7 Steps process in COPD

Quality prescribing strategy for respiratory: a guide for improvement
Scottish Government Effective Prescribing & Therapeutics Division
Polypharmacy icon of two pills

A polypharmacy review (following the 7 Steps approach) should ensure optimal management of respiratory conditions, and include addressing aggravating lifestyle factors, consideration of the most appropriate medication at the right dose with regular review.

The 7 Steps to appropriate polypharmacy demonstrate that the review process is not a linear single event, but cyclical, requiring regular repeat and review as shown in the image below.

The circle is centred on what matters to the individual, ensuring they are provided with the right information, tools and resources to make informed decisions about their medicines and treatment options.

Step 1 - What matters to the patient?

  • Ask the patient what matters to them. 
  • Ask patient to complete Patient Reported Outcomes Measures (PROMs) (questions to prepare for my review) before the review
  • Is the patient’s day to day life or activities affected?
  • Do they have relief of symptoms and would they like to consider prevention of deterioration or repeat attacks.
  • Clear guidance and advice on when to use rescue medication – this may involve the use of digital technology (e.g. COPD self-management app)
  • How to improve activity and exercise tolerance and the introduction of pulmonary rehabilitation to improve quality of life at the appropriate point.  Advice regarding pacing and lifestyle
  • Knowledge of and avoidance of known triggers for exacerbations, e.g. infection.
  • Do environmental considerations matter? (see Environmental impact of inhalers)

 

Step 2 - Identify essential drug therapy

  • Ensure COPD diagnosis confirmed by spirometry carried out by trained professionals
  • Check adherence and inhaler technique before stepping up or adding medicines
  • Ensure treatment is optimised with local / GOLD guidelines47
  • When considering therapy, note when patients may have COPD with a background of asthma
  • Acute COPD exacerbations, defined as a sustained worsening of respiratory symptoms with acute onset, from their usual stable state beyond normal day-to-day variations, usually triggered by a respiratory tract infection. Initial treatment is with SABA. Consider the use of oral corticosteroids (OCS) with the possibility of antibiotics if indicated, for five days following the local formulary and personalised self-management plan48
    • Indication for antibiotics (three of the following symptoms, or only one additional symptom if change in sputum colour is present)47
      • worsening breathlessness and
      • cough
      • increased sputum production
      • change in sputum colour
  • For regular exacerbations, consider referral to secondary care where recommended antibiotic prophylaxis may be prescribed, referring to local formularies for guidance. Consider risk-benefit due to increased bacterial resistance.47,49
  • Monitoring during antibiotic therapy may be required46
  • Secondary care review to confirm ongoing need for and effectiveness of medication and screen for side effects

 

Step 3 - Does the patient take unnecessary drug therapy?

  • Review use of ICS as part of combination therapy in people with COPD who are not exacerbating or who do not have blood eosinophils >300 cells/μL to reduce the risk of pneumonia and other potential ADRs47
  • Long term OCS are not recommended due to the potential for adverse effects
  • Steroid treatment cards should be provided to patients on high dose steroids (both oral and inhaled). A steroid emergency card may also be required.18
  • Ordering six or more SABA inhalers per year may indicate continued breathlessness and therapy optimisation may be needed
  • Repeated use of ‘rescue medication’ (two or more per year)47 should trigger a review to optimise long term management. Sputum samples are necessary to guide antibiotic prescribing, especially if empirical prescribing has not resolved symptoms.47
  • Review the need for mucolytics on a regular basis and continue only if symptomatic improvement (reduction in cough and sputum)48
  • Regular use of nebuliser therapy should be a prompt for review. Nebulisers should only be used under medical recommendation. They require regular servicing and a pMDI with a spacer is at least as good as a nebuliser in treating mild / moderate asthma attacks66
  • If oxygen saturations are below 92% on air consistently, refer for oxygen assessment as per local Health Board criteria
  • Patients with significant emphysema and air trapping may benefit from lung volume reduction surgery

 

Step 4 - Are therapeutic objectives being achieved?

