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					                                                                                   London Respiratory Team

         Responsible Respiratory Prescribing – Key messages

         1.         3 out of the top 5 drugs in terms of total spend to the NHS are respiratory inhalers

         Doing the right thing:

         2.         When prescribing any new respiratory inhaler, ensure that the patient has undergone
                    NICE-recommended support to stop smoking
         3.         If prescribing triple therapy for COPD (LABA+LAMA+ICS), ensure that the patient has
                    been referred for pulmonary rehabilitation

         Doing things right:

         4.          When prescribing any inhaled medication, ensure that the patient has undergone patient
                    centred education about the disease and inhaler technique training by a competent trainer
         5.          When prescribing an MDI (except salbutamol), ensure that a spacer is also prescribed and
                    will be used
         6.          When prescribing high dose inhaled corticosteroids (>1000ug BDP equivalent?), ensure that
                    the patient is issued a steroid safety card
         7.          Prednisolone EC should not be prescribed over plain Prednisolone without good clinical
                    reason

         Rationale:

               1.   It is not widely known that respiratory medications constitute 3 of the top 5 drugs in terms of total
                    spend in the NHS, and that respiratory medications have the highest average cost per item.
               2.   Around 50% of COPD patients continue to smoke at diagnosis, and stopping smoking is THE most cost
                    effective treatment in the management of COPD
               3.   There is strong evidence that pulmonary rehabilitation is more effective than drug treatment in the
                    management of COPD at MRC breathlessness stage 3 and above
               4.   Many COPD patients are confused about their medications and unable to use their inhalers effectively.
                    Also, many healthcare professionals are unclear about inhaler technique. Thus it is important that
                    patients receive good education from someone who has been trained to do so.
               5.   Combination metered dose inhalers are very expensive. Many patients cannot use a metered dose
                    effectively and would benefit from using a spacer device. Even in those with good technique, a spacer
                    will increase the amount of drug being delivered into the lungs which would potentially improve their
                    efficacy.
              6.    High doses of inhaled corticosteroids (>1000ug BDP equivalent) have been associated with increased risk
                    of pneumonia, diabetes, skin thinning and osteoporosis. If such high doses are necessary, the benefits
                    and risks should be explained to the patient, and they should be issued with a steroid safety card.
               7.   Enteric coated prednisolone does not confer gastric protection, is no more effective and is expensive.


         For further information please contact the Responsible Respiratory Prescribing Clinical Lead :
         Dr Vince Mak at: londonrespiratoryteam@csl.nhs.uk




Commissioning Support for London
Stephenson House, 75 Hampstead Rd, London NW1 2PL

				
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