Biologics and working with asthma patients
As an independent prescriber Dr Anna Murphy, Consultant Respiratory Pharmacist, keenly aware that she is accountable for what she prescribes. Here, she describes how she uses her pharmaceutical expertise and how biologics have added to the therapeutic options for asthma.
“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.