OTC asthma preventers, restricted relievers proposed

asthma reliever puffer on its side

Experts alarmed at a possible figure of a million people with uncontrolled asthma have proposed major structural changes to the way asthma medicines are handled, including OTC preventers and restricting the OTC sale of relievers without preventers.

Tunn Ren Tay, Michael J Abramson and Mark Hew write in MJA Insight that the results of an asthma survey, recently published in the MJA, are “disappointing and disquieting,” with a quarter of respondents not regularly using preventers, despite having uncontrolled disease.

Of significant concern was the lack of regular preventer use, with patients apparently preferring immediate symptom relief to long term disease control.

“Ironically, the present dispensing system reinforces such behaviour,” the authors write.

“Relievers are readily available over the counter, but preventers require prescriptions, necessitating additional effort, time and expense.

“The logical solution to this problem is to re-design access to asthma medications. Preventers must be made more accessible.

They also suggested a measure be implemented “to detect and attempt to reduce the high volume dispensing of relievers without adequate concomitant preventers, because this pattern of medication use is implicated in asthma deaths.

“Such a move would require electronic coordination across pharmacies, with the ability to trigger referral for asthma review.”

They also suggest increasing the rebate for asthma reviews in general practice.

Jenny Gowan, the pharmacist member on the National Asthma Council Australia Guidelines Committee, told the AJP that she is not convinced the first two recommendations would be of benefit.

“I think it’s an advantage to have Ventolin available without a prescription, but it must be with adequate, compassionate counselling by the pharmacist,” she says. “This needs to be thoughtful counselling, not accusative counselling.

“When they ask for Ventolin, I immediately get it off the shelf so they know they’re going to get it, and ask a question: how’s your asthma been with all these changes in the weather? How does sport affect your asthma?

“It’s a conversation, which opens up a dialogue, and then we can actually do some constructive counselling about how many puffs, and techniques, and then explain why it’s necessary to give a preventer.

“I don’t believe we should have preventers available over the counter unless you have people that are trained and prepared to spend the time in developing a proper asthma plan.”

She says that allowing OTC preventer sales could also play a role in other lung conditions remaining undiagnosed, as buying preventers would then cut out the GP.

“I want to have a diagnosis,” Gowan told the AJP. “I want to know whether they’ve got asthma or not, and I think a full history-taking exercise needs to be done, with family history, triggers and a full asthma plan.

“Pharmacists could do it, but it would need to be a specialist consultation, like a health destination pharmacy, and some sort of certification or competency achieved.

“I’d also like an improvement in the MBS for the doctors: for years it’s been a poorly funded area. They get a lot more from diabetes than asthma.

“It’s not just about the rebate, though; there needs to be increased remuneration as a priority.”

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  1. Peter Crothers

    Jenny, I don’t agree about the specialist consultation. It is dead easy for pharmacists to get into the conversation about preventers and to assess who should be using one: the vast majority of the time the patient has been prescribed one but has stopped taking it. What follows is some gentle work on the patients’ health literacy (why the preventer matters and what the risk is of not using one and so on) and then . . . . . we can’t ‘close’ consultation in the obvious way by recommencing the preventer and referring to the GP for follow-up. Instead we end up saying (as we always do) that they really should follow-up with the GP, knowing that 90+% of the time they’ll do no such thing. It costs lives. I had a case last year where a young asthmatic patient had stopped taking her preventer and was using Ventolin 3 x daily. She promised me that she’d talk to the doctor about a preventer script. Maybe if I had been able to recommence the preventer, she would still be alive? She died from an asthma attack 2 weeks after seeing me, without having recommenced her preventer or seeing a doctor. We mustn’t let the ideal situation stand in the way of the absolutely necessary. PS: it’s not just doctors who should be properly paid for their work.

  2. Irvine Newton OAM

    I think both Jenny and Peter make really good points and in an ideal world Peter’s response and suggestions would no doubt work well. On the other hand, I believe the “accreditation” Jenny is describing would be necessary to ensure we have committed and competent pharmacists providing a quality pharmacy service. Either way sufferers would benefit.
    However, the elephant in the room is that many (maybe even most) patients haven’t a clue how to use their inhalers correctly and effectively. Studies talk about 50% compliance. In my experience, that understates the problem enormously. So, if we accept the premise that many people are not using their inhalers effectively, then the starting point surely must be to address that issue first. Like many of our colleagues I have been continually frustrated to witness the lack of understanding of people being prescribed inhaler medication. But not only first time inhaler users but even those who have been using these medications for years. We ALWAYS ask if patients have been shown how to use the device and invariably, the response is ” Oh yes, my doctor TOLD me how to use it”. As we all know, “telling” doesn’t work. It ain’t easy. Some people will never be able to master the task.
    So first step must be in getting some sort of buy in by both prescribers and pharmacists on their responsibilities as true health care professionals. The patient Peter talks about is surely evidence enough that we are failing people who could / should be doing so much better.

