Patient safety spotlight: the risks of overprescribing Salbutamol inhalers for asthma

Specialist inspectors have identified cases of Salbutamol inhaler overprescribing of up to six inhalers per prescription by online prescribers. In this article, co-produced by our CPhO Clinical Fellow Aileen O’Hare and Toby Capstick, Consultant Pharmacist Respiratory Medicine; we explore the risks of prescribing high volumes of Salbutamol inhalers. We highlight the need for ongoing patient monitoring, counselling advice, inhaler device choices and discuss the clinical considerations when continuing treatment.

May 2022

Clinical guidance

The information below outlines best practice guidance for the prescribing of salbutamol inhalers and what clinical history, signs, symptoms and monitoring prescribers should consider when initiating salbutamol prescriptions or continuing treatment on a long-term basis.

We also want to highlight that the risk of severe exacerbations and mortality increase incrementally with higher short acting beta agonist (SABA) use.

  • Salbutamol inhalers should only be recommended for occasional relief of asthma symptoms. They should not be prescribed to treat asthma. Pharmacy teams can use the Right Care asthma slide rule to support conversations with patients about excessive and appropriate SABA use.
  • In the SABINA study, an association across all asthma severities was found between high SABA use of more than three inhalers per year, and an increase in exacerbation rates and healthcare utilisation.
  • Pharmacy teams should monitor SABA prescription volumes and encourage patients to continue taking inhaled corticosteroids (ICSs) as maintenance therapy. Good asthma control is associated with using a SABA inhaler no more than twice a week.
  • Pharmacy teams should focus on improving asthma inhaler maintenance and preventer management to reduce need for breakthrough reliever use. Where possible, prescribe the same or similar inhaler device for both ICSs and reliever therapy when initiating an ICS. 
  • If the patient is using DPI (dry powder inhaler) maintenance inhalers, use a DPI reliever. Prescribing combinations of DPI and MDIs (metered dose inhalers) are associated with worse outcomes, such as exacerbations and poor control in asthma.
  • For some patients, with appropriate education and training, using ICS-formoterol as a maintenance and reliever inhaler (MART) reduces the risk of asthma exacerbations compared with using traditional fixed dose maintenance ICS inhalers with a SABA reliever.
  • Observe and give advice on the person’s inhaler technique before prescribing. If a patient can inhale quickly and deeply within 2-3 seconds, prescribe DPIs. If the patient can inhale slowly and steadily over 3-5 seconds, consider aerosol inhalers such as MDIs or Respimat inhalers.
  • Review patients using three or more Salbutamol inhalers per year (allowing for them to be kept at different locations, such as one at home and one at work, for example). Use the Reliever Reliance Test to understand what patients think about their reliever inhalers.
  • Pragmatically, pharmacy teams may want to initially target people who use the highest number of Salbutamol inhalers, such as those who use more than six inhalers per year and patients with a history of exacerbations. Teams should issue and review personalised asthma action plans. 
  • Patient education is key to ensuring people understand how and when to use maintenance and preventer inhalers versus reliever inhalers; including when to use salbutamol and when not to. Signpost patients, carers, and other healthcare professionals to Rightbreathe resources and Asthma & Lung UK inhaler videos to help them optimise inhaler technique and compliance.
  • Consider the Greener NHS programme when prescribing MDIs as 60% of MDIs prescribed in England are salbutamol. By improving patients’ asthma control (optimise treatment and inhaler technique) this will ultimately reduce their overall salbutamol use and benefit the environment. Where patients can inhale quickly and deeply Salbutamol DPIs should be prescribed, alongside maintenance DPIs to aid adherence. 
  • SIMPLES is a structured primary care approach to the review of people with uncontrolled asthma which encompasses patient education, monitoring, lifestyle (smoking cessation), pharmacological management and patient support.

GPhC standards and guidance

In practice: Guidance for pharmacist prescribers, recommends safeguards for the online prescribing of certain medicines. It highlights that some categories of medicines are not suitable to be prescribed or supplied at a distance unless further safeguards have been put in place to make sure that they are clinically appropriate. The categories include: Medicines that require ongoing monitoring or management. For example: medicines with a narrow therapeutic index, such as lithium and warfarin; and medicines used to treat diabetes, asthma, epilepsy, and mental health conditions. 

The guidance also recommends safeguards are put in place if the above categories of medicines are to be supplied online. If a pharmacist prescriber decides to prescribe at a distance or work with an online prescribing service, the above categories of medicines should not be prescribed unless the prescriber has contacted the GP in before issuing a prescription for medicines which are liable to abuse, overuse or misuse (or where there is a risk of addiction and ongoing monitoring is important) and the GP has confirmed to the prescriber that the prescription is appropriate for the person, and that appropriate monitoring is in place.

The standards for pharmacy professionals highlight that pharmacy professionals should provide person centred care, work in partnership with others, communicate effectively, maintain, develop and use their professional knowledge and skills, and use their professional judgement.

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