Traditionally, pharmacists are not known for blowing their own trumpets, yet their pivotal role in multidisciplinary teams is growing in recognition. One area of practice in which clinical pharmacists are particularly impactful is respiratory medicine. Allie Anderson speaks to Gráinne d’Ancona, consultant pharmacist for respiratory and sleep medicine at Guy’s and St Thomas’ NHS Foundation Trust in London, to find out more.
In December 2023, the European Respiratory Society journal, Breathe, published a paper extolling the many and varied ways in which clinical pharmacists add knowledge and value in respiratory and sleep medicine.
According to the paper’s lead author, consultant pharmacist Gráinne d’Ancona, the profession is uniquely placed to have an enormous impact on health outcomes thanks to their expertise in medicines – especially those used to treat lung disease.
‘Pharmacists have the skillset to support and adapt medicines-taking behaviour and adherence, and respiratory is a clinical area with a significant patient need,’ she explains. ‘There are lots of patients with outcomes that could and should be better, and a pharmacist’s skills are essential in filling the gaps. Seemingly very simple interventions like improving someone’s inhaler technique or increasing adherence can be transformative.’
Notwithstanding the potentially life-changing benefits of optimising inhaler use in patients with poorly controlled disease, pharmacists are increasingly assuming the clinician mantle as independent prescribers, training to consultant-level practice and contributing to academic research. These are just some of the innovative ways pharmacists not only work in but lead multidisciplinary teams.
Affecting change in theory and practice
Pharmacist roles have been acknowledged in manifold ways. For example, pharmacists in all sectors were seen as pivotal to delivering key objectives of the Accelerated Access Collaborative (AAC). The AAC brings together patients and clinical stakeholders to widen access to the best NHS healthcare through increased access to innovations in diagnosis and new treatments.
The AAC has supported the roll-out of innovations in respiratory care, including improving uptake of biologics to treat severe asthma, with pharmacists considered integral to ensuring patients are prescribed these treatments appropriately and responsibly by leading on medicines optimisation.
Currently, the National Institute for Health and Care Excellence recommends six biologic therapies for sever asthma: omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab and tezepelumab. However, in the UK it is estimated that fewer than one in five of the approximately 60,000 patients who could benefit from biologics are prescribed them.
‘People who had been very unwell from their asthma in the past are doing fantastically well on biologics, but for NHS-funded care, there are eligibility criterion that must be met. For example, one of the prerequisites is that patients must have demonstrable adherence to their standard therapies – namely, inhaled corticosteroids,’ Gráinne explains. ‘There seemed to be no clinical evidence to support that restriction, so I wanted to explore whether it made a difference to outcomes.’
She published a paper in the European Respiratory Journal, comparing outcomes in patients on mepolizumab who were adherent to inhaled corticosteroids with those who were not.
She then studied outcomes in patients prescribed benralizumab, again looking at how well those who adhered to their standard therapy fared versus patients who did not use their inhaled corticosteroid regularly.
‘We found there was a difference. With mepolizumab, if you don’t use your inhalers alongside it, you tend to do worse. So that gave some value to ensuring adherence in these patients,’ Gráinne says. ‘But, conversely, with benralizumab, we found adherence to inhaled corticosteroids didn’t appear to affect outcomes very much.’
These findings fed into the development and subsequent publication in January 2024 of a randomised controlled trial examining inhaler titration alongside benralizumab. It found that almost two-thirds of patients could successfully wean their inhaled corticosteroids to a lower dose without increasing exacerbation or symptom frequency, potentially to an ‘as required’ regimen, though this needs to be explored further.
‘This is a seismic change in how we manage these patients, who are at the most severe end of the disease spectrum and should encourage us to challenge potentially unnecessarily high dosing,’ Gráinne adds.
Developing opportunities for pharmacists
Clinical pharmacists have a range of knowledge, skills and expertise that provide great insights into research, and Gráinne believes more should embrace these opportunities. ‘It’s incredibly important because, as we develop our roles and we evolve what we do in clinical pharmacy, we should investigate and justify our own contribution,’ she comments.
