Case studies on transition to CFC-free inhalers

Dr Pam Brown discusses the practicalities of changing to CFC-free inhalers and cites two practices which have embarked on the process


During the next two to three years more than three million asthma patients will switch to CFC-free metered dose inhalers. This will be the most significant change in medication ever seen in primary care, but if managed proactively, it will offer GPs a unique opportunity to review and improve asthma care for all these patients.

Historically, metered dose inhalers (MDIs) have been formulated using chlorofluorocarbon (CFC) propellants. Production of CFCs was banned in the EU in 1995 following concerns about ozone depletion; however, an Œessential use¹ exemption was granted for asthma MDIs until a safe and economical alternative could be developed. MDIs using hydrofluroalkane (HFA) as the propellant have been available in the UK since 1995 and there are now three different salbutamol and one beclomethasone CFC-free MDIs available.

The EU Transition Guidelines1 recommend that once two formulations of salbutamol or beclomethasone are available from different manufacturers with a full range of indications, CFC containing formulations need no longer be produced. As a result, CFC-containing Ventolin Œpress and breath¹ inhalers were discontinued at the end of August 1999. This means that transition is now becoming a real priority, and many health authorities have issued guidance to practices and pharmacists encouraging them to initiate transition.

A publication produced by the Department of Primary Care at the University of Liverpool, proposes three possible models for transition of asthma patients from CFC to CFC-free treatment:



The first two options listed above provide the practice with a clear opportunity to review the patient¹s asthma control, reinforce education about the disease, and ensure that control is optimised at the time of transition.

Below are described the experiences of implementing transition of two practices in different parts of the country. Both are well down the transition pathway and have important insights to share with readers embarking on the transition process.

Practice 1

Practice profile
  • Location: The Black Country Practice, Tipton, Nr Birmingham
  • List size:12,500 patients 6 partners (4 full-time and 2 part-time)
  • 3 practice nurses
  • 2 nurse practitioners
  • Recently moved to new purpose built premises within one of the first 'Health Parks' where a variety of community and health services are available in one building.


Practice asthma profile
  • The practice has over 1,000 asthma patients
  • In August 1999, 748 patients were using beclomethasone, 244 were on budesonide and 22 were using fluticasone, 1004 were using salbutamol (including some COPD patients), and 281 were on terbutaline
  • A weekly asthma clinic is run by practice nurses who have completed the NARTC training course. 16 to 20 patients are seen in each clinic.
  • Current prescribing is a mixture of branded and generic asthma products.


The transition process
A pilot transition study was conducted with patients on BDP MDIs to extra fine HFA-BDP MDI/Autohaler. This involved:
  • A pilot of 25 patients on beclomethasone MDIs who were sent invitation letters on the basis that they were likely to attend the asthma clinic At the clinic appointment
  • The patients inhaler technique was checked using a MDI plus or minus a spacer device if appropriate
  • If suitable for change to extra fine HFA-BDP MDI or Autohaler, a demonstration of the new device was given with the opportunity for the patient to try a placebo device to experience the different taste and feel
  • Education about transition to CFC-free inhalers and dosing change with extra fine HFA-BDP (the extra fine formulation of Qvar enables physicians to halve the dose of inhaled beclomethasone with equivalent control)
  • Education about asthma management and importance of regular use of preventers was also addressed
  • Review appointments were made for one month and again at three months to monitor asthma control and side-effect profile.


