To prescribe or not to prescribe, that is the question…

Cut to pharmacy…

Your patient walks in to collect his regular inhaled medication for asthma. He is 30 years old with no other co-morbidity. He is on your asthma clinical list and you have been watchfully observing his control on his visits to collect his regular inhalers. He is on SIGN 101 step 2 and his repeat scripts are for Salbutamol cfc inhaler and a Clenil Modulite 100mcg.

You noticed that when labelling his script for Salbutamol MDI this time he has had his Salbutamol quite a few times recently. In fact he has had 18 Salbutamol MDI’s dispensed in the last 12 months and the rate of dispensing is increasing recently. You note he is a non-attender at the annual asthma review. The last time he attended was 20 months ago.

So the question is what are you going to do?

Dispense as normal, move on and have a coffee, or intervene and get this patient’s asthma controlled?

Let’s assume the latter…

Based on his non-attendance and his overuse of Salbutamol you decide to do a chronic medication intervention and conduct an Asthma UK control test. You do this on his visit to pick up his Salbutamol opportunistically. His score comes out at 14/25 which is indicative of poor control. You listen to his chest and hear a classic asthma wheeze. His peak flow is below expected. The weather has just recently turned colder and he admits that the cold weather can trigger him to cough a lot. You update his basic values of O2 sats, BP, pulse and record on his patient record.

So you decide to put your prescribing hat on and trigger a ‘prescribing encounter’. You log on to the patient record and do the normal checks of his history and, most importantly, confirm his diagnosis of asthma.

He clearly needs to be stepped up to regain control. SIGN 101 recommends going in at the step that regains control.

Before you do anything you check his technique… terrible… surprise! He is unable to co-ordinate the use of either inhaler. As with any prescribing decision there are many options but you decide to step him up to step three — try him on a Symbicort 200 Turbohaler and use Terbutaline as a reliever inhaler. This is evidence based in SIGN 101 and is also in line with your local formulary.

You use your video on your iPad of you demonstrating the use of a Turbohaler and then observe his technique there and then. His natural speed of inhalation is better suited to a Turbohaler.

You use the patient record to make a note in his records about the assessments you have undertaken and the plan put in place. You agree a written asthma plan and you prescribe him a peak flow meter then give him an Asthma UK peak flow diary. You use the access to his records to make him an appointment at your asthma clinic in two weeks to follow up on his progress. You tell him you will do his flu jab at this review.

He is overwhelmed by the proactive nature of the care he has received and is very happy to attend for follow up at you Saturday morning clinic. Remember, most asthmatics are either working or at school and hence are poor attenders for review. He confides that he has struggled for years with his asthma but thought that was just part of the illness.

This example, I believe, is a model for how we, as community pharmacists, should be operating for many chronic disease states now and into the future. Payment by volume must be superseded by fair payment based on clinical outcomes.

By adopting this approach as pharmacists we have the chance to ‘manage’ a patient from start to finish. The only limiting factor could potentially be our level of competence as pharmacists and when that happens the ball is firmly back in our court.