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Cost-effective prescribing in chronic obstructive pulmonary disease

Article · September 2013with5 Reads
DOI: 10.12968/npre.2013.11.9.460
  • Steven Hickey at Northampton General Hospital NHS Trust
    Steven Hickey
    • 3.94
    • Northampton General Hospital NHS Trust
Abstract
This article highlights the cost implications when prescribing the different delivery devices available for salmeterol/fluticasone (Seretide, Allen & Hanburys) in patients with chronic obstructive pulmonary disease (COPD). The prescribing licence for combination inhalers in COPD is specific to both drug dosing and delivery device. The perception amongst some practitioners is that patients with moderate to severe airflow obstruction (FEV1 <60%) are unable to generate sufficient inspiratory flow to adequately use the Accuhaler. This audit found this not to be the case and recommends that independent prescribers can prescribe the licenced device confident that patients with COPD can generate sufficient inspiratory flow. The cost savings are significant if patients can be changed from the Evohaler to the Accuhaler.
Better Practice
460 Nurse Prescribing 2013 Vol 11 No 9
© 2013 MA Healthcare Ltd
Cost-effective prescribing in chronic
obstructive pulmonary disease
Steven Hickey
Abstract
This article highlights the cost implications when prescribing the different delivery
devices available for salmeterol/fluticasone (Seretide, Allen & Hanburys) in
patients with chronic obstructive pulmonary disease (COPD). The prescribing
licence for combination inhalers in COPD is specific to both drug dosing and
delivery device. The perception amongst some practitioners is that patients with
moderate to severe airflow obstruction (FEV1 <60%) are unable to generate
sufficient inspiratory flow to adequately use the Accuhaler. This audit found this
not to be the case and recommends that independent prescribers can prescribe
the licenced device confident that patients with COPD can generate sufficient
inspiratory flow. The cost savings are significant if patients can be changed from
the Evohaler to the Accuhaler.
Steven Hickey is Respiratory Nurse
Specialist, Northampton General Hospital
Email: Steven. Hickey@ngh.nhs.uk
The use of combination inhalers
in severe chronic obstructive
pulmonary disease (COPD) is well
established. The two combination
inhalers currently licensed for use in
COPD are:
Budesonide and formoterol fumarate
(Symbicort)
Fluticasone propionate and
salmeterol (Seretide)
Numerous studies have demonstrated
the benefit of commencing patients
with severe disease on long acting
beta2 agonists and corticosteroid
combination inhalers to help reduce
exacerbations (Calverley et al, 2003;
Szafranski et al, 2003).
Commencing combination inhalers
can reduce exacerbations by up to 33%
in exacerbations) should be similar
with both devices.
However, the implications are
twofold. First, the prescribing licence
for Seretide in COPD is for use
with the Accuhaler. Second, the 250
Evohaler costs £18.56 more per device
(£59.48 for the Evohaler versus £40.92
for the Accuhaler) (Joint Formulary
Committee, 2013). This equates to an
increased annual spend of £222.72
per patient who has been prescribed
the Evohaler over the licensed 500
Accuhaler (£713.76 versus £491.04,
based on 12 devices prescribed a year).
The exact reason for the abundant
prescribing of a more expensive
device that is unlicensed for COPD is
unclear. Are prescribers unaware of the
increased cost? Are prescribers aware
of the product licence in COPD? Is
there a perception among prescribers
that patients with COPD are unable to
effectively use the 500 Accuhaler? In
the current economic climate cost-
effective prescribing is essential. It is
unlikely that primary and secondary
care prescribers are knowingly
prescribing a device that is unlicensed
for COPD and more expensive.
To use any dry powder inhaler (DPI)
the patient must be able to generate
sufficient inspiratory flow for effective
lung deposition. DPIs require a fast and
deep inhalation to ‘suck up’ the drug in
the inhaler device. Capstick and Clifton
(2012) cite that a fast inhalation rate
generates a large internal turbulent
force in the inhaler device, which is
required to break up the formulation of
the metered dose to produce particles
of a size distribution that will penetrate
the peripheral airways. The minimum
effective inspiratory flow through the
Turbohaler and the Accuhaler has
been identified as 30 l/min (Azouz
in patients with a forced expiratory
volume in 1 second (FEV1) <50%
predicted (Calverley et al, 2003;
Calverley et al, 2007; Szafranski et al,
2003; National Institute for Health and
Care Excellence (NICE), 2010) and
are recommended in patients having
three or more exacerbations per year.
The licence for combination inhalers in
COPD is Symbicort Turbohaler 400/12
and Seretide 500 Accuhaler, both one
puff twice daily.
This article focuses on the results
of an audit carried out into the
prescription of the inhaler used to
dispense Seretide for the treatment of
COPD.
Background
As a secondary care respiratory nurse
specialist, the author frequently
comes across patients with COPD on
Seretide. The author’s has observed
that in his practice approximately 50%
of patients on Seretide appear to use
the 250 Evohaler, which is not licensed
for use in COPD, rather than the 500
