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Pharmacy

Information for pharmacists and pharmacy teams to support and improve outcomes in asthma patients.

Contents

Useful links

Pharmacist and pharmacy teams

Pharmacists and pharmacy teams can support and improve outcomes in asthma patients using your expert clinical skills in managing patients and educating patients on asthma medications, provide training on inhalation technique, address patients' concerns around the potential side effects of medications, and improving adherence to treatment.

You can play an active role in asthma management.

Visit the Primary Care Respiratory Society for the blog series - asthma outcomes, community pharmacy perspective.

Flu immunisation

If patients have been prescribed a preventer inhaler and has the blue inhaler or the patient have been admitted to hospital because of asthma, they can get a free flu vaccine.

More information can be found on the Community Pharmacy England website.

COVID-19 vaccine

Visit the NHS website to find out how to get a COVID-19 vaccine.

Pneumococcal vaccine

The pneumococcal vaccine protects against serious illness It is also known as the pneumonia vaccine.

Pneumococcal infections can be fatal and are caused by the bacterium Streptococcus pneumoniae and can lead to pneumonia, blood poisoning (sepsis) and meningitis.

Who should have the pneumococcal vaccine?

Anyone can get the infection. There are some people are at higher risk of serious illness, so it is recommended they are given the pneumococcal vaccination on the NHS.

The cohort includes:

  • adults aged sixty-five or over
  • children and adults with certain long-term health conditions, such as serious heart or kidney conditions
  • Babies are offered two doses of pneumococcal vaccine, at 12 weeks and at 1 year of age

People that are aged sixty-five and over need a single pneumococcal vaccination. This vaccine is not given annually like the flu jab.

If they have a long-term health condition you may only need a single pneumococcal vaccination, or may need a vaccination every 5 years, depending on your underlying health problem.

Find out who should have the pneumococcal vaccine.

Inhalers

This information is on how to use inhalers and includes supportive resources for pharmacies such as materials that can be used to help patients manage their asthma.

Supporting patients with good inhaler technique is important in order to ensure the drug is delivered correctly and most of the medicines reaches the lungs and not the back of the throat. Good technique is associated with less admissions to the emergency department. Pharmacy teams should encourage children and young people to use a spacer device and healthcare professionals need to ensure the correct type is chosen.

How do I help a child use their inhaler with a spacer device?

  1. Check the spacer device fits the inhaler
  2. Position the spacer mask over the child's face or ask them to place their lips around the mouthpiece with a good seal
  3. Put one puff of the inhaler into the spacer and breathe in slowly and gently through the mouthpiece
  4. Ask the child to hold their breath for 10 seconds (or for as long as is comfortable) then breathe out slowly
  5. Many children and young people are more familiar with the tidal breathing technique
  6. Repeat the steps above for each dose/puff needed
  7. Wash the spacer once a month with washing up liquid – leave it to drip-dry
  8. Spacers should be replaced yearly

Tools to help the patient or child use inhalers

Healthcare professional should be aware of the UK Inhaler Group (UKIG) which has developed a set of standards and competencies to enable healthcare teams to work with patients to optimise technique and maximise the benefit of the medication.

Asthma UK has lots of resources to download that supports managing and living with asthma, including how to use an inhaler. These resources can be shared with patients.

Training materials

Community pharmacists play a key role in providing quality healthcare particularly in the area of medicines optimisation. Developing a pharmacy workforce that is fit for the future will be key in supporting the implementation of the standards.

Please find useful workforce related guidance and free online training courses here:

  • Optimising inhaler technique: improving outcomes. This Centre for Pharmacy Postgraduate (CPPE) course is designed to enable pharmacists to describe the different types of inhaler devices and their instructions for use, outline how the delivered dose is made in each type of device, explain the technique required to achieve the optimum inspiratory flow for each device, discuss the potential implications of sub-optimal inhaler technique, demonstrate your role as a healthcare professional in optimising inhaled medicines.
  • Asthma (Children and young people) - elearning for healthcare

Pharmacies providing salbutamol to schools

Schools are now allowed to purchase a salbutamol inhaler without a prescription for use in emergencies when a child with asthma cannot access their own inhaler, this was introduced from 1 October 2014. The following guidance provides schools that choose to keep an emergency inhaler, the basis to create a policy or protocol for using it, ensuring that the medicines is available to children when required. The Royal Pharmaceutical Society has published a pharmacy guide to supply of salbutamol inhalers to schools to support pharmacists.

