I first started writing prescriptions as a supplementary prescriber in 2005 and did the conversion course to become an independent prescriber in 2007 — “specialising” in respiratory care, namely chronic obstructive pulmonary disease and asthma.
My mentoring GP had suggested doing spirometry testing for COPD patients and I found a niche at the surgery for my skills. Also the excellent guidelines for both COPD and asthma, along with my generic clinical management plan (in the early days), provided a cosy blanket to wrap myself in when it came to making prescribing decisions.
Recently, however, I have had to reconsider my stance around guidelines, both Scottish and local, as I have found myself in conflict with my own recommendations! When providing pharmaceutical advice for a nearby practice, I try to get GPs to adhere to the local formulary, which is based on evidence and best value for money (funds are, of course, in short supply).
A GP recently asked me which fluticasone/salmeterol inhalation device to use for a COPD patient — Accuhaler or metered-dose inhaler? Because only the Accuhaler is licensed for COPD and its cost is considerably less than the MDI, the answer is, to me at least, clear cut. I advised him to prescribe the Accuhaler forthwith, thus saving the local health board a not inconsiderable sum over the remaining lifetime of this particular patient.
Yet, I do occasionally prescribe this particular drug combination in the MDI form for use with a spacer because the patient may not like the Accuhaler, cannot use it (they do exist, believe me), does not like the taste, etc, etc.
So, now that I have been asked to do an audit of high-dose fluticasone/salmeterol prescribing within the practice, how on earth am I going to defend my own position when I have been telling the GPs they must conform to the guidelines as a cost-saving measure?
Patient care is at the forefront of my prescribing decisions. No matter how hard you try to teach them, some respiratory patients simply cannot use what one would consider to be the simplest of inhalers (the aptly named Easi-Breathe device comes to mind). Some people will need a more expensive device or a different medicine altogether. Ultimately, to ensure good outcomes, I believe the choice of inhaler needs to be patient-led.
Valerie Sillito is a community pharmacist in Aberdeen