Pharmacists Play a Vital Role in Asthma Management

According to the CDC, 1 out of 13 people have asthma and more than 11.2 million people report having experienced 1 or more asthma attacks or episodes in 2018.^1-2 Asthma is a condition that causes the airways to narrow and swell, making it hard to breathe. This can affect a person’s quality of life by limiting them to do their daily activities. Medications can play an important role in asthma management. Therefore, adherence to medications is important to optimize treatment and improve quality of life.

Regarding asthma treatment, an estimated 30% to 70% of adults and up to 50% of children have poor adherence.³ This poor adherence can lead to uncontrolled asthma and a reduced quality of life. In the past, asthma treatment generally consisted of an inhaled corticosteroid (ICS) controller with a short acting beta agonist (SABA) as rescue therapy. However, new updates from the 2020 Global Initiatives for Asthma (GINA) Guidelines show that the overuse of a SABA (dispensing >3 canisters/year) may lead to exacerbating lung conditions.

Pharmacists can play an important role in a patient’s asthma management by examining the patient’s refill history, adherence, and proper inhaler techniques. A systematic review and meta-analysis in 2018 showed that pharmacist-led interventions can significantly improve medication adherence.⁴

LIST OF COMMONLY USED INHALERS⁵

Class

Generic

Brand

Short-Acting Beta₂ Agonist (SABA)

Albuterol

Levalbuterol

Proair, Proventil, Ventolin

Xopenex

Long-Acting Beta₂ Agonist (LABA)

Indacaterol

Salmeterol

Olodaterol

Aracapta

Serevent

Striverdi

Short-Acting Muscarinic Antagonist (SAMA)

Ipratropium

Atrovent

Long-Acting Muscarinic Antagonist (LAMA)

Umeclidinium

Glycopyrrolate

Tiotropium

Aclidinium

Incruse

Seebri

Spiriva

Tudorza

Inhaled Corticosteroid (ICS)

Ciclesonide

Fluticasone

Mometasone

Budesonide

Beclomethasone

Alvesco

ArmonAir, Arnuity, Flovent

Asmanex

Pulmicort

Qvar

Combination SAMA + SABA

Ipratropium + Albuterol

Combivent

Combination ICS + LABA

Fluticasone + Salmeterol

Fluticasone + Vilanterol

Mometasone + Formoterol

Budesonide + Formoterol

Advair, Airduo, Wixela

Breo

Dulera

Symbicort

Combination LAMA + LABA

Umeclidinium + Vilanterol

Glycopyrrolate + Formoterol

Tiotropium + Olodaterol

Indacaterol + Glycopyrrolate

Anoro

Bevespi

Stiolto

Utibron

Combination ICS + LABA + LAMA

Fluticasone + Umeclidinium + Vilanterol

Trelegy

Image adapted from Allergy and Asthma Network 2020⁵

New 2020 GINA guidelines now recommend low dose ICS-formoterol as the preferred rescue therapy over albuterol. This is because recent studies have shown that patients with asthma have a degree of airway inflammation, and the use of ICS-formoterol can be a safety net in patients by providing anti-inflammatory benefits that SABAs do not offer. Two studies published in 2019 showed that the use of as needed ICS-formoterol produced significant reduction in severe lung exacerbations compared to SABA alone.^5-6

THE IMPACT OF PHARMACISTS

Checking Refill Histories on Rescue Inhalers

Pharmacists can check how often patients refill their rescue inhalers the next time they are verifying a rescue inhaler. There is an opportunity for an intervention if patients are filling frequently and dispensing more than 3 canisters a year based on the GINA Guidelines. Pharmacists can refer the patient to see their provider if they suspect the patient is using their rescue inhaler more than recommended.

Checking Adherence on Maintenance Inhalers

Adherence to maintenance inhalers can help control asthma symptoms and avoid the overuse of a rescue inhaler. Pharmacists can play an important role in reminding patients to refill their maintenance inhalers and to use it daily as directed to prevent asthma exacerbations.

Proper Inhaler Technique

Poor inhaler technique can lead to non-adherence and subtherapeutic treatment. It is important that patients know how to properly use inhalers for optimal treatment. Inhalers, such as an ICS, require specific instructions to avoid undesirable effects, such as thrush.

Patient Education

Talk to patients about recent changes in guidelines and educate them on how changing their rescue inhaler to include an ICS can be life-saving and may improve their quality of life. Patients can have their as needed albuterol as a backup as well.

Provider Education

After discussing with the patient, pharmacists may communicate with the provider if a patient has been filling frequently and provide recommendations based on updated guidelines. The dynamic nature of guideline recommendations makes it challenging to stay up to date. Communicate with the provider to ensure their reasonings and recommend accordingly.

REFERENCES

• CDC.gov. (2019). CDC - Asthma. [online] Available at: https://www.cdc.gov/asthma/default.htm [Accessed 3 December 2020].
• CDC.gov. (2018). CDC - Asthma - Most Recent Asthma Data. [online] Available at: https://www.cdc.gov/asthma/most_recent_data.htm [Accessed 3 December 2020].
• Engelkes M, Janssens HM, de Jongste JC, Sturkenboom MC, Verhamme KM. Medication adherence and the risk of severe asthma exacerbations: a systematic review. Eur Respir J. 2015;45(2):396-407. doi:10.1183/09031936.00075614
• Mes MA, Katzer CB, Chan AHY, Wileman V, Taylor SJC, Horne R. Pharmacists and medication adherence in asthma: a systematic review and meta-analysis. Eur Respir J. 2018;52(2):1800485. Published 2018 Aug 23. doi:10.1183/13993003.00485-2018
• Allergy and Asthma Network 2020. Respiratory Treatments. Allergy Asthma Network. Updated June 2020. Accessed December 18, 2020. https://members.allergyasthmanetwork.org/store/viewproduct.aspx?ID=9982674
• Beasley R, Holliday M, Reddel HK, et al. Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma. N Engl J Med. 2019;380(21):2020-2030. doi:10.1056/NEJMoa1901963
• Hardy J, Baggott C, Fingleton J, et al. Budesonide-formoterol reliever therapy versus maintenance budesonide plus terbutaline reliever therapy in adults with mild to moderate asthma (PRACTICAL): a 52-week, open-label, multicentre, superiority, randomised controlled trial [published correction appears in Lancet. 2020 May 2;395(10234):1422]. Lancet. 2019;394(10202):919-928. doi:10.1016/S0140-6736(19)31948-8
• "2012 GINA Main Report — Global Strategy for Asthma Management and Prevention” Global Initiative for Asthma.

Michelle George, PharmD, is a pharmacist at the University of Iowa's Hospital and Clinic. Julie Nguyen is a PharmD candidate 2021 at the University of Iowa's College of Pharmacy.