M Pharm Project

A Project on Role of Pharmacist to Improve the
Inhalation Pattern of Asthma in OPD Patients
A project report submitted to the Department of Pharmacy, University of Asia Pacific in partial
fulfillment of the requirements for the degree of Master of Pharmacy in Clinical Pharmacy &
Pharmacology
Submitted By
Registration No.: 23222034
Semester: Spring 2023
Submission Date: October 2024
Department of Pharmacy
University of Asia Pacific
Summary of the Study
Table of Contents
Topic Page
Summary of the Study
Table of Contents
List of figure
1 Introduction
2 Pathophysiology of
Asthma
1. Introduction
The symptoms of asthma, a long-term disease (LTC) marked by life-threatening acute
exacerbations, include dyspnea, chest tightness, coughing, and wheezing. With an
estimated 235 million sufferers worldwide, asthma is a serious health concern because
of its high incidence, chronic nature, and negative effects on quality of life.According to
a 2009 systematic analysis, asthma among LTCs had a significant financial burden. It is
true that pharmacists assist in asthma care worldwide. Pharmacists may evaluate
patients seeking care at emergency departments in the United States (US) for an asthma
exacerbation, as well as their medication adherence or administration technique,
patient-specific medication use concerns, the need for therapy modification, access to
medications upon discharge, contraindicated medications, and vaccinations if
relevant.In contrast, pharmacists in the US teach patients how to control their asthma
on their own in an outpatient setting. In the United Kingdom (UK), for example, the role
of pharmacists has been steadily changing to include treating adult patients with
asthma.Patients may see a practice pharmacist in primary care to assist with long-term
asthma control.Pharmacists are essential in community pharmacy settings because they
not only prescribe drugs to patients with asthma but also actively participate in patient
education regarding medications and offer helpful advice, especially regarding quitting
smoking.
2. Pathophysiology of Asthma
The varied illness known as asthma is typified by reversible airflow
restriction, bronchial hyperresponsiveness, and persistent airway
inflammation. Allergy-induced asthma, nonallergic asthma, late-onset
asthma, asthma with fixed airflow limitation, and obesity-associated
asthma are among the prevalent asthma phenotypes.A significant
inflammatory component, affecting mainly the bigger conducting airways,
is linked to asthma.Depending on the phenotype, different cell types—such
as T cells, mast cells, eosinophils, basophils, neutrophils, and lymphocytes
—are involved in different types of inflammation. The pattern of respiratory
symptoms that characterize asthma, such as wheezing, shortness of breath,
tightness in the chest, and coughing, is identified, and spirometry is used to
confirm the variable expiratory airflow limitation. This is the basis for the
initial diagnosis of asthma. The severity of asthma is defined based on the
amount of treatment needed to control symptoms and exacerbations.
3. Asthma Treatment
Numerous treatment obstacles are brought about by the varied nature of
asthma and the existence of several phenotypes.As a result, individuals'
clinical characteristics and how they respond to medicine must be taken
into account when designing individualized asthma therapy.The overall
objectives of managing asthma are to limit the likelihood of exacerbations
in the future, maintain normal activity levels, and effectively control
symptoms with medication.
Globally, there are a plethora of clinical practice guidelines at HCPs'

disposal to help them make data-driven clinical decisions. The National
Heart, Lung, and Blood Institute (NHLBI) in the United States offers
guidelines for the diagnosis and treatment of asthma. These guidelines
were most recently updated in 2007.But since its last update, a number of
noteworthy advancements in the identification and management of asthma
have been documented. Medication for controller and/or reliever asthma is
part of treatment. Controller drugs, which are used for routine
maintenance treatment, include immunomodulator (anti-immunoglobulin E
or anti-interleukin-4/5) treatments, leukotriene receptor antagonists, oral
corticosteroids (OCS), ICS, and combinations of ICS and LABA.These
medications reduce inflammation in the airways, manage symptoms of
asthma, and lower the chance of recurrent flare-ups. It has been
demonstrated that the use of inhaled corticosteroids reduces
exacerbations, hospitalizations, and mortality. They are the cornerstone of
controller therapy and the standard of care in the long-term treatment of
asthma.Furthermore, it was found that using ICS in conjunction with a LABA
was more successful than raising the ICS dosage.
HCPs may think about intensifying treatment for patients who still have
uncontrollable symptoms or exacerbations after reevaluating their asthma
diagnosis, inhaler technique, and medication compliance. (Figure 1)
Similarly, individuals who report no worsening of their symptoms after
three months of treatment may choose to reduce their dosage. But it's not
a good idea to fully cease using ICS. SABAs and ICS/formoterol combination
therapy are examples of reliever (rescue) drugs that are used "as needed"
to treat breakthrough symptoms during asthma worsening or
exacerbations.The necessity for efficient add-on treatments is shown by the
fact that 46.9% of American asthma patients reported exacerbations in
2016, despite the availability of these diverse treatment alternatives.
Nonpharmacological therapies can be used to treat asthma symptoms and
lower the likelihood of relapses in addition to pharmacological therapy.
These include getting regular exercise, eating a balanced diet, quitting
smoking, staying away from indoor allergens, being around smoke, going to
work, and using drugs that aggravate asthma.It's also advised to treat
comorbidities and modifiable risk factors like anxiety and obesity.Lastly, it's
critical to remember that while GINA offers population-based
recommendations based on treatment alternatives that are generally
beneficial for the majority of patients, health care professionals (HCPs)
should make individualized treatment decisions after taking patient- and
disease-related aspects into account.
Figure 1. Stepwise approach to control symptoms and minimize risk of future
exacerbations in adults and adolescents 12 years and older with asthma as per GINA.
For children 6-11 years, the preferred Step 3 treatment is low dose ICS-LABA or medium
dose ICS. *Off-label; data only with budesonide-formoterol †Off-label; separate or
combination ICS and SABA inhalers. ‡Low dose ICS-formoterol is the reliever for patients
prescribed budesonide-formoterol or BDP-formoterol maintenance and reliever
therapy. #Consider adding HDM SLIT for sensitized patients with allergic rhinitis and
FEV1 >70% predicted. BDP indicates beclomethasone dipropionate; FEV1, forced
expiratory volume in 1 second; GINA, Global Initiative for Asthma; HDM SLIT, house dust
mites–sublingual immunotherapy; ICS, inhaled corticosteroids; IgE, immunoglobulin E;
IL, interleukin; LABA, long-acting β2-agonist; LTRA, leukotriene receptor antagonist; OCS,
oral corticosteroids; SABA, short-acting β2-agonist. Note: Reused with permission from
Global Initiative for Asthma pocket guide 2019 (©: 2019 Global Initiative for Asthma,
Inc.).
4. Inhaler devices in asthma treatment