Learning points
  • Transition is a good opportunity to review asthma control and inhaler technique as well as to reinforce educational and compliance messages.
  • As the transition was carried out with face-to-face consultations, we did not experience any problems with the altered feel or taste of the inhalers, or non-compliance with therapy; no one asked to change back to the CFC-containing inhalers. This is very different from our previous experience when we tried to change patients to generic inhalers by simply altering their repeat scripts and providing a letter of explanation.
  • It is important to explain to patients that we are doing the transition for the right reasons, ie because their current inhalers are damaging to the environment and will be withdrawn shortly, and that this is not a cost-cutting exercise. It is also good to stress that all the principles of good asthma care continue to stay the same.
  • Using leaflets to reiterate the information supplied verbally in the clinic is helpful. It is important not to force patients to use a device with which they are not happy. Our policy has always been to offer patients a choice between the two devices which the nurse thinks are most suitable at the initial clinic visit. If they try both out and are not happy with either, then the nurse will continue to try other devices until the patient is comfortable with the one on offer. In this pilot study, all our patients were given the opportunity to contact us and change to another device or preventer if they were not happy in the early days of treatment. Only one of the patients involved in this small pilot study chose to change.
  • The main issue identified by the patients was that it is difficult to work out when their inhaler is almost empty, even though they can calculate the number of days an inhaler should last with regular use.

Practice 2

Geraldine Richardson, Practice Nurse for Violet Lane Health Centre, Violet Lane, Croydon

Practice profile:
  • List size: 6,800 patients
  • 3 partners ( Dr William Barclay, Dr Agnes Marossy and Dr Krishan Arora) all dealing with asthma care
  • Practice Nurse Geraldine Richardson specialises in asthma care
  • 3 other partners and 1 assistant
  • 2 practice nurses (part-time)


Practice asthma profile
  • This practice has many older asthma patients.
  • 480 patients are on therapy using DPIs or MDIs (80 per cent of patients are on MDIs)
  • In September 1998, 314 patients were using beclomethasone, 19 budesonide (turbo inhaler) and 240 were using salbutamol (including some COPD patients)
  • There is no specific asthma clinic but patients are referred to practice nurse, Geraldine Richardson, who has completed the NARTC training course. The transition process
  • Croydon Health Authority started to plan transition in September 1998. A guidance document was issued to each practice and pharmacy. The district pharmacist reviewed asthma patient records in each practice and prioritised those patients with poor control
  • Invitation letters were sent out requesting these patients to make an appointment with the practice nurse for a review of their asthma. These had a very poor response.
  • In May 1999, the practice met and agreed to proactively address transition, and to simplify this by restricting their prescribing to Qvar (extra fine HFA-BDP) and Airomir (CFC-free salbutamol). A message was attached to all repeat prescriptions encouraging patients to make an appointment with the nurse as their asthma inhalers would soon be changed.
  • Each patient was given a double appointment. The asthma-trained practice nurse: provided education about CFC-free inhalers and transition as well as education on self-management plans; completed the asthma review template on the computer for each patient issued a script for the appropriate CFC-free inhaler
  • Initially all patients were invited for a review two weeks later. However, since there were few problems, patients were later asked to return only if they developed problems during the transition.
  • If patients were reviewed by the GPs in surgery, the asthma monitoring information was recorded manually and the notes passed to the practice nurse to update the computer records
  • 77 patients are now on Qvar and 86 on Airomir


Learning points
  • It is very important to have an accurate register of all asthma patients before undertaking transition
  • Encouraging patients to attend the clinic needs persistence‹many do not respond to the first invitation
  • Patients responded very positively to the idea of transition to CFC-free inhalers and to the idea of being able to halve their inhaled steroid dose
  • Most patients who did return for review in the early stages reported that they felt better and their asthma symptoms seemed better controlled
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Croydon Health Authority have set a deadline for all patients using salbutamol inhalers to be switched to CFC-free inhalers by September 1999, said Geraldine Richardson: "I am glad that we started transition early, as we would not otherwise have been able to complete it within the recommended timescale. Autumn will be a busy time with the influenza immunisation programme so it is good that we are already well advanced with transition".

References
1 European Commission. European Community: Strategy for the Phaseout of CFCs in Metered dose inhalers. January 1998
2 Rannard A, Bundred P, Walley T, Bogg J. Managing the Transition from CFC to CFC-Free Inhalers, Department of Primary Care, University of Liverpool 1998
3 Leach CL. Improved delivery of inhaled steroids to the large and small airways, Journal of Respiratory Medicine 1998; 92; suppl A

Dr Pam Brown is a GP in Swansea