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CPD ACTIVITY 63 Asthma relievers: the new paradigm 2 CPD CREDITS month or seven per day.23 However, many patients resist seeking counselling and advice from community pharmacists.24 Pharmacists conducting home medicines reviews and GP practice pharmacists may have greater influence on asthma outcomes within pharmacist-physician models.24 There is often discordance between patient perceptions of asthma control and actual asthma control.23 Questions to ask patients when requesting salbutamol over the counter can be modelled on the Asthma Control Test (see Table 4).6 Overall, the score provides an indication of asthma control and the need for further assessment by their general practitioner. A score of 20 or more indicates well-controlled asthma, but a score of 15 or less indicates uncontrolled asthma. Community pharmacists are acknowledged as highly accessible, and yet have unrealised potential to impact on suboptimal asthma control.23 Australian research has shown poor awareness of the ‘Guidelines for provision of a pharmacist only medicine: short acting beta agonists’ (SABA guidelines) by pharmacy assistants, despite their significant involvement in the sale of SABAs.25 In this research pharmacists’ awareness of the SABA guidelines was high, but pharmacists felt resistance of patients to interactions about their asthma management and time barriers to effectively support optimal asthma management.25 Guidelines indicate that pharmacists should refer patients to their GP if they fulfil the following: 26 • Experiencing an acute exacerbation. • Do not have a written asthma action plan. • Have not had a medical review in the past six months. • Assessed as having poor asthma control. As medication experts, pharmacists are well placed to monitor the step-up and step-down medication regimen recommended for asthma to optimise therapy. As asthma is a variable chronic lung condition, and due to the accessibility of OTC SABA relievers, community pharmacists have many opportunities for patient education and assessment. The strong evidence for anti-inflammatory relievers as needed, coupled with significant evidence of harm from over-reliance on SABA relievers, creates an opportunity for pharmacists to optimise asthma management in the community. Conclusions Poor adherence to regular inhaled corticosteroids in patients with intermittent asthma symptoms has led to research into alternative approaches to treatment. It is clear that a significant number of patients with mild asthma practise intermittent medication when symptoms occur. Recent trials have explored the use of ICS taken only in response to symptoms. As-needed budesonide/ formoterol reduces the risk of exacerbations and loss of lung function, the most serious outcomes of poorly controlled asthma. As-needed budesonide/ formoterol is less effective at mitigating symptoms but lowers exposure for corticosteroids substantially compared with budesonide maintenance therapy. Anti-inflammatory reliever therapy in patients with mild asthma should be considered a population-level risk reduction strategy. Accreditation Number: A2008RP2 (exp: 31/07/2022). This activity has been accredited for 1 hour of Group One CPD (or 1 CPD credit) suitable for inclusion in an individual pharmacists CPD plan, which may be converted to 1 hour of Group Two CPD (or 2 CPD credits) upon successful completion of the associated assessment activity. 1. Which of the following statements is INCORRECT? A) Excessive use of SABA relievers is a risk factor for severe exacerbations and death. B) Over-reliance on SABA relievers increases airway hyper-responsiveness. C) Regular SABA use reduces sputum eosinophil counts. D) Regular use of SABA relievers reduces asthma symptom control. 2. Which of the following statements about the key findings from an Australian survey on use of over-the-counter relievers for asthma is INCORRECT? A) Short acting beta2-agonist overuse is extremely high. B) Regular use of inhaled corticosteroid preventers is low. C) Short acting beta2-agonist overuse leads to well-controlled asthma. D) SABA overusers are more likely to use oral corticosteroids. 3. Which of the following outcomes from the SYGMA trials for as-needed low-dose budesonide/formoterol use for mild asthma is CORRECT? A) Reduced the risk of severe exacerbations compared with budesonide maintenance therapy. B) Improved symptom control compared with budesonide maintenance therapy. C) Increased daily inhaled corticosteroid dose compared with budesonide maintenance therapy. D) Reduced risk of severe exacerbations compared with as-needed short acting beta2-agonist. 4. The Novel START trial demonstrated similar results to the SYGMA trials comparing as-needed ICS/formoterol with budesonide maintenance therapy EXCEPT for which outcome? A) Inferiority of as-needed short acting beta2-agonist. B) Overall use of budesonide. C) Annual rate of exacerbations. D) Rate of severe exacerbations. 5. James is a 26-year-old man who presents to the pharmacy requesting a salbutamol inhaler. He describes his asthma as controlled most of the time, but has been reducing his exercise activities over the past month. Further questioning shows he uses his SABA reliever most days of the week and after exercise, wakes early morning with coughing about once a week and experiences shortness of breath a couple of times every week. How would you rate his asthma control? A) Well controlled. B) Partially controlled. C) Uncontrolled. D) Need more information. RETAIL PHARMACY • AUG 2020