With the treatment landscape of respiratory care moving at a rapid pace, consultant paediatric asthma pharmacist Sukeshi Makhecha speaks to Saša Janković about how the profession’s contribution to medicines optimisation, adherence and education has evolved, and why getting the basics right could transform paediatric asthma care.
‘One in 11 children has asthma, and one child dies every month from it, yet too often the fundamentals of care are still going wrong,’ says consultant paediatric asthma pharmacist Sukeshi Makhecha, who works cross site at the Royal Brompton Hospital and the Evelina London Children’s Hospital – part of Guy’s and St Thomas’ NHS Foundation Trust.
It’s an uncomfortable truth that illustrates precisely why pharmacists must be at the centre of the solution.
Sukeshi’s professional focus lies in raising the profile of pharmacists’ contribution to paediatric asthma and in improving medication adherence – an area that also underpins her research. Over more than two decades in hospital pharmacy, she has watched the profession’s role shift from one that was largely unseen to one that is increasingly recognised as clinically indispensable.
‘When I first went into this area, I didn’t see pharmacists as having a big role in paediatric asthma, but that view changed for me when I began to specialise. Once I started working in children’s asthma, I realised that pharmacists are actually key, and with the right education and training, that’s something pharmacists are very well placed to do,’ she says.
‘As our prescribing responsibilities have expanded, we’re very available and people find it easy to talk to us, especially about medicines. That puts us in a strong position to support families, spot problems early and intervene in ways that genuinely make a difference.’
Supporting adherence and optimising outcomes
Building on this, Sukeshi points to medication adherence as the clearest illustration of how pharmacists’ role in paediatric asthma has deepened.
‘Adherence takes up a lot of our day-to-day work,’ she says, ‘but pharmacy is a really good place to do that work properly, because we can see what’s actually being collected, not just what’s been prescribed. For example, pharmacists are often the first to spot patterns that indicate risk, such as repeated requests for reliever inhalers or gaps in preventive therapy.’
In her consultant role, with responsibility for specialist clinics and prescribing, this insight becomes actionable. ‘I can run my own clinics, make changes to medicines, initiate treatment and communicate directly with GPs,’ she explains. ‘That continuity is really important, especially for children with more complex asthma.’
Despite this progress, Sukeshi is clear that the biggest challenges in paediatric asthma often sit far beyond medicines optimisation alone. ‘Adherence is important, but I wouldn’t say it’s the biggest challenge when it comes to optimising outcomes for children with asthma,’ she says. ‘The bigger issues are things like air pollution, poor housing, mould, deprivation and exposure to smoke and vaping.’
Within that context, she believes the opportunity for pharmacists lies in focusing on what can be changed. ‘We can’t fix housing or air quality,’ she says, ‘but we can step in on education, inhaler technique, smoking and vaping cessation advice, medicines use and adherence, and that’s where pharmacy can really add value.’
Current treatment landscapes in paediatric asthma
Sukeshi sees her recent research on adherence as sitting squarely within the realities of today’s treatment landscape, where unmet need is often driven by complexity rather than a lack of therapeutic options. ‘We have good treatments,’ she says, ‘but the problem is not always the medicine itself. It’s whether it’s being taken, taken correctly, and understood.’
Her work, including the recent Paediatric asthma: are we getting it right? study, reflects what she encounters daily in practice. ‘There’s a huge amount of focus on prescribing data, but prescribing doesn’t always marry up with what’s actually being collected or used,’ she explains. ‘Families may be doing their best, but the systems around them aren’t joined up.’
As a result, she is particularly wary of assumptions around non-adherence. ‘Before you label a child or family as not taking their medication, you need to be absolutely sure,’ she says. ‘Sometimes the records don’t tell the full story, and that’s where families can fall through the cracks.’
For Sukeshi, the unmet need her research highlights is not only better monitoring, but a more compassionate, informed interpretation of adherence data, which is where pharmacists can come into their own. ‘We’re trained to look at medicines use in context, and that context really matters in paediatric asthma,’ she adds.
Sustainability in paediatric asthma care
Sustainability is another issue that is inseparable from safe and effective asthma care, according to Sukeshi, and she says pharmacists have a critical role to play in closing that gap.
‘We are part of Grundon’s inhaler recycling pilot across several hospital and community sites that capture both dry powder and metered-dose inhalers (MDIs). While MDIs can be fully recycled, dry powder inhalers present a different challenge. Their plastic can’t be recycled at all, so if it goes to landfill, it’s there forever,’ she explains.
‘But sustainability is not just an environmental issue. We’re seeing inhalers returned with drug still left in them, or being used when they’re effectively empty due to the lack of dose counters on most devices, coupled with a lack of patient education about how to use the device correctly and understand when it is empty.’
So, what’s the solution? ‘A dose counter helps, but it should go further,’ Sukeshi says. ‘When there’s no drug left, the device should stop working, but until this is built into the product pharmacists are uniquely positioned to address both sides of the problem: we can educate families, check technique, explain dose counters and reinforce when an inhaler really needs replacing. Getting that right improves adherence, reduces waste and ultimately makes asthma care more sustainable in every sense.’
Emerging innovations in paediatric asthma
Looking ahead, Sukeshi is optimistic that a combination of policy change, smarter use of data and therapeutic innovations could significantly improve paediatric asthma outcomes.
The anti-inflammatory reliever (AIR) and maintenance and reliever therapy (MART) treatment approaches, which both use inhaled corticosteroids and long-acting beta-agonists, were recommended in the UK joint guidelines for chronic asthma, published in November 2024.
Sukeshi says these are an important step forward, provided they are implemented properly and ‘only if people are educated and confident in using their devices appropriately’, she adds.
Beyond treatment models, she believes better systems for monitoring medicines use are urgently needed. ‘We need digital pathways that actually talk to each other,’ she explains. ‘Databases that flag children who are overusing blue inhalers, or where prescriptions and collections don’t align, would be transformative.’
The importance of real-world practice
Advances in severe asthma treatment also feature strongly in Sukeshi’s vision for the future. ‘Biologic therapies are already making a big difference, but we need them to come down in age and become more accessible for children who clearly need them,’ she says, adding that less frequent dosing could be particularly valuable: ‘A biologic given once or twice a year would be hugely helpful for children who are needle-phobic.’
Ultimately, Sukeshi believes innovation must stay grounded in real-world practice. ‘Asthma is a complex disease, and we’re unlikely to ever have a single test that solves everything,’ she reflects. ‘But if innovation helps us diagnose more accurately, target treatment better and support families more effectively, then that’s where the real revolution will be.’
Her priority now is getting that agenda out there and her ambition is to ‘get more people fired up about children’s asthma’, as well as supporting more pharmacists to have the knowledge and confidence to treat it.
And her concluding message is simple: ‘If we get the basics right, we can make a real difference to children’s lives.’