  • Ensure at least annual review
  • Can the patient use their inhalers properly? Consider addition of spacer to aid MDI lung deposition or consider DPI/SMI if appropriate
  • Improvement in general health and exercise tolerance
  • Reduction in breathlessness and reduction of the risk of exacerbations or hospital admissions
  • Use COPD Assessment Test (CAT)50 and/or Modified Medical Research Council (MRC) breathlessness scales51 score as objective measurements of effect on activities of daily living (ADLs) 
  • Optimise therapy if there are frequent exacerbations and update self-management plans
  • Manage comorbidities affecting management and symptoms of COPD e.g., depression, heart failure, osteoporosis, obesity, anxiety and dysfunctional breathing
  • Vaccinations should be offered if not up to date (influenza, pneumococcal, DTaP (if not vaccinated in adolescence) and Covid-19)
  • Patients should be encouraged to engage in appropriate physical activity, including pulmonary rehabilitation. Social prescribing such as exercise, dependant on ability and singing classes  
  • Smoking cessation should be advised and the adverse effects of smoking on children highlighted. Offer appropriate support. Signpost patients to the NHS inform Quit Your Way Scotland website (which includes community pharmacy services) Weight reduction is recommended in obese patients (BMI >30)
  • Nutritional advice and support will be necessary in those with a BMI less than 20

 

Step 5 - Is the patient at risk of Adverse Drug Reactions (ADR)s or suffer actual ADRs?

  • Appropriate use of ICS as part of combination therapy ensures reduced risk of developing pneumonia (low eosinophil counts are predictive of increased risk of pneumonia) and adrenal suppression47
  • Oral corticosteroid use should not be used routinely unless comorbidity diagnosis requires OCS treatment. If withdrawal not possible, prescribe the lowest possible dose. Monitor for the possibility of adrenal suppression/ glucocorticoid effects and osteoporosis if on long term or frequent (more than three or four courses a year) treatment19
  • Assess for oral thrush - ensure correct technique to reduce incidence and add spacer device for pMDI if required
  • Dry mouth is common due to anticholinergic effects of long-acting muscarinic antagonist (LAMA) inhalers.
  • Antibiotic use may cause adverse effects including potential allergies and are not suitable for all COPD exacerbations. Minimal course length should be prescribed to reduce the risk of resistance. Ensure true antibiotic allergies are recorded and review accuracy of previous records. Scottish Antimicrobial Prescribing Group (SAPG) have a penicillin de-labelling toolkit52
  • Yellow card reporting of ADRs

 

Step 6 - Sustainability

  • Triple therapy may be more cost effective compared to using separate long-acting beta2 agonist (LABA)/ LAMA and ICS inhalers and aids adherence as well as reducing the carbon footprint of the inhalers (single versus multiple inhaler use)
  • Consider whether a DPI or SMI would be appropriate
  • Opportunities for cost minimisation should be explored but only considered if effectiveness, safety or adherence would not be compromised
  • For new medicines ensure prescribing is in line with Health Board formulary recommendations

 

Step 7 - Is the patient willing and able to take drug therapy as intended?

  • A personalised action plan is a key factor, with focus on inhaler technique, worsening symptom advice and awareness of symptom control
  • Refer to Pulmonary Rehabilitation (PR) or physiotherapist management of dysfunctional breathing, when necessary, as per local Health Board criteria
  • Consider end-of-life and palliative care support. Does the patient have an Anticipatory Care Plan (ACP)?
  • Make patient aware of support information e.g. the MylungsMylife website (see Resources for patients and clinicians)
  • Agree with the patient arrangements for repeat prescribing. Signpost to Medicines Care and Review (MCR) service in community pharmacy where appropriate.
  • Ask patient to complete the post-review PROMs questions after their review