Transcript What’s new in asthma

Wendy Pigg
Practice support Pharmacist/Independent Prescriber
NICE Quality standards Qs25
 Launched in February 2013
 Provides best clinical practice statements for a health topic
Statement 1. People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance.
Statement 2. Adults with new onset asthma are assessed for occupational causes.
Statement 3. People with asthma receive a written personalised action plan.
Statement 4. People with asthma are given specific training and assessment in inhaler technique before starting any new
inhaler treatment.
Statement 5. People with asthma receive a structured review at least annually.
Statement 6. People with asthma who present with respiratory symptoms receive an assessment of their asthma control.
Statement 7. People with asthma who present with an exacerbation of their symptoms receive an objective measurement of
severity at the time of presentation.
Statement 8. People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute
exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.
Statement 9. People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a
specialist respiratory team before discharge.
Statement 10. People who received treatment in hospital or through out-of-hours services for an acute exacerbation of
asthma are followed up by their own GP practice within 2 working days of treatment.
Statement 11. People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.
Ref :http://guidance.nice.org.uk/QS25
New licensing for Fostair®
 The product license for the pMDI Fostair® (beclometasone
and formoterol) dose inhaler (pMDI) has been updated
with a new indication to allow use as maintenance and
reliever therapy.
 Dose is 1 inhalation of the inhaler regularly twice daily for
maintenance and then take up to 6 additional
inhalations as needed in response to symptoms.
 Symbicort® DPI are already licensed in this way (SMART).
The license extension for Fostair® now provides a patients
choice of delivery device (pMDI or DPI).
 Patients must be carefully selected and patient education is
key to the success of the regime which in the studies can
provide an overall lower steroid load to patients.
New Inhalers - Flutiform®
New Inhalers - Flutiform®
 Combination MDI inhaler containing fluticasone and
formoterol
 Available in 3 strengths, with a dose schedule of two
puffs twice daily. (120 dose)
 Flutiform 50 mcg/5 mcg and 125 mcg/5 mcg are
licensed for use in adults and adolescents aged > 12
years.
 Flutiform 250 microgram/10 microgram is licensed for
use only in adults.
Combined inhalers BDP equivalence (note the dose of long
acting bronchodilator (LABA) may vary)
BDP equivalence
Daily dose
Licensed for
use in COPD
Cost for 30
days
Expected no
inhalers/yr
Fostair® (BEC + formeterol) 100/6 MDI 1pBD (120 dose)
400-500mcg
no
£14.66
7
Flutiform® ( FLU + formeterol) 50/5 MDI 2pBD (120 dose)
400mcg
no
£18.00
13
Seretide® (FLU+ salmeterol) 50/25 MDI
400mcg
no
£18.20
13
400mg
no
£18.00
13
Symbicort® (BUD + formeterol) 200/6 1pBD (120 dose)
400mcg
no
£19.00
13
Symbicort ® (BUD + formeterol) 100/6 2pBD (120 dose)
400mcg
no
£33
13
Fostair® (BEC + formeterol) 100/6 MDI 2pBD (120dose)
800-1000mcg
no
£29.32
13
Symbicort® (BUD + formeterol) 400/12 1pBD (60 dose)
800mcg
yes
£38
13
Symbicort® (BUD + formeterol) 200/6 2pBD (120 dose)
800mcg
no
£38
13
Flutiform®( FLU + formeterol) 125/5 2pBD (120 dose)
1000mcg
no
£29.26
13
Flutiform® ( FLU + formeterol) 250/10 MDI 1pBD (120 dose)
1000mcg
no
£22.78
7
Seretide® (FLU+ salmeterol) 125/25 MDI 2pBD (120 dose)
1000mcg
no
£35
13
Seretide ® 250/50 ACCUHALER 1P BD (60 dose)
1000mg
no
£35
13
Flutiform® ( FLU + formeterol) 250/10 MDI 2pBD (120 dose)
2000mg
no
£45.56
13
Seretide® 500/50 ACCUHALER 1p BD (60 dose)
2000mg
yes
£40.92
13
Seretide® (FLU+ salmeterol) 250/25 MDI 2P BD (120 dose)
2000mcg
no
£59.48
13
Symbicort® (BUD + formeterol) 400/12 2pBD (60 dose)
1600mcg
no
£76
25
(2pBD - must use 2 puff to get full dose of LABA)
Seretide® (FLU+ salmeterol) 100/50 ACCUHALER 1pBD
(only 1 puff needs to get full dose of LABA) (60 dose)
Worcestershire Spend on ICSCost effective prescribing
 N.I.C.E states to use the combination inhaler that is
least costly that is suitable for that patient.