‘I want people to see that there are lots of different ways to contribute to research. It may sound very frightening, but everybody starts somewhere,’ Gráinne adds. ‘It builds over years and there will be knockbacks, but if you are in a supportive environment, you pick yourself up and keep going.’
Being part of a multidisciplinary team can benefit pharmacists in developing their skills, enabling them to see how other experienced clinicians are using their own expertise to expand their experience and practice. ‘We have a very educated and willing cohort of healthcare professionals in pharmacy, but we have lower confidence than some of our colleagues,’ she notes. ‘But increasingly, we have changes in policy and agendas that are almost begging us to be involved in hands-on clinical care.’
Notable among these changes was the development first of supplementary prescribing for pharmacists, followed by independent prescribing. From 2026 all UK pharmacy graduates will be eligible to prescribe after successful completion of their days in practice and year of foundation training.
The consultant pharmacist curriculum has been updated, too, to reflect the part advanced-level pharmacists play in in supporting clinical delivery of services to complex patients, as well as their contribution to research, education and healthcare strategy.
In respiratory medicine, these roles include supporting decision-making around medicines and ensuring availability of drugs; counselling patients on different therapies, risks and benefits; initiating, monitoring and titrating medicines; managing reimbursement of drug costs; and undertaking clinical audit, teaching and practice-based research.
Working across sectors to improve respiratory care
In some areas, hospital pharmacists can traverse the interface between secondary and primary care to expand their reach and impact. When Gráinne began developing the specialist respiratory service at Guy’s and St Thomas’, she was co-funded by the trust and the local clinical commissioning group – as it was then called.
‘Part of the money was to tackle overuse of high-dose inhaled corticosteroids seen in our COPD patients, where there was clear evidence of harm. Many were on these therapies who shouldn’t have been,’ she says.
Starting in 2015, Gráinne and a consultant physician began visiting local GP practices and case-reviewing this patient cohort alongside GPs and practice staff. They looked at changes in prescribing practice, modelling the number of pneumonias that could be avoided by stopping or down-titrating inhaled corticosteroids.
During the first year of the intervention, it delivered savings of around £200,000, which was reinvested back into services like pulmonary rehabilitation. It has streamlined patient care, too, and these benefits mean the intervention still happens to this day.
Gráinne says: ‘As a result of that collaboration, I believe we have one of the best-established and most cohesive cross-care respiratory teams. We have joint care pathways for primary, secondary and tertiary care so whether patients are managed in hospital or their GP practice, the clinicians are following the same path. This consistent and joined-up approach is important.’
Through optimising inhaler prescribing, pharmacists are also supporting the sustainability agenda. The Greener NHS Programme estimates that inhaler emissions account for some 3% of the NHS’s total carbon footprint. Reducing inappropriate inhaler use and optimising uptake of ‘greener’ alternatives therefore can significantly lower the environmental impact of respiratory inhalers and improve care for patients.
The future of respiratory pharmacy
Lung disease represents a mammoth global health burden. For instance, COPD and lower respiratory infection are ranked third and fourth in the top 10 causes of death worldwide.
Gráinne foresees ‘an entire pharmacist workforce with competency in optimising respiratory medicines’ as key to tackling these challenges.
She circles back to helping patients to improve their inhaler technique as an example. ‘That could fundamentally revolutionise the management of up to 10% of the adult population – the approximate numbers who have asthma and COPD,’ she says.
She adds that specialist pharmacists could also use their skills to lead on managing specific cohorts of vulnerable patients, such as pregnant women worried about taking asthma medicines during their pregnancy, those with specific medicines-related needs who are struggling to take their treatments, and those transitioning from paediatric to adult care.
These young patients, navigating chronic ill health at a time when they may tend to engage in rebellious behaviour, often fail to take their medication. ‘We can negotiate with them and educate them on the pros and cons, risks and benefits, and talk to them about smoking and vaping besides medicines.’ Gráinne comments. ‘This is a beautiful example of how we can use shared decision-making and empower patients to self-care.’
Any aspect of healthcare that involves medicines, she says, should have pharmacists at its core, concluding that ‘medicines don’t work if people don’t take them, and for me that’s our raison d’être’.
