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Medicines optimisation in asthma – Role of a Paediatric Specialist Pharmacist

by Sukeshi Makhecha, Specialist Paediatric Asthma Pharmacist, Royal Brompton and Evelina Hospitals

Asthma deaths in the UK are amongst the highest in Europe, with children being the most vulnerable, particularly the adolescent population. Yet frustratingly the figures do not seem to be improving, despite the fact that most are avoidable.

So I decided to join the team of world-renowned asthma experts at the Royal Brompton Hospital, who I admire not only for their expert knowledge but their enthusiasm to improve the quality of care for children with asthma, in addition to driving research in asthma to improve future care.

My interest in this area was further enhanced during my MSc researching into new electronic monitoring devices (NEMD) for monitoring adherence in asthma inspired by my clinical supervisors, which totally challenged my digital technology skills. I learned that there is no ‘one device that fits all‘ and NEMD’s should be individualised to suit the needs of the patient.

My role as a specialist paediatric asthma pharmacist was further consolidated when I joined the Evelina Respiratory team where I was able to set up pharmacist-led asthma clinics. Seeing patients in the clinic is totally different from seeing them on the ward. There is more time to focus on them without interruptions and easier to develop rapport and get to know them well.

I realised that one of the most important aspects of my role was actually getting the basics right. This includes:

  • Checking inhaler technique. Use every opportunity to ask them to demonstrate how they use the inhaler.
  • Checking the spacer device is appropriate for the age of the child: children greater than 3 years should be changed from a mask to a mouthpiece. Children under 3 years using a mask, the seal around the mouth should be checked to ensure it fits well. Additionally, Metered Dose Inhalers (MDI) of inhaled corticosteroids (ICS) and ICS/Short-acting beta-agonists (SABA) should not be used without a spacer even in adolescents who may think they are ‘babyish’.
  • Adherence check, a topic I am passionate about, using either electronic monitoring devices, prescription uptakes or medication possession ratios. It is a well-known fact that the vast number of acute asthma attacks are due to non-adherence to ICS and overuse of short-acting beta agonists (NRAD).
  • If a child is using a dry powder inhaler (DPI) they should have adequate inspiratory flow to use that DPI otherwise it won’t work.
  • Review of patients on ICS and long term oral corticosteroids (OCS) and consideration of adrenal function
  • Discussion of side effects, especially parenteral concerns on growth. It’s amazing what parents tell pharmacists that they don’t tell Dr’s or nurses.
  • Smoking cessation and discussion on vaping – both parents and children. Vaping has become a popular activity amongst adolescents and has caused serious acute and chronic lung injury and even deaths.
  • Encouraging uptake of flu vaccinations
  • Advice on Vitamin D supplementation where appropriate

Other aspects of my role include management of biologics: ensuring the blue teq criteria is followed and involvement in IFR’s, previous to COVID setting up Service Level Agreements (SLAs) with other hospitals so that children could have their medication administered closer to home. Following COVID, leading on the service to organise biologics at home and homecare, with complexities of organising delivery of medication to local community nurses instead of patient’s homes and cold sprays for needle-phobic children, solutions to datix incidents, GP refusals, and transitioning to adult care.

I am also privileged to be part of a team of asthma activists in the London Asthma Leadership and Implementation Group (LALIG) for children and young people to make asthma deaths a non-event and be involved in the latest London Asthma Standards for Children and Young People as part of the Healthy London Partnership which has been doing some amazing work.

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