Accuhaler. Given that each device
contains identical drugs, one could
assume that the net effect (a reduction
Nurse Prescribing 2013 Vol 11 No 9 461
Better Practice
© 2013 MA Healthcare Ltd
and Chrystyn, 2012). Some concern
has been expressed about impaired
inspiratory efforts during exacerbations
and its potential to result into a reduced
dose emission from a DPI (Azouz and
Chrystyn, 2012). This concern usually
Audit
Aims
The object of the audit was to establish
if:
Patients could generate sufficient
inspiratory flow to use the Accuhaler
If they had ever been offered the
Accuhaler before being prescribed
the Evohaler
Had their inspiratory flow ever been
checked?
Was their forced expiratory volume
in 1 second (FEV1) <60% predicted?
Methods
Over a 3-month period during the
author’s normal daily work, inhaler
devices were discussed with patients
admitted to secondary care with auggs butikk>n
acute exacerbation of COPD. If patients
had a Seretide 250 Evohaler, their
inspiratory flow was measured using
an In-Check Dial after gaining consent.
The In-Check Dial is a training aid
that can be used to improve inhalation
technique to help patients achieve
a faster inhalation flow (Azouz and
Chrystyn, 2012). Patients were also
asked if they had ever been offered an
Accuhaler and if their inspiratory flow
had been checked. Medical notes for up
to date FEV1 results were also reviewed
to see if the drug was being prescribed
within its licence.
Results
Over the period of the audit, 35
patients admitted to hospital with acute
exacerbations of COPD were found
to be on the 250 Evohaler. Inspiratory
flow was recorded on all of them and
all 35 achieved equal to or greater than
30l/min (Figure 1). The recordings were
made during an exacerbation, therefore
their actual inspiratory flow when
stable was probably underestimated.
FEV1 recordings found that six
patients had recordings >60% predicted
and that seven patients had never had
spirometry performed at either the
hospital or their GP surgery (Figure 2).
Only one patient had ever had his or
her inspirator y flow checked previously
and four had been on the Accuhaler but
had been changed to the Evohaler upon
their request. Also of note was that two
involves patients with COPD and
young children with asthma. Azouz and
Chrystyn (2012) found that in COPD
the reduced dose emission during acute
exacerbations was not sufficient to
cause concern but how this reflects to
real life is not known.
Figure 1. Inspiratory ow was recorded on all of them and all 35 achieved equal to or
greater than 30l/min
Figure 2. FEV1 recordings found that six patients had recordings >60% predicted and
that seven patients had never had spirometry performed at either the hospital or their
GP surgery
45 50
100
60
80
40
20
90
50
70
30
10
0
05 10 15 20 25 30 35 40
Inspiration Flow I/min
Inspiration flow
FEV1
FEV1
100
60
80
40
20
90
50
70
30
10
0
010 20 30 40 50
Better Practice
462 Nurse Prescribing 2013 Vol 11 No 9
© 2013 MA Healthcare Ltd
patients were on the 50 Evohaler and
four on the 125 Evohaler.
According to prescribing data
supplied by GlaxoSmithKline
(GSK) for 2012, the authors clinical
commissioning group (CCG) had
spent £865 089 prescribing the Seretide
250 Evohaler in patients with COPD.
GSK calculated savings based on a
25%, 50% and 75% conversion to
the licensed 500 Accuhaler (Figure
3). It was found that with minimal
intervention, savings of up to £147 000
per year could be achieved after the
cost of implementation is considered by
swapping over to the licensed device.
Conclusions
The use of combination inhalers is an
effective treatment recommended in
the NICE (2010) guidelines for the
management of COPD. The licence for
prescribing is specific with reference
to device and dosage. Although both
versions of Seretide offer the same
dosage of Fluticasone and Salmeterol,
there are considerable price differences
between the devices. In this audit,
it was found that even during acute
exacerbations of COPD patients can
generate sufficient inspiratory flow to
effectively use a DPI.
It is suggested that

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Hace no demasiado tiempo una de las noticias más llamativas del mundo del turismo era la denuncia puesta por varios turistas británicos después de sentirse estafados al haber pagado 64 euros por cuatro helados en el centro de Roma. Ya sabemos que la capital italiana puede llegar a ser bastante cara, pero hay mucha gente que intenta hacer su agosto a costa del turismo y por ello para que no nos suceda esto debemos buscar bien y aprovecharnos de las estupendas ofertas de viajes que siempre encontraremos en la red.

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Uno de los precios más baratos lo encontramos en la capital de Lituania, Vilnius, donde el precio medio de una noche y habitación se sitúa en torno a los 51 euros y otros de los países más asequibles los encontramos en el sur de Europa.

En Lisboa, los viajeros ahorraron en torno a un 7% este año si lo comparamos con el primer trimestre de 2012. Asimismo disminuyeron presupuesto los clientes de los hoteles de Atenas y de Roma. Las ciudades que más han disminuido sus tarifas han sido Londres y París, con un descenso del 8% y Copenhague con un 13%.

Escrito por Neon | 9 de mayo de 2013 con 1 comentario.
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