 All new starters for pMDI ICS/LABA inhalers should
be on Fostair®/Flutiform®
 Switching can be an option in suitable patients now we
have a fluticasone pMDI alternative to Seretide®
 Switching 50% of patients from Seretide® 250 evohaler
to Flutiform® 250 could save £183,249
 Switching 50% of patients from Seretide® 125 evohaler
to Flutiform® 125 could save £62,313
Worcestershire Spend on ICS- YTD
Dec 2012
 The volumes of combined ICS is increasing year on year
 59% (49% in 2010) of total inhaled corticosteroid inhalers (ICS) prescribing is
for combination inhalers . (Step 3 or more of BTS guidelines for asthma or
COPD FEV1 <50%)
 This equates to a spend of £4,490,521
 £2.2 million is spent on Seretide® 250 Evohaler/Seretide® 500 Accuhalers 
high dose inhaler




??Why ??
More patients moving from step 2 –to step 3 of BTS guidelines too early ?
Patients started on step 3 of BTS guidelines with higher dose steroid than
needed ?
Patient started on higher dose steroids to gain control but not stepped down
when stable
More COPD patients on triple therapy LAMA + ICS/LABA ? - limited
evidence base for use
Q.I.P.P –High dose Inhaled
corticosteroids in Asthma
 QIPP – Quality, Innovation, Productivity and
Prevention
High dose = high cost = increased risk of side effects
Numbers of patients with serious side effects may be
small but
Cost of fracture to the NHS
Lifetime cost of a diabetic
Cataract surgery cost
Worcestershire ICS Volume Changes so far
Combined ICS trends in Worcestershire
12000
10000
8000
Seretide 125_Evohaler 125mcg
Seretide 500_Accuhaler
500mcg
6000
Symbicort_Turbohaler 200/6
Seretide 250_Accuhaler
250mcg
Seretide 50_Evohaler 50mcg
4000
Fostair 100/6 Inh
Symbicort_Turbohaler 400/12
2000
Seretide 100_Accuhaler
100mcg
Symbicort_Turbohaler 100/6
3rd Q
2012/2013
2nd Q
2012/2013
1st Q
2012/2013
4th Q
2011/2012
3rd Q
2011/2012
2nd Q
2011/2012
1st Q
2011/2012
4th Q
2010/2011
3rd Q
2010/2011
2nd Q
2010/2011
0
1st Q
2010/2011
No. of inhalers prescribed
Seretide 250_Evohaler
250mcg
BTS guidelines
– Optimising Step 2 of treatment ?
 Are we ensuring step 2 of BTS guidelines are followed
with optimisation of ICS first before adding LABA .
 Impact Project in Bristol found adequate inhaler
training and education for these patients meant they
gained control without need to step up.
 In asthma reviews look at prescription ordering
history – are patients actually using their ICS ?
 Is stepping down ICS dose discussed and documented
at every asthma review ? (is it on your templates ?)
 Is inhaler technique actually checked every time ?
Number of HCP's who demonstrated all 7 steps correctly &/ or correct inspiratory flow rate
using the In-Check Dial.
Baverstock M et al. Thorax 2010;65:A117-A118
BTS guidelines –
Step 3 of treatment
 Ensure patient using at least 400mcg BDP equivalent
before adding LABA
 No need to increase steroid when LABA added –
therefore should be using low dose combined ICS
inhalers which are more cost effective and lower doses
of steroids. Fostair®/Flutiform 50®/Sertide
50®/Symbicort®
 Step down when asthma control is achieved to
reduce long term side effects of steroids.
BTS guidelines –
Stepping up and stepping down
 Stepping down 25% of patients from
 Seretide® 250 Evohaler  Seretide® 125 Evohaler =
£161,133
 Seretide® 250 Evohaler Flutiform® 125 Evohaler =
£198,908
 Seretide® 125 Evohaler  Seretide®/Flutiform® 50
Evohaler = £92,276
 Seretide® 250 Accuhaler  Seretide® 100 accuhaler
= £91,000
Key messages
 Asthma is a variable disease so patients can be over
treated or undertreated.
 In stable asthma with no symptoms consider step
down in treatment every three months , decreasing
dose by 25-50% at a time .
 Scottish study in 259 stable asthma patients on high
dose ICS (>1200 BDP) had 50% reduction in dose and
in 1 year no difference in exacerbation rate, GP
attendance or health status SGRQ
 If inhaler technique not correct – treatment is in vain.
Hawkins et al BMJ 2003:325:1115
15