Preventable factors are present in about 90 percent of asthma deaths which underlines the importance of helping patients to understand and use their treatments effectively.

Biologics are an important new addition to the treatments available for asthma and can help to reduce the frequency of exacerbations and the dose of oral corticosteroids required to control exacerbations. Dr Murphy says that she uses her qualification as an independent prescriber nearly every day. She believes that it has expanded her role as a pharmacist and helped her relationship with both patients and with the other members of the multi-disciplinary team. As part of her work, she is able to explain her approach to prescribing to junior doctors and help them to learn about the factors to be considered, she says.

There are numerous opportunities for pharmacists to work in respiratory medicine across the whole spectrum of health care in a variety of roles, including work in community pharmacies, in GP practices, in hospital and in integrated care.  The community pharmacist’s role is important not only in educating patients about their treatment but also in identifying “red flags” that could indicate serious underlying disease.

Steroid stewardship – analogous to antibiotic stewardship – is an important task for respiratory pharmacists and is one of the measures that can have a positive impact on the overall outcomes of asthma. The aim of steroid stewardship is to minimise the risk of harm and maximise the benefits of oral steroid treatment.

When it comes to making the case for respiratory pharmacists there are a number of useful publications. These include work done at Guy’s and St Thomas’ Hospital in collaboration with the integrated care service and work done at Bart’s Health NHS Trust with a pharmacist in general practice. In addition, a community pharmacy service that was developed in Leicestershire called the SIMPLE service has proved to be an effective tool in ‘difficult to manage’ asthma.  Furthermore, a workforce assessment by the British Thoracic Society has set out future requirements for specialist pharmacists and the NHS Accelerated Access Collaborative has described the role of a respiratory pharmacist in GP practices.

Pharmacists bring a special and distinctive set of skills to the care of people with asthma – their approach is different but complementary to that of doctors. Moreover, the skills that someone develops as a respiratory specialist pharmacist are transferable across a wide range of pharmacy practice settings. Dr Murphy concludes that respiratory pharmacy is an area that can offer a stimulating and rewarding career and a role that is much valued by patients.

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Asked if there is a danger that pharmacists could become the low-budget alternative to doctors Dr Murphy says, “I am not a doctor; I have … never really wanted to be a doctor; I’m very proud to be a pharmacist and I believe that my strength to the multidisciplinary team is not as a little mini-registrar or a junior doctor, it’s a pharmacist because what I bring to that team is very different”. Her approach to assessing and prescribing for a patient is different. Although there is some overlap, the pharmacist’s perspective is different and useful to the MDT, she says.

Having worked in respiratory medicine for 25 years now, Dr Murphy believes it is an area that offers a lot of opportunities for pharmacists. Moreover, the skills that someone develops as a respiratory specialist pharmacist are transferable across a wide range of pharmacy practice settings. “Wherever you wish to work as a pharmacist your skills that you develop as a respiratory pharmacist will work across the patient pathway. I think that’s important – we should be following that patient and utilising our skills that way…. Also, remember, respiratory is not just asthma and COPD, ….. there [are] over 200 different interstitial lung diseases – you’ve got cystic fibrosis, bronchiectasis, pulmonary diseases [such as] pulmonary embolism and lung cancer so there’s lots of different areas that you can get involved in”, she explains.

In conclusion Dr Murphy says: Finally, I find respiratory clinicians and the MDT extremely welcoming [to] the role of the pharmacist…  I think that [they are] generally very nice people to work with and also there is great support nationally [from] bodies like the British Thoracic Society [and] the Primary Care Respiratory Society……… I think [at] the end of the day our roles as pharmacists are valued by the clinicians and the rest of the MDT but, you know what is important to me  – I think our role is extremely valued by our patients”.

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Steroid stewardship

The concept of steroid stewardship is analogous to antibiotic stewardship. It emphasises appropriate use of the drugs to minimise harm and achieve the maximum benefit.

Dr Murphy explains: “We’re all very familiar with how we need to be really mindful of how many antibiotics we prescribe, making make sure that we’re prescribing at the right time for the right patient because of resistance. Now, what we’re talking about with steroid stewardship is similar…… we need to make sure that we’re prescribing at the right time for the right patient, the reason being that we know oral corticosteroids are very, very effective and they treat and they manage – they’re life-saving for – acute exacerbations of asthma, and potentially COPD as well. But unfortunately, we are all too well aware of the adverse side effects of oral steroids and we are only talking oral steroids here, not inhaled, but all steroids we know can lead on to diabetes, ischemic heart disease, weight gain, osteoporosis – and the list goes on and on and on. We know that if patients have more than a thousand milligrams of prednisolone then you are leading on to more serious side effects.”