Who can provide a signed order for salbutamol inhalers for a school?

A written order signed by the principal or head teacher at the school must be provided to enable a supply to be made to the school.

What information should be contained in the signed order?

In line with legislation requirements:

"The order must be signed by the principal or head teacher at the school concerned and state:

  • the name of the school for which the medicinal product is required,
  • the purpose for which that product is required, and
  • the total quantity required"

It is best practice for the school to use a headed paper however this is not a legislative requirement.

How many inhalers can a school obtain?

There is no set number of inhalers that can be obtained by individual schools as this is not specified in legislation.

When pharmacies are providing the inhaler, it is acknowledged that the number held for emergency used would be dependent on a several factors including the school size and the number of sites, the number of children known to have asthma, and past experiences of children who had not been able to access their inhaler. It has been agreed generally that only a small number of inhalers were likely to be needed annually. Schools can purchase salbutamol inhalers from pharmacies provided it is for small quantities, on an occasional basis and not for profit and in line with Medicines and Healthcare products Regulatory Agency (MHRA) guidance for pharmacists on the repeal of Section 10(7) of the Medicines Act 1968.

What records do I need to keep in the pharmacy?

The signed order needs to be retained for two years from the date of supply or an entry made into the Prescription-only-medicine (POM) register. It is good practice to make a record in the POM register for audit purposes. In line with normal record keeping requirement an entry in the POM register must include:

  • Date the POM was supplied
  • Name, quantity and where it is not apparent formulation and strength of POM supplied
  • Name and address, trade, business, or profession of the person to whom the medicine was supplied
  • The purpose for which it was sold or supplied.

What other information could I be asked to provide?

The pharmacist could also be asked to support the school:

  • Explain how to use a salbutamol inhaler and provide any associated information
  • Advise schools on the selection of the most appropriate spacer device for the different age groups and show how to use them correctly.

What guidance is available for schools on the changes?

The Department of Health has issued guidance outlining the principles of safe use of inhalers to capture the good practice which schools in England should observe.

The document covers issues such as storage arrangements and disposal of medication within the school environment. This can be shared with the local schools or kept in pharmacy for reference.

Where can I locate information on a school including head teacher or principal details if required?

There is no database that containing details of all schools and head teachers across the UK however you could use the following links to help identify those schools:

Campaigns

Get involved to promote asthma week using the healthy living pharmacy champion and create an event for your local community to raise awareness:

Pharmacy national incentive schemes

This area contains information for Pharmacy teams about NHS England services for children and young people with asthma.

New medicine service (NMS)

The New Medicine (NMS) service provides support for people with long-term conditions newly prescribed a medicine to help improve adherence to the medicines.

Patients need support when starting a new medicine or a change in regime this can lead to confusion and uncertainty in patients which then leads to non-adherence. An example is a child newly prescribed an inhaler and parents who do not know how to help the children get the best from their inhalers.

NMS is applicable to children and young people as it is to adults. It can be vital in identifying issues with non-adherence at an early stage in treatment.

The New Medicine Service includes the following conditions:

  • Asthma and Chronic Obstructive Pulmonary Disease (COPD)
  • Diabetes (Type 2)
  • Hypertension
  • Hypercholesterolaemia
  • Osteoporosis
  • Gout
  • Glaucoma
  • Epilepsy
  • Parkinson's disease
  • Urinary incontinence/retention
  • Heart failure
  • Acute coronary syndromes
  • Atrial fibrillation
  • Long term risks of venous thromboembolism/embolism
  • Stroke / transient ischemic attack; and
  • Coronary heart disease

Learn more about the New Medicine Service

For further information, visit the NHS England NMS webpage

You can also follow advice from Community Pharmacy England on the new medicines service.

The Pharmacy Quality Scheme 2023-24

The aim of the Pharmacy Quality Payments Scheme (PQS) related to asthma were for community pharmacy to:

The PQS aims to support improvements in asthma care, reducing morbidity and preventable deaths from asthma through targeted clinical and evidence-based interventions.

