Medications Education
Patients should bring all of their medications for asthma and for other conditions, (including eye drops and nasal sprays) to each review. Watch patients use their inhaled medications and assess technique.
Inhaler devices and technique
Adverse effects of medications
Adherence
Inhaler devices and technique
- Involve patients in the choice of devices when possible.
- Aim for the least number of inhaler device “types”, to avoid inhaler device polypharmacy.
- With the patient write or get the patient to write out all of their severe asthma medications / or use pictures; ensure they understand what each medication is for, and when and how long to use each one. Make a copy for the patient to keep.
- Use their own asthma medications to talk about how each medication class works.
Adverse effects of medications
- Provide advice about the risks and benefits of asthma medications.
- Check for any medication side effects, including of high dose inhaled corticosteroids and high dose beta-agonists (short-acting and long-acting).
- Offer advice to minimize side effects (e.g. spacer for pMDI’s, switch accuhalers to pMDI’s via spacers, rinsing mouth after all ICS, handihaler to respimat, avoiding overuse of short acting bronchodilators).
- Check for side-effects of oral corticosteroids, including mood effects, weight gain, osteoporosis, cataracts etc.
- Check for medications that may affect asthma, including eye drops and heart medications
Acknowledge the frustration some patients may feel taking a lot of medications and still experiencing frequent symptoms and flare ups.
Example Discussion:
“Mrs B: I’m so sick of being short of breath. All I do is use this puffer, then use that puffer. I take the tablet that make me feel terrible. Then I have that injection that hurts. I still end up in hospital all the time. Sometimes I wonder if any of it helps?”
“Dr G : I am sorry you are feeling that way, I realise that sometimess it feels like your medications aren’t helping. Remember before you started taking them, you used to end up in intensive care and stay in hospital for weeks. Now at least you only have to go to the ward for a few days.”
Adherence
- Acknowledge that most patients don’t take all their asthma medications as prescribed and offer suggestions and tools to help: simple things like mobile reminders or more complex reminder solutions – e.g. smart inhaler devices;
- Discuss the cost burden some patients may have with multiple asthma prescriptions and that this may impact on adherence. If available, the generic version of some medications may be less costly and shopping around local pharmacies for best prices can be helpful.
Monoclonal Antibody Therapy Education
Education commences when patients are being assessed for the medications.
Monoclonal antibodies work by blocking the activity of some of the immune system molecules that trigger inflammation in the airways. This reduces the chance of asthma attacks / flare-ups, and in some patients, reduces the frequency of asthma symptoms.
Explain to the patient that there are very specific requirements for obtaining these medications through the Pharmaceutical Benefits Scheme (PBS) system. For more information see Monoclonal Antibodies.
Currently available monoclonal antibodies for severe asthma in Australia are:
- Omalizumab (XOLAIR) – binds to excess IgE in circulation
- Mepolizumab (NUCALA) – blocks IL-5, which regulates eosinophil production
- Benralizumab (FASENRA) – blocks IL-5Rα, and thereby the effects of IL-5 on eosinophils
- Dupilumab (DUPIXENT)- blocks the IL-4Rα subunit which inhibits IL-4/IL-13 mediated Type 2 inflammation
Discussion Points
- Use comprehensive medication-specific patient information booklets from peak bodies or the relevant manufacturer. These booklets describe the action of the medication and possible side effects.
- Clinical recommendations for monoclonal antibodies are available at the Centre of Excellence in Severe Asthma Website: Omalizumab, Mepolizumab, Benralizumab and Dupilumab.
- Inform patients approved for subsidised treatment that it is important to see the same respiratory physician for initial assessment. Assessment must be face to face and not by phone.
- Explain to the patient that improvements in asthma control or a decrease in oral corticosteroid dose are required to qualify for continued access to treatment (beyond 6-months).
- Recommend taking prescriptions to the local pharmacy up to a week in advance to allow the pharmacist time to order the medication from suppliers. These are not stock items. An alternative is to leave the prescription with the pharmacist, and prompt the pharmacist of the order by telephone.
- The first three doses will be administered in a severe asthma centre, tertiary care facility or respiratory physician’s rooms and patients are closely observed post injection. This is a precautionary step, as in rare cases anaphylaxis has been observed post injection.
- Explain to the patient the requirement to stay for an observation period after the injection.
- Inform the patient of the need to keep medications refrigerated from 2-6°, until they are administered.
- Advise the patient that ongoing doses need to be administered where access to medical care is available; usually their General Practitioner (GP). Patients are not able to self-administer or have family members administer the medications.
- People on omalizumab treatment should receive education about possible anaphylaxis. Some sites also give patients taking omalizumab an Anaphylaxis Plan from ASCIA
Macrolide Therapy Education
At the commencement of therapy, involve patients in discussion of frequency of doses and length of macrolide treatment.
- Provide education about not taking antacids simultaneously with macrolides.
- Advise patients to immediately report any hearing or balance changes that occur after they commence therapy.
- Discuss the possibility of side effects: the most common are nausea, vomiting, diarrhoea and abdominal pain.
- Ensure that the patient is aware of the need for ongoing reviews to evaluate therapy effectiveness.
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