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CONTINUING PROFESSIONAL DEVELOPMENT
Clinical intervention Issue
Recommendation for clinical intervention
Change in patient
Is there a need for combination inhaler?
The patient may have had poor control as she was not using
any preventer for the past few months.
Symptoms of breathlessness can sometimes be brought on
with beta-blockers (even beta 1 selective such as metoprolol).
These usually disappear after a few weeks of use.
It is recommended that drugs such as metoprolol should
be used with caution in people with severe or uncontrolled
asthma, even though they offer valuable benefits in terms
of preventing acute coronary syndromes.2
Non-adherence and recent prescription of a beta-blocker
could be brought to the attention of the patient's regular
doctor (GP). The same dose of preventer (budesonide 800
mcg daily), that the patient had been prescribed before,
could be effective at achieving control if adhered to rather
than initiating a combination preventer medicine. The patient
may have experienced additional symptoms due to the
initiation of a beta-blocker. The doctor could consider
these two factors and review the decision of introducing a
combination preventer in favour of urging the patient to use
the usual preventer regularly.
The patient should be on a regular preventer. She has not
been using the preventer for the past two months.
Reasons for non-adherence should be explored and addressed.
These may involve medication-related issues such as:
• experiencing side effects (i.e. oral thrush). Counselling may be
required to help minimise this (i.e. regarding rinsing after use).
• cost may need to be discussed and addressed if possible.
• inconvenience and forgetfulness and these should be
addressed, e.g. suggesting preventers that can be used
once a day (e.g. ciclesonide). Medication alteration and
review would be considered as a clinical intervention.
Suboptimal inhaler technique
The patient has been using Pulmicort (budesonide), a dry
powder inhaler (turbuhaler), long term as a preventer.
Now she has been commenced on Seretide (fluticasone/
salmeterol) metered-dose aerosol -- an aerosol inhaler.
The patient has expressed difficulty in using a pMDI
device properly. In fact, she cannot use her reliever
medication properly and uses a double dose to make up
for her inadequate technique.
There is a combination preventer available in a turbuhaler
device (Symbicort). The patient may be more efficient at
using her preventer if she had a device of her preference.
Given she has been using a turbuhaler in the past, it may
be recommended that the doctor consider prescribing the
turbuhaler-based combination for her preventer therapy
instead of the pMDI-based one.
Further, the turbuhaler-based preventer can also be used
as a reliever on an 'as necessary' basis (the SMART regimen
i.e. Symbicort as maintenance and reliever therapy).
It may be recommended that she be prescribed the
SMART regimen, so she can use the same inhaler for both
prevention and relief. This way she will not have to use the
pMDI device even for her reliever medicine.
Table 1. Possible clinical interventions for Mrs M
Current prescription data analyses
suggest that medication-use levels are
inconsistent with what is required for
good asthma control. In the latest ACAM
report (Asthma in Australia, 2011), of
those prescribed inhaled corticosteroids,
30% had these dispensed only once in
12 months.4 This suggests that factors
such as non-adherence may be a
common problem in asthma.4 The report
also highlighted that 80% of adults with
asthma were supplied combination
preventer medications.4 There was
also a higher than justifiable level of
reliever dispensing.4 Another issue may
be usage or technique related. Most
treatment in asthma is administered via
inhaler devices, and most patients (in
fact even healthcare professionals) do
not use appropriate techniques whilst
using devices.5 Available data also
suggests that many people do not avoid
triggers that can worsen their asthma.
For example, people with asthma
smoke at least as much as people
without asthma, despite the known
adverse effects.4 Other prevention-
related recommendations include
getting a vaccination for influenza and
pneumonia. Respiratory infections are
a key trigger for asthma. In fact asthma
flare-ups in adults happen largely in
winter. Here again, patient uptake of
vaccinations is suboptimal.6
Clinical interventions with
In Australia, there is a robust
body of evidence suggesting that
pharmacists' clinical interventions
can improve patient outcomes such
as asthma control, quality of life,
medication adherence, and are also
cost effective.7 Such evidence, and the
increasing professional emphasis on
service provision, provides support for
pharmacists considering focussing on
chronic respiratory disease as an area of
Table 1 highlights possible clinical
interventions for Mrs M.
Clinical interventions are part of
the Fifth Community Pharmacy
Agreement as professional practice
initiatives, and are defined as 'the
process of a pharmacist identifying,
and making a recommendation in
an attempt to prevent or resolve a
drug-related problem'.8 The pharmacist's
recommendation may be for a change in
the patient's medication therapy, means
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