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MUR case study: 55-year-old with COPD

Your patient is having trouble with her inhalers and adhering to metformin. How can you help?

Mrs Cox is 55 years old and has been a smoker for most of her life. She has cut down but is still smoking despite her chronic obstructive pulmonary disease (COPD). Her diet is poor and she has been put on metformin due to her recently diagnosed diabetes. Raj, the pharmacist, suggests to Mrs Cox that they sit down in the consultation room to talk about her medicines.


During their discussion Raj learns that Mrs Cox wants to stop smoking. She uses her salbutamol inhaler on most days and often because it provides quick relief. She uses the combination inhaler once a day in the morning because if she gets breathless in the evening she uses salbutamol.


Raj asks Mrs Cox about her diet because she is on metformin and learns that Mrs Cox has difficulty eating a ‘healthy’ diet and is confused about whether she should follow a Mediterranean or 5-a-day diet.


Below is an excerpt from Mrs Cox’s MUR form:


Taken as directed?


Tiotropium inhaler 18mcg 1 puff daily


On testing Mrs Cox’s technique, Raj ascertains that she is using this inhaler correctly

Fluticasone/salmeterol 50mcg/250mcg (Seretide Accuhaler) 1 puff bd


Mrs Cox only uses this in the morning. Raj ascertains that Mrs Cox finds this device ‘fiddly’ to use

Salbutamol MDI inhaler 1-2 puffs prn


Mrs Cox is over-reliant on this for quick relief and is therefore overusing it. Raj also learns that Mrs Cox has difficulty using this inhaler because she has to coordinate pressing the device with inhaling

Metformin 500mg tablet tds


Mrs Cox sometimes forgets to take these tds


Main action points


Non-adherent to the prescribed dose of Seretide Accuhaler.


Raj explores the reason for non-adherence, which is mainly Mrs Cox’s belief that the Seretide Accuhaler does not provide quick relief but the salbutamol does. She does not know the purpose of the Seretide Accuhaler. Raj advises Mrs Cox to ensure she uses the Seretide bd to achieve maximum control of symptoms. She needs to take the medicine every day because it helps open the airways and reduces swelling and irritation in the lungs. He further advises her not to stop taking this medicine except on her GP’s advice.

Raj demonstrates how to use the inhaler using the patient information leaflet as a guide and asks Mrs Cox to practise several times until both of them are happy she has got the hang of the technique.

For consideration by

Patient If this does not control symptoms then Mrs Cox should see the practice nurse or GP to discuss increasing the dosage to Seretide 500 Accuhaler one puff bd.


Overusing salbutamol.


Raj explains that taking Seretide regularly bd would give Mrs Cox better control of her symptoms, and to take salbutamol prn only. If she still needs to use the salbutamol frequently, that may suggest deterioration of her COPD. Mrs Cox last had a COPD review more than a year ago. She might benefit from using a spacer device, which would negate the need to coordinate her breathing when actuating the device and allow her to take deeper breaths.

For consideration by

Patient Mrs Cox should make an appointment with her practice nurse for her annual COPD review.

GP To prescribe a spacer device.


Non-adherent to prescribed dose of metformin.


Raj found that the non-adherence was due to the tds dosage. Raj emphasises the need to take metformin tds with food and suggests it may be helpful if Mrs Cox has reminders to do so in various places around her home, such as on the fridge, dining table or near the TV. Raj ascertains that Mrs Cox does not monitor her blood glucose; Raj counsells that she may need to regularly monitor this, and that she can get a free monitor from the practice nurse at the surgery.

For consideration by

Patient Mrs Cox should place reminders to take her metformin in strategic locations and to make an appointment to visit the practice nurse for advice on blood glucose monitoring and a plasma glucose level check.


Healthy living advice - stop smoking.


Raj explains the contribution of smoking to COPD and the various options available to quit smoking. For example, nicotine replacement therapy with medications such as Champix or Zyban, and support from the local stop smoking clinic.

For consideration by

Patient Mrs Cox should make an appointment with her GP or practice nurse to discuss giving up smoking. If Raj's pharmacy offers a stop smoking service, he could also suggest that Mrs Cox might like to take advantage of support the pharmacy can offer.

GP/practice nurse To further discuss options with Mrs Cox and prescribe a suitable course of action.


Healthy living advice - diet.


Raj explains that the 5-a-day and Mediterranean diets are there for guidance. He advises Mrs Cox to make gradual changes to her diet and reduce intake of fats, sugars and salt.

For consideration by

Patient Eat a varied diet - everything in moderation.


Samir Vohra is a lecturer in pharmacy at Preston’s College, Preston, Lancashire


SAMIR VOHRA, Primary care pharmacist

Hi, about the metformin - that's why I wrote 'may' need to monitor and that the nurse to 'advise on' monitoring. Salbutamol - Mrs Cox finds the accuhaler 'fiddly to use', may not be wise to then give her salbutamol accuhaler, in my practice (I also work as a practice pharmacist) I have often found the spacer device more useful to try first than changing to other devices.

Victoria Birchall, Primary care pharmacist

I agree with overworked pharmacist re blood glucose testing when this patient is prescribed metformin only, for her diabetes. I also wondered whether once she had got the hang of the Seretide accuhaler, a salbutamol accuhaler may also be an option instead of a spacer.

Overworked Pharmacist, Primary care pharmacist

Thanks for this. Only comment is testing blood glucose levels when taking metformin alone is not beneficial.

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