Rescue packs – in COPD

Pelham Medical – Standard Policy

Pelham Medical do not routinely prescribe COPD rescue packs.

Historically rescue packs for COPD have been recommended by NICE (National Institute for Clinical Excellence) but this guidance is under review. A rescue pack may be appropriate for some patients, but this needs to be reviewed on an individual basis.

This will be considered at annual reviews and, where rescue packs are not considered suitable, patients will be advised on reasons why it is not indicated.

How Safe are Rescue Packs?

It is easy to prescribe a patient antibiotics and steroids and tell them to go away and take the medication when they feel an exacerbation is coming on. But this may not be safe and effective because it may result in inappropriate use. Overuse of steroids is linked with adrenal suppression, bone fractures, diabetes, pneumonia, psychosis, thinning skin and cataracts. Overuse of antibiotics risk antimicrobial resistance both in the individual and in society in general.

Exacerbation of COPD can be difficult to define. To verify it requires testing. A range of factors, including smoking and viral infections, can trigger exacerbations. Many exacerbations are not caused by bacterial infections and so they will not respond to antibiotics.

When Might Rescue Packs Be Issued?

A rescue pack is more than just a prescription; it needs to be tied in to other aspects of a patient’s care. Patients who are most likely to benefit from a rescue pack are those who are susceptible to frequent exacerbations and have had two or more in a year.

The indicators that are needed to evaluate bacterial exacerbation include:

• Positive sputum sample,
• Raised CRP, White Cell Count and Chest Xray.
• New evidence that a prescription of steroids may be better guided by looking at acute blood eosinophil counts, to assess if the patient may benefit from prednisolone at the time of exacerbation.

Pelham Medical’s Approach in Response to a Suspected Exacerbation

Pelham Medical can facilitate urgent access to the practice for a same day face to face clinical review. This is considered a better standard of care than routinely issuing a rescue pack to take home. This is because it allows us to assess whether the patient is experiencing an exacerbation and, if so, the most appropriate intervention (i.e., issuing of medication or identifying if hospital admission is required).

Things Clinicians Consider When Issuing Rescue Packs:

Risks and benefits of treatment:

• How susceptible is this patient to at least two or more exacerbations a year?
• Can the patient understand and recognise an exacerbation.
• How likely are they to contact the surgery when they experience an exacerbation.
• Red flags: Things to be alert for that are not typically part of an exacerbation or indicate that something else is going on e.g., pulmonary embolism.
• Patient education and understanding and safety netting i.e., the expectation that the patient will contact the surgery at the time of an exacerbation.