  3. Cameron

    As an asthmatic for over 20 years, I can attest to the benefits of seeing an asthma specialist and being ‘read the riot act’ after having been admitted to hospital with an asthma attack. Like my father before me, I assumed that Ventolin was the best ‘medicine’ for asthma as it made the lung tightness and anxiety that comes with it disappear instantly.
    It was only after my asthma specialist appointment (and I only needed the one) that I clearly understood the triggers of asthma attacks, why relievers are only a band aid solution if you have genuine asthma, and why preventers enable you to live a healthy/ stress-free life knowing your lifelong condition is properly managed.
    What annoys me most, however, is the need for/ and cost of a GP referral for a repeat script on a condition I’ll have for life but that is well managed. Yes, I understand the duty of care benefits of GP follow ups to check for underlying conditions but I am otherwise perfectly fit and healthy and this is an inconvenience I could do without.
    Knowing that I can renew my script OTC at the chemist would make this life long responsibility much easier and cheaper to manage.

  4. Linda Graham

    Hurray! What a fantastic recommendation. I’ve been married to Cameron (below) for longer than he’s been an asthmatic and can safely say that the ONLY time he has any symptoms is when his damn Seretide script has run out and he hasn’t had the time to get a new one. In my experience (with 3 family members being severe asthmatics), severe asthmatics don’t tend to rely on relievers. They’d be dead if they did. The MJA recommendations to make preventers more easily accessible would make a huge difference and could positively impact the burden on hospital emergency services. DO it. Do it NOW.

    • Jenny Gowan

      Dear Linda,
      The combination ICS and LABAs are not included in the proposal . It is low dose ICS only.

      • Peter Crothers

        Well the proposal is flawed Jenny

  5. Debbie Rigby

    I think this discussion really highlights the important role of community pharmacists responding to requests for Ventolin OTC. There is much room for improvement. Too often I hear “have you had this before?” as the opening (and last question). 90% of people do not use their inhalers correctly. The need is clear, the opportunity presents every day, so why is the situation seemingly getting worse around Australia?

    There are many resources available, as well as training. Videos are available for all devices. Why aren’t they playing on screens in pharmacies, instead of advertising the latest special? I use the videos very effectively on my iPad during HMRs. The same could be done in a community pharmacy.

    The idea of OTC low-dose ICS for adults was suggested at the Asthma Australia conference in Brisbane last year. I think there is some merit to the suggestion, but it needs to be coupled with improved performance by pharmacists assessing device technique and supporting adherence and persistence to therapy. According to the NAC guidelines, virtually all adults with adults should be using a low-dose ICS. He same cannot be said for children. So it may be problematic to restrict access to OTC Ventolin to adults and not children.

    I strongly believe appropriately trained and credentialed pharmacists should be able to write an asthma action plan. With less than 20% of patients with an asthma action plan, and strong evidence of improved control for people with a plan, it is a gap that pharmacists can fill. I see it as a role for pharmacists n general practice where they have access to medical notes and spirometry. It must be collaborative and poorly controlled patients and those with hospital admissions must be assessed by their GP.

    Perhaps it’s also an opportunity for pharmacist prescribing, or continued supply. And we could initiate step-down therapy after good control is achieved and maintained.

    I stress it should be low-dose ICS and not in combination with a LABA, as these patients need to be further assessed.

  6. Stephen Hughes

    Dear all,

    I am interested that all the responses discuss ‘telling’ or ‘counselling’ the person with asthma just one more time and that this will change their behaviour and all will be ok. I don’t believe there is much evidence for this. As a wise person once said ‘don’t keep asking the same question and expect a different answer’

    Cameron I think it would be good for you to unpack a bit more the reasons why you changed behaviour after being ‘read the riot act’ from your specialist but not after the many other interactions you had with health care professionals over the 20 years of your asthma.

    I believe we all need to start listening to people with asthma before we ‘tell’ them any more. Considering people with asthma as empty vessels just waiting for us to ‘counsel’ them dismisses the experience and knowledge gained from many years of living with breathing difficulties. It also dismisses the very important psychosocial factors that are intertwined with individual asthma beliefs and behaviours.

    What are we to do about it? Listen, engage. The disruption has to be in our behaviour as health care practitioners I think. Counselling more, is just business as usual.

    Happy to be convinced otherwise.

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