The cornerstone of asthma treatment is inhalation therapy, which
minimizes systemic adverse effects, enables drug delivery to the intended
site of action, and requires a smaller dosage of medication.The
management of asthma is contingent upon both the pharmacological agent
and the inhaler used to provide the drug. Therefore, it is imperative to
appropriately match the inhaler to the patient, taking into account their
individual needs, limitations, and preferences.In fact, it has been noted that
improper inhaler technique is frequently seen in everyday situations,
underscoring the significance of using an inhaler correctly. Small-volume
nebulizers (SVNs), breath-actuated inhalers (BAIs), pressurized metered-
dose inhalers (pMDIs), dry powder inhalers (DPIs), and soft mist inhalers
(SMIs) are the five primary kinds of asthma inhaler devices. Every gadget
has its own. Small-volume nebulizers take aqueous solutions or suspensions
and turn them into a respirable aerosol by using electrical or pneumatic
energy. They are appropriate for toddlers, the elderly, and patients who are
not conscious since they do not require synchronization between actuation
and inhalation. SVNs can cause significant drug loss during expiration, are
difficult to transport, only deliver a small portion of the medication to the
lungs, take a long time to treat, and require a lot of cleaning and
maintenance.Propellers are the energy source used by pMDIs, as opposed
to SVNs, to create aerosols from liquids or suspensions. Coordination
between actuation and inhalation is necessary for the effective use of
pMDIs, although it can be challenging to accomplish and lead to insufficient
drug delivery. But these difficulties can be solved with the use of spacers or
BAIs.All DPIs are breath actuated, meaning they create turbulent energy by
using the patient's inspiratory flow to assist break up the powder into a
spectrum of respirable fine particle sizes.As a result, actuation and
inhalation do not need to be coordinated. The maximum airflow produced
during the inspiratory cycle is known as the peak inspiratory flow rate, or
PIFR. Different DPIs require different minimum and optimal PIFRs.
Furthermore, it has been demonstrated that when asthma symptoms
worsen, particularly in young people, PIFR dramatically drops. Furthermore,
there is an inherent airflow resistance in every DPI. Low resistance dry
powder inhalers need more inspiratory effort to degglomerate the powder,
making it challenging to achieve adequate inspiratory flow in patients with
advanced respiratory disorders, including children and the elderly.
Therefore, taking these factors into account is necessary for selecting the
right inhaler.DPIs can be classified as single-unit dosage inhalers, multidose
reservoir inhalers, or multiunit dose inhalers, depending on the mechanism
used for the drug's storage and administration. Soft mist inhalers
circumvent the drawbacks of both pMDIs and DPIs by not requiring
propellants, requiring less effort to inhale, and enabling steady delivery of
the medication aerosol .
5. Role of Pharmacists
With their clinical expertise in patient management, ability to educate
patients about asthma medications, teach inhalation technique, address
patients' concerns about potential medication side effects, and enhance
adherence to treatment, pharmacists are in a unique position to improve
outcomes for asthma patients. In fact, in an integrated health care system,
the National Governors Association emphasizes the value of pharmacists in
providing patients with direct medical care. In addition, pharmacists are
frequently the initial point of contact in community settings and are easier
to reach than HCPs. Consequently, pharmacists are in a position to offer
guidance on chronic illness prevention. Pharmacists can actively participate
in the management of asthma since they regularly engage with patients
during prescription refills.

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A Project on Role of Pharmacist to Improve the

Inhalation Pattern of Asthma in OPD Patients

Registration No.: 23222034

Semester: Spring 2023

Submission Date: October 2024

Globally, there are a plethora of clinical practice guidelines at HCPs'

4. Inhaler devices in asthma treatment

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