Making the case for respiratory pharmacists
Steroid stewardship is an important task for respiratory pharmacists and is one of the measures that can have a positive impact on the overall outcomes of asthma explains Dr Anna Murphy, Consultant Respiratory Pharmacist, University Hospitals of Leicester NHS Trust.
The concept of steroid stewardship is analogous to antibiotic stewardship. It emphasises appropriate use of the drugs to minimise harm and achieve the maximum benefit.
Dr Murphy explains: “We’re all very familiar with how we need to be really mindful of how many antibiotics we prescribe, making make sure that we’re prescribing at the right time for the right patient because of resistance. Now, what we’re talking about with steroid stewardship is similar…… we need to make sure that we’re prescribing at the right time for the right patient, the reason being that we know oral corticosteroids are very, very effective and they treat and they manage – they’re life-saving for – acute exacerbations of asthma, and potentially COPD as well. But unfortunately, we are all too well aware of the adverse side effects of oral steroids and we are only talking oral steroids here, not inhaled, but all steroids we know can lead on to diabetes, ischemic heart disease, weight gain, osteoporosis – and the list goes on and on and on. We know that if patients have more than a thousand milligrams of prednisolone then you are leading on to more serious side effects.”
The aim of steroid stewardship is to minimise the risk of harm by monitoring patients who are taking steroids and ensuring that all aspects of care are in place. This includes ensuring that other [concurrent] drug therapy is optimised, patients are adherent and are able to use their inhalers, all of which may help to reduce exacerbations of asthma. Another aspect of this is prompt referral to secondary or tertiary specialist respiratory centres for review. “So, if patients have two or more oral steroids for asthma exacerbations, then we should be thinking about referring those patients through to secondary care”, says Dr Murphy. The use of biologics may reduce the need for steroids, she adds.
Similarly, with COPD patients we can’t just keep giving COPD patients antibiotics and steroids every time. We need to stop and think – can we do anything more for this patient? And that’s again where perhaps a referral to secondary care or even, if you’ve got integrated care services that’s ideal for them to perhaps to look more closely at that patient and help you to review them”, she says.
Making the case for respiratory pharmacists
There is good evidence of the positive impact of pharmacists working in respiratory care both in the UK and internationally. “I would encourage any pharmacist working in respiratory to look at evaluating their role and to publish ……. or to produce a poster just so that we can collate more and more information [about] our role and impact in working with patients and within the MDT”, says Dr Murphy.
Good examples of published work include work done at Guy’s and St Thomas’ Hospital in collaboration with the integrated care service and work done at Bart’s Health NHS Trust with a pharmacist in general practice. In addition, a community pharmacy service that was developed in Leicestershire called the SIMPLE service has proved to be an effective tool in ‘difficult to manage’ asthma.
Additional support for business cases can be drawn from national documents such as workforce assessments by professional bodies. “The British Thoracic Society – and I chaired the BTS Pharmacist Specialist Advisory Group – we’ve just published an NHS workforce requirement [document] setting out what we need for [the] respiratory workforce in the future. And that’s very much to have one specialist lead pharmacist for every trust, so that’s a fully-funded 250 pharmacists for respiratory [medicine] across the UK, a specialist comms pharmacist working with high-cost therapies and also seven regional consultant pharmacists working in respiratory care. So that is a very useful document [published] by the British Thoracic Society”, says Dr Murphy.
Another very useful document has been published by the NHS Accelerated Access Collaborative which is hosted by the Oxford Academic Health Science Network (AHSN). This looks at the role of the pharmacist in GP practices focusing on adherence in asthma and referral on to severe asthma centres.
“Finally, it’s worth just looking at what the Federation of International Pharmacists are also doing and there’s publications coming out about the role of pharmacists working internationally in respiratory and again, although that doesn’t relate necessarily just to the UK there will be reference to other services that have been published across the UK in that document as well”, concludes Dr Murphy.
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