The Pharmaceutical Journal
Vol 270 No 7235 p182
8 February 2003

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Guideline may lead to more pharmacist interventions over high-dose steroids

The new BTS/SIGN asthma guideline provides opportunities for pharmacists to become more involved in managing chronic conditions. Naomi Kempner reports

Pharmacists could find themselves making more interventions on prescriptions for asthma patients in the light of a new asthma guideline published last week.

The updated guideline on asthma management comes from the British Thoracic Society and the Scottish Intercollegiate Guidelines Network (PJ, 1 February, p141).

According to respiratory pharmacist Anna Murphy, Glenfield Hospital, Leicester, one of the biggest changes involves new recommendations on doses of inhaled steroids (see Panel 1), largely unspecified in previous guidance.

The guideline advocates introduction of inhaled steroids for patients with recent exacerbations, nocturnal asthma or impaired lung function or those using b₂-agonists more than once a day. It also recommends that inhaled steroids be initially given twice daily with once a day administration considered if good control is established.

Another difference in the new guideline comes at step 3 in treatment. Before increasing the daily dose of inhaled steroid above 800µg in adults and 400µg in children, prescribers are urged to recheck compliance, recheck inhaler technique, and carry out a trial of other treatments as add-on therapy. The guideline recommends that inhaled long acting b₂-agonists (LABAs) are first choice add-on therapy in adults and children over five years. Other add-on treatments are leukotriene receptor antagonists (included for the first time), theophyllines and slow release b₂-agonist tablets (in adults only).

According to Ms Murphy, "Pharmacists should ideally be getting back to prescribers to discuss high doses of inhaled steroids.

"Prescribers forget that Qvar (in well controlled asthma) and fluticasone are double the potency of beclometasone, with patients ending up on large doses.

"Large doses of inhaled steroids should be reduced in any patient, even those who have been stable for three months or more. The guideline recommends slow reductions, considered every three months, decreasing the dose by about 25–50 per cent each time," Ms Murphy says.

Ms Murphy says that recommendations for using inhaled LABAs first choice as add-on therapy reflect some excellent data published since previous guidelines. However, she notes that inhaled LABAs do not work for every patient. She concurs with advice in the guideline to stop ineffective LABA treatment, increasing steroid doses to 800µg daily (adults) or 400µg (children 5–12) and trying other add-on therapy if control is still inadequate.

Pharmacy intervention should also be considered when anticholinergics are prescribed in anything other than mild, intermittent asthma. Anticholinergics are no longer considered an option for add-on therapy. Although some patients have a mixture of asthma and chronic obstructive pulmonary disease, in which anticholinergics are useful, Ms Murphy doubts this will be the case for patients under 40 years who have never smoked.

Other changes in the guideline noted by Ms Murphy include:

• Oral prednisolone dose for acute attacks in adults increased (now 40–50mg daily)

• Doubling the dose of inhaled steroids at the time of an exacerbation now cited of unproven value

• Patients to continue inhaled steroids through an acute attack. There is no added benefit but it forms the start of the chronic asthma management plan (discontinuation can lead to their exclusion from discharge notes)

• Inhaled b₂-agonists deemed at least as efficacious and preferable to the intravenous (IV) route in the majority of adult acute asthma cases

• IV aminophylline now recommended only in near fatal or life threatening cases

Pharmacist review

The guideline nominates pharmacists as one of the health professionals suitable to carry out routine clinical review of people with asthma, though it says that nurses with training in asthma management may achieve better outcomes for their patients.

The new guideline is published as a supplement to the February issue of Thorax (2003;58) and can be downloaded from the BTS website

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