  • Supporting patients to optimise inhaler technique and outcomes in patients with asthma
  • Encourage patients to promote safe and environmentally friendly disposal of unwanted and/or used inhalers by engaging in discussions with all patients, their carers and/or representative
  • Participating pharmacies audit Patients aged 5-15yr using pMDIs without a spacer device or patients who did have a personalised action plan, and refer them back to their GP
  • Patient-facing pharmacy staff are trained and advise on the reasons why any used, unwanted, and expired inhalers should be returned to the pharmacy for safe disposal and the adverse effects on the environment when inhalers are disposed of in general waste bin.

The Green agenda – inhaler options

  • The aim of the green agenda is to support patients over the age of 12 years to consider low carbon inhalers where clinically appropriate.
  • The NHS are working to reduce its carbon footprint to zero by 2040, and have a clear ambition of 80% reduction by 2028- 2032.
  • When we look at emissions medicines account for 25% and inhalers account for 3% of this
  • NICE has developed patient decision aid on asthma inhalers and climate change which may be used and how to use them effectively.
  • Metered dose inhalers, contain powerful greenhouse gases these propellants are known as Hydrofluorocarbons. These help to propel the dose into the patient's lungs, however a lot of people will be able to achieve the same benefit from Dry Powder Inhalers (DPIs).
  • When we compare the carbon footprint the metered dose inhalers have an estimated 500g CO2 (Carbon Dioxide) equivalent per dose, compared to 20g in DPIs.

Technique tips

The National Institute for Health and Care Excellence (NICE) patient decision aid on asthma inhalers has links to a series of short videos by Asthma UK, which give demonstrations of correct inhaler technique, potentially improving their effectiveness and preventing future exacerbations and attacks. The videos how to use an inhaler on the Asthma UK website support the NICE guidance.

Pharmaceutical Services Negotiating Committee (PSNC), now called Community Pharmacy England, produced a briefing as a training resource to meet the 2021/22 Pharmacy Quality Scheme requirement for all patient-facing pharmacy staff to have been trained to speak to patients about safe disposal. A factsheet can be found on the Community Pharmacy England (formerly PSNC) website.

Two of the most common health conditions are Asthma and COPD with millions of people using inhalers to manage their condition.

As an example, a metered dose inhaler with 10g of propellant can have a carbon footprint of 13-33kg depending on the type of propellant. This is equivalent to driving an average car 45- 115 miles. When an inhaler is used it still has around 30% of the propellant in the cannister this means that disposing in general waste has a significant impact on the environment.

Any inhalers that are returned to pharmacies are sent for safe disposal and will be incinerated at high temperature This process destroys the propellant gases, so they do not escape into the atmosphere. Once this process has been completed some inhalers can then be recycled.

There is also an initiative to offer patients an alternative inhaler that has a lower carbon footprint where clinically indicated and appropriate.

The pharmaceutical industry is developing new propellants with less impact on climate change to support the green agenda.

Pharmacy teams should be encouraged to take the lead to educate patients who use inhalers about the environmental benefits of returning all their inhalers regardless of type to the pharmacy for disposal, and not to put them in their domestic refuse.

Final outcomes of the PQS scheme 21/22

9,860 contractors met the requirement of the respiratory Domain, which means they participated in:

  • The pharmacies referred all children aged 5 to 15 years who were dispensed an inhaled press and breathe pMDI for asthma for a spacer device if appropriate, in line with TA38 NICE guidelines.
  • The pharmacies referred all patients 5 years and above to get a personalised asthma action plan. This would be the case for those patients who did not already have one.
  • The pharmacies identified patients with asthma or COPD who between 1 April 2020 and 31 August 2021 did not have their inhaler technique checked due to the COVID-19 pandemic and offered as part of NMS catch up an inhaler technique check.
  • Pharmacists had completed distance learning on inhaler technique; and
  • The pharmacies ensured that all patient-facing staff had completed training on discussing with patients the environmentally safe disposal of inhalers at the pharmacy and the impact. This meets the Green Agenda.

The outcomes of the incentive scheme are available to read on the links via the Community Pharmacy England (formerly PSNC) website:

For more information on PQS see NHS England or Community Pharmacy England.

More resource links for pharmacy teams: