is, however, something we as pharmacists can have an impact on, and I would argue that in this case community pharmacists should be monitoring compliance.
If we can educate and support patients to use more preventer inhaler, and hopefully as a result use much less reliever inhaler, then we can have a positive impact on their care.
I have blogged previously about checking how frequently reliever inhalers like beta-2 agonists are dispensed, but monitoring the frequency of dispensing of preventer inhalers like inhaled steroids is equally important. In my experience, if a patient is overusing their beta-2 agonist, then it is likely that they are underusing their inhaled steroid preparation.
Spotting this at the point of dispensing, and then engaging with the patient in England through a medication use review or in Scotland through the chronic medication service could help prescribers to manage patients better and lower their risk of exacerbation.
For pharmacists there is no better time to have this chat than when dispensing the inhaler.
I always find it interesting to note that this type of intervention requires no access to the patient record, it does not depend on the pharmacist being a prescriber and also can be completed in a busy community pharmacy.
Johnathan Laird is a GP pharmacist independent prescriber with a special interest in asthma. He is based in based in Aberdeenshire.
Follow Johnathan @JohnathanLaird