The aim of steroid stewardship is to minimise the risk of harm by monitoring patients who are taking steroids and ensuring that all aspects of care are in place. This includes ensuring that other [concurrent] drug therapy is optimised, patients are adherent and are able to use their inhalers, all of which may help to reduce exacerbations of asthma. Another aspect of this is prompt referral to secondary or tertiary specialist respiratory centres for review. “So, if patients have two or more oral steroids for asthma exacerbations, then we should be thinking about referring those patients through to secondary care”, says Dr Murphy. The use of biologics may reduce the need for steroids, she adds.

Similarly, with COPD patients we can’t just keep giving COPD patients antibiotics and steroids every time. We need to stop and think – can we do anything more for this patient? And that’s again where perhaps a referral to secondary care or even, if you’ve got integrated care services that’s ideal for them to perhaps to look more closely at that patient and help you to review them”, she says.

Making the case for respiratory pharmacists

There is good evidence of the positive impact of pharmacists working in respiratory care both in the UK and internationally. “I would encourage any pharmacist working in respiratory to look at evaluating their role and to publish ……. or to produce a poster just so that we can collate more and more information [about] our role and impact in working with patients and within the MDT”, says Dr Murphy.

Good examples of published work include work done at Guy’s and St Thomas’ Hospital in collaboration with the integrated care service and work done at Bart’s Health NHS Trust with a pharmacist in general practice. In addition, a community pharmacy service that was developed in Leicestershire called the SIMPLE service has proved to be an effective tool in ‘difficult to manage’ asthma.

Additional support for business cases can be drawn from national documents such as workforce assessments by professional bodies. “The British Thoracic Society –   and I chaired the BTS Pharmacist Specialist Advisory Group – we’ve just published an NHS workforce requirement [document] setting out what we need for [the] respiratory workforce in the future. And that’s very much to have one specialist lead pharmacist for every trust, so that’s a fully-funded 250 pharmacists for respiratory [medicine] across the UK, a specialist comms pharmacist working with high-cost therapies and also seven regional consultant pharmacists working in respiratory care. So that is a very useful document [published] by the British Thoracic Society”, says Dr Murphy.

GP practices

Another very useful document has been published by the NHS Accelerated Access Collaborative which is hosted by the Oxford Academic Health Science Network (AHSN).  This looks at the role of the pharmacist in GP practices focusing on adherence in asthma and referral on to severe asthma centres.

“Finally, it’s worth just looking at what the Federation of International Pharmacists are also doing and there’s publications coming out about the role of pharmacists working internationally in respiratory and again, although that doesn’t relate necessarily just to the UK there will be reference to other services that have been published across the UK in that document as well”, concludes Dr Murphy.

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Working with people with respiratory disease is enjoyable and rewarding.  “The MDT [multi-disciplinary team] are often very welcoming to having pharmacists involved, which is always a good starting point,” says Dr Murphy.

Community pharmacist have a vital role in supporting people with respiratory disease including work as part of the New Medicines Service and health promotion activities such as smoking cessation services, exercise and weight-reduction advice.  “We hope to have a new contract which encourages community pharmacists to support more with inhaler technique because, of course, for them to check and optimise inhaler technique when a patient collects their inhalers – it’s the best time for that to happen”, she says.

Another important role for community pharmacists is identifying “red flags” in people with respiratory complaints. These might be patients receiving frequent courses of antibiotics and steroids who have not yet got a diagnosis or patients who are self-treating persistent coughs. “It could be lung cancer or it could be COPD or, indeed, could be asthma”, says Dr Murphy.  “We can actually help pharmacists to identify and then to refer through to the GP practice nurses and so on for diagnosis”, she adds.

Pharmacists working in GP practices are able to undertake structured medication reviews for people with respiratory disease and also deal with effective use of inhalers. In addition, “There’s obviously a big push at the moment with the NHS agenda to become carbon neutral, so there’s an incentive for GP practices to look at using ‘greener’ inhalers such as dry powder inhalers and a lot of GP practice pharmacists have been getting involved at the moment with that piece of work”, says Dr Murphy. There’s also a massive backlog of patients with asthma and COPD that have not been reviewed because of covid and a lot of GP practice-based pharmacists are working with their GP teams to help with reviewing some of these patients, she acknowledges.

There are also opportunities in respiratory medicine in hospitals including, for example, in specialist commissioning for high-cost therapies such as biologics.

“The last area is integrated care. So, pharmacists working across the integrated care system ….. trying to break down the barriers between primary [care], secondary care, community hospitals and councils to try and improve health and prescribing of respiratory care across the whole integrated care system…..So huge opportunities for pharmacists within respiratory”, says Dr Murphy.

