Key messages

Asthma

• Recommend that a patient prescribed six or more SABA inhalers annually is a trigger for timely, priority review, before the authorisation of the next prescription
• Review patients on SABA inhalers alone, establishing reasons for SABA only use
• Review patients with asthma prescribed SABA and LABA without ICS
• Review patients with asthma who have been prescribed an ICS inhaler and do not order on repeat prescription for adherence and understanding of treatment and to establish appropriate use of SABA inhalers
• Review inappropriate use of high strength corticosteroid inhalers (maintaining patients at the lowest possible dose of inhaled corticosteroid)
• Reductions in inhaled high dose ICS should be considered every three months, decreasing the dose by approximately 25–50% each time, arranging for a regular review of patients as treatment is reduced
• Issue a steroid treatment card to patients on inhaled high dose corticosteroids. A steroid emergency card may also be required
• Review montelukast four to eight weeks following initiation to ensure that there has been a response and that it is still required

Severe asthma

• Identify patients with severe asthma and where modifiable risk factors are addressed and asthma care remains suboptimal, referral made to secondary care for treatment optimisation

Children with asthma

• Record regular growth monitoring when treating children with ICS
• Ensure children on medium/high-dose ICS are under the care of a specialist paediatrician 

COPD

• Review patients with COPD following initiation of inhaled ICS and stop if there is insufficient response or if there are adverse effects
• Regular review of mucolytic therapy should be undertaken and may be stopped if there is no productive cough or if symptoms have not improved with use
• Review patients with COPD on separate LAMA and LABA/ICS inhalers and, if appropriate change to triple therapy inhalers. Recommend review after three months to assess benefit, discontinuing the ICS if there is no improvement.  
• Review antibiotic course length (five-day course recommended) if needed for infective exacerbations of COPD, with sputum cultures for treatment failure

Bronchiectasis

• Antibiotic choice should be directed by previous positive cultures. In the absence of previous positive sputum cultures, broad spectrum oral antibiotics to cover common respiratory pathogens are recommended, using local formulary guidance if available
• Azithromycin 250mg three times a week is recommended for patients with four or more exacerbations in any 12-month period, usually started after advice from secondary care.
• Recommend six-month review of effectiveness of mucolytics

Idiopathic pulmonary fibrosis

• Anti-fibrotics prescribed only by a clinician with experience of treating IPF
• Only prescribe anti-fibrotics when there is confirmed fibrotic lung disease with evidence of physiological progression

• Promotion of patient reviews to optimise disease control and reduce inappropriate prescribing of inhalers
• Prioritise review of patients with asthma who are over-reliant on SABA inhalers (See 'Asthma')
• Streamline devices for patients, avoiding mixed device use where possible 
• Review separate inhalers where a combination inhaler device would be possible 
• Review individuals prescribed SABA alone, check diagnosis and if appropriate consider DPI
• Update local formularies to highlight and promote inhalers which have lower CO₂ emissions  
• Use Scriptswitch in GP practices to promote better asthma care and environmental messages e.g.
  • highlighting SABA overuse 
  • prescribe small cannister salbutamol pMDI with lower global warming potential (Salamol or Airomir) 
• Run local public advertising campaigns to promote good asthma care and the environmental impact of respiratory prescribing
• Utilise resources to support patients and clinicians in environmentally friendly and sustainable prescribing (see 'Resources for patients and clinicians')

For new patients:

• Use inhalers with low global-warming potential where they are as equally effective
• Where there is no alternative to a pMDIs, lower volume HFA 134a pMDIs should be used in preference to large volume or HFA 227ea pMDIs

For existing patients:

• Switch to DPI if appropriate, based on a patient review. We do not recommend a blanket switch 
• Use the decision aid to consider switching  to DPI inhalers for patients with asthma who are interested and meet most of the criteria. 

Clinicians should:

• Develop a clear management plan collaboratively with patients at the centre adopting the what matters to me principles and the Seven-step medication review process. Clinicians should optimise prescribing of medicines, reduce harm for patients, manage patient expectations of potential therapeutic control and consider environmental impact of their prescribing.
• Follow a clinically appropriate approach to initiation of medication, discussing risks and benefits and incorporating agreed criteria for stopping/continuing medication. Inhaler technique remains a key component of co-production of positive clinical outcomes. Therefore, review of technique should be undertaken as a priority. This is of particular importance due to the growing variety of inhaler devices – ongoing review is recommended.
• Review effectiveness, tolerability and adherence on a regular basis. Medicine burden should be reduced where possible, in line with Polypharmacy guidance
• Ensure awareness of relevant changes to inhaler formularies, new inhalers to market, carbon emissions of inhalers and updated guidance            
• Pursue non-pharmaceutical approaches wherever possible, either alone or in conjunction with medicines. Self-management should be actively encouraged and supported for appropriate patients.

Clusters should:

• Engage with local Medicines Management Teams and review respiratory prescribing data. The national therapeutic indicators for respiratory prescribing including prescribing information by GP cluster can be found here.⁷⁴
• Respiratory prescribing issues should be included in the Cluster Quality Improvement plan if deemed a priority. Reduction of carbon emissions is a national priority and this guidance describes how to reduce carbon emissions due to respiratory prescribing.

Secondary care should:

• Engage with pharmacy teams to ensure hospital prescribing is in line with local formulary.
• Understand the influence that secondary care prescribing has in the primary care setting and educate associated staff.

Health Boards should:

• Consider this guidance alongside the data provided on prescribing positions and trends. Prescribing action plans set out local priorities for how Health Boards will continue to improve quality of medicines management – these action plans should, where appropriate, encourage use of this document to drive that improvement.
• Nominate a local lead from within Medicines Management and a local clinical lead from within the local Managed Clinical Network or Respiratory Community. The two leads should work closely together to drive delivery and implementation of the recommendations within this document with the local Managed Clinical Network, where possible.
• Ensure the primary/secondary care interface is appropriately developed. Given the considerable influence that local secondary care prescribing culture has on primary care clinicians, it is vital to ensure engagement with secondary care clinicians. Encourage ownership of primary care data by clinicians in both settings.
• Review local prescribing pathways and formulary and support clinicians, based on current SIGN guidance and environmental issues.
• Ensure non-pharmacological management is promoted within prescribing action plans.