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Reliever inhaler overuse and how to find those high risk asthmatic patients in community pharmacy

People with asthma will often not present at their annual review appointment and many will not turn up for years. I think this is down to the reversible and episodic nature of asthma but it does present an important opportunity for community pharmacists to make a positive difference to these patients. Basically, if patients don’t feel unwell they often won’t turn up in my view.


However, one thing people with asthma have in common is a need to either use or keep a short-acting beta agonist near to them most of the time. This need for access to a short-acting beta agonist drives these people into community pharmacies and it is at this point that as community pharmacists we should be actively risk-assessing, engaging with and safety netting these patients.


It has been really interesting working on the ‘other side of the fence’ in general practice now for over a year because patients, in general, have to decide themselves when to present for review or treatment and if they have no symptoms or feel well at that moment they often will not come. There are some high-value messages about inhaled steroid use, prevention and messages about the reversible nature of asthma that we really need to deploy to people with asthma if we want to ensure there are many fewer deaths in this area.


The National Review of Asthma deaths published in 2014 highlighted a range of issues with asthma care that was suboptimal. They found that salbutamol use was an indicator potentially of poor asthma control and that action was needed to safety net these patients. Although most community pharmacies do not yet have access to the patient record they certainly can track salbutamol use which is a great place to start.


I think we need to use various tools and processes to identify, risk assess and then manage asthmatic patients. The cohort of patients of interest to me in this area is those that were at increased risk of exacerbation. Critically, these are the patients that, for various reasons, our multidisciplinary team colleagues in primary care cannot reach.


A good few years ago now the broad aim underpinning my ambition to become an independent prescriber was to attempt to prove that the unique relationship and footfall of community pharmacy could be converted to positive clinical outcomes for patients. I think every community pharmacist should be an independent prescriber because without this qualification we would not be able to deliver pharmaceutical care in the most complete way possible. Operating as a non-prescriber, the process of identifying the higher risk cohort of asthmatics would be useful, but ultimately we would have to hand care of the patient back to the GP. It should never be the aim to duplicate the great respiratory care GPs and nursing colleagues deliver in this area. We are all too busy for that. However, if community pharmacists can identify and engage with these non-attending and often ‘higher-risk’ patients it forms the basis of a compelling argument to manage this cohort going forward.


In making the case for community pharmacy, we have to use the strengths of accessibility, excellent relationships, the flexibility of opening hours we as pharmacists in the community are all familiar with. The key fact that is much underexploited in pharmacy clinically, is the fact that patients have to attend the pharmacy to collect their repeat medicines. However, that same patient must choose to present to the GP surgery based on symptoms. Strategically, case finding higher risk asthmatics within this disengaged cohort should be our aim as they collect their repeat inhalers. I think the psychology around the decision of a patient to present to the GP is really interesting. It is important for community pharmacists to focus on the cohort of patients that come to the pharmacy but not the GP. Community pharmacists should be risk assessing these people and then potentially intervening to deliver pharmaceutical care as pre-cursor to managing them using various tools, including prescribing.


I think we need to use services like the chronic medication service brief interventions to identify this group of more vulnerable asthmatics. A few years ago I did this and this was my early interpretation of ‘CMS plus’. Risk assessment should be undertaken initially upon receiving and clinically checking the repeat prescription. For example, we should be looking at the frequency of prescribing of reliever inhalers and preventer inhalers, as well as spotting oral steroids prescribed as a response to a recent exacerbation. Based on these parameters, a decision can be made as to whether a brief intervention could be of benefit.


Although not always possible it is really useful if you can request that your GP colleagues provide you with a list of patients who did not attend the annual respiratory review at the clinic. This list can then be used this list to further prioritise my time. It should feel a little like going fishing for these higher-risk patients. We are obviously not fishing for not for fish but instead looking for unmet pharmaceutical care issues. The key factors to use for identifying higher risk asthmatics, in my opinion, as you clinically check and dispense prescriptions for people with asthma are as follows:


1. The patient used more than 12 reliever inhalers in the preceding 12 months.

2. Patient compliance with preventer medicine was poor in the previous 12 months.

3. The patient was prescribed an oral steroid in the previous 12 months.

4. The patient did not attend the respiratory clinic in the previous 12 months.

5. The patient is a smoker.


At this stage, you should flag the need for a pharmacist conversation upon hand out of their repeat medication prescription. The brief interventions are just that, brief. I would recommend the use of the asthma control test was useful in many cases at this stage to convince the patient of the need to present for review.


Once identified, these patients can then be invited to the respiratory clinic or they can be managed within the community pharmacy if you have competence in this area. I now run these clinics independently in the surgery. I hope the advantage of eventually using remote read/write access to the records within the pharmacy will mean that community pharmacists can increase the level of flexibility in terms of where and when patients with asthmatics can be engaged.


It is useful to note that many asthmatics are of school or working age, so a community pharmacy clinic run in an evening or at the weekend may help to increase attendance rates. The main barrier to opening up this sharing of information is the risk attributed to the Cauldicott guardian of making the decision to share patient data with a third party, like a community pharmacist.


This problem of non-attendance of asthmatic patients for review is common across the country. During my training time, I managed to increase engagement in this cohort of patients. Many of these patients were, at best, disengaged with the management of their condition or, at worst, required quite urgent care.


Many of us in community pharmacy will have dabbled with case finding sometimes by using opportunistic clinical tests like blood pressure. However, finding cohorts of patients that are only willing to engage with you as a community pharmacist creates a compelling argument to support this type of practice within the heart of our local communities. If we can then use read/write access to the patient records and skills linked to independent prescribing to manage these patients safely in the community pharmacy we could maybe make a real difference to patients.


It will be interesting to see if those in charge will now pull the contractual levers required to make the community pharmacy environment favourable to solutions such as this or others.


The views expressed in this article are Johnathan’s and should not be attributed to, or be seen to represent any organisation he is associated with.


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