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“Biologics are actually quite an exciting aspect of managing asthma”, says Dr Murphy.  The first biologic for asthma was omalizumab (Xolair), launched in 2005.  “It targets the allergic aspect of asthma so it works very well in people who have atopy, perhaps associated urticaria, eczema, allergic rhinitis – so very much where allergens are driving people’s asthma”, she explains.  More recent biologics target the type II inflammatory aspect of asthma. These are given by injection, often subcutaneously, and they work in helping to reduce exacerbations, often reducing the amount of oral corticosteroids that have to be given for exacerbations. These “can be life-changing for some people …… you know, can really improve people’s asthma control”, says Dr Murphy.  More recently another new type of biologic for asthma has been introduced. It is a rapidly-evolving area of research and this means “that we can offer people with asthma new treatments that can really help to prevent mortality and morbidity of the disease”, she says.

Dr Murphy has been an independent prescriber since 2008. She says: “I can honestly say to you that I probably use my qualification nearly every day”.  She believes that it has expanded her role as a pharmacist and helped her relationship with both patients and with the other members of the multi-disciplinary team. “It means that I’m actually responsible and actually accountable for the prescription. So, I’m assessing the patient – they may be diagnosed with the condition or they may not – I’m looking for differential diagnoses, making sure that I’m prescribing at the right time for that patient, making sure it’s you know it is the right drug that I’m using for the right condition. I think for me it is about that accountability. For years as a pharmacist you know, you say, “Excuse me, would you mind prescribing this or could we do that….”, and now I can still do that as part of my role, you know, in terms of teaching other members of the multi-disciplinary team but I’m actually putting my name against that prescription and I think that’s really important to take that accountability”, she explains.

The interaction with patients in the clinic is critical and a large part of Dr Murphy’s role, especially in the severe asthma clinic is helping patients to understand their treatment and how to use it effectively and this is very much about shared decision-making.  “I want to understand what my patient feels about their condition, I want to understand what they feel about their medicines, what do they like about them what are their beliefs about medicines, you know. Some people just do not understand about prevention, for instance, and prevention in diseases like asthma is absolutely key. So, you have to have that understanding, …… and I think during that consultation to be able to then say, “OK, let’s look at your medicines let’s look see what suits you better. What do you like? What don’t you like? What can we do to help you?” and then to finish that consultation with a prescription that they can walk away with … .. it’s a shared decision”, she says.

Dr Murphy emphasises that she only prescribes within her area of practice and sphere of competence. “The number of medicines that I prescribe is actually quite limited”, she notes.

It has been suggested that junior doctors my become deskilled in prescribing if pharmacists take on much of this function.  “I think from a junior doctor point of view, I think we can teach as part of that prescribing process – so it’s about trying to work together as a team. What I bring to a team as a pharmacist is different from what the junior doctor will bring”, says Dr Murphy.  She is able to explain the reasons for her prescribing decisions and how she approaches the task. For example, she routinely considers renal function, liver function and patient’s ability physically to handle the medicines or devices. “That’s what I want to share with the doctor so I’m not de-skilling them. Actually, by the process I’m showing them how, and hopefully, you know, enhancing their competency”, she says.

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Dr Murphy holds three outpatient clinics per week – two for asthma and one for interstitial lung disease. She also has a role in integrated care working across the integrated care system and participating in a virtual multidisciplinary team (MDT) for chronic obstructive airways disease (COPD). In addition, she is involved in training for GPs, practice nurses and community pharmacists and also teaches at universities. “I’m very clinical – patients are extremely important to my role and what I do”, she says.

Asthma is a chronic inflammatory disease that commonly starts in childhood. Some children grow out of it as they get older, some will continue and some people find that the asthma comes back later in life.  For some people, asthma actually presents for the first time much later in life.  “Fundamentally, in most cases of asthma it’s really where your immune system is being overactive. It’s reacting to environmental triggers that the patient breathes in, so what you get is an influx of inflammatory cells, largely probably eosinophils which cause inflammation in the lungs – and that’s key for us to understand as pharmacists and key for our patients to understand as that is fundamental to how we manage asthma”, Dr Murphy explains.

About 1300 people die of asthma each year in England and Wales, according to the Office for National Statistics. “Probably 90 percent of those people have factors that could be preventable, so if we actually got care better – prescribing the right medicines for them, give them action plans, make sure they know what to do if they have asthma symptoms – then we can probably prevent a lot of those deaths”, says Dr Murphy.  Providing the information is one thing, but helping patients understand and “take on board” the advice is one of the challenges of effective asthma management. “For instance, it’s vital that people with asthma can inhale appropriately their inhaled corticosteroids. We try and encourage people not to over-rely on their salbutamol – their shorter-acting beta-2 agonist – and getting those messages across is really, really important”, she adds.

Dr Murphy says: “The national review of asthma deaths in 2014 actually showed that nearly 40 percent of people who died used more than 12 salbutamol inhalers in a year and about 80 percent of people who had died were using less than 12 of their inhaled corticosteroids a year, which, of course, is what you would expect a patient to be doing. So, these are the fundamentals that we need to look at to try and prevent people from dying of asthma”.

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