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Scottish Government Effective Prescribing & Therapeutics Division
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  1. Scottish Government, 2021. Respiratory Care Action Plan. 2021- 2026.  https://www.gov.scot/publications/respiratory-care-action-plan-scotland-2021-2026/ (Accessed 19 February 2024).
  2. Scottish Government, 2021. Scottish Health Survey. https://www.gov.scot/collections/scottish-health-survey/ (Accessed 19 February 2024).
  3. World Health Organisation, 2020. WHO package of essential noncommunicable (PEN) disease intervention for primary health care. https://www.who.int/publications/i/item/9789240009226 (Accessed 19 February 2024).
  4. Scottish Government, 2022. Realistic Medicine. https://realisticmedicine.scot/ (Accessed 19 February 2024).
  5. Scottish Government, 2018. Polypharmacy Model of care Group. Polypharmacy Guidance Realistic Prescribing 3rd https://www.therapeutics.scot.nhs.uk/polypharmacy/ (Accessed 19 February 2024).
  6. Scottish Intercollegiate Guidelines Network / British Thoracic Society (BTS), 2019.  https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma/?UID=77927875120242972126 (Accessed:19 February 2024).
  7. National Institute of Clinical Excellence, 2021 Asthma: Diagnosis, monitoring and chronic asthma management. NICE guideline [NG80] 2017. Update March 2021. https://www.nice.org.uk/guidance/ng80/ (Accessed: 19 February 2024).
  8. Scottish Government, 2022. NHS Scotland Climate emergency and suitability strategy: 2022-2026. https://www.gov.scot/publications/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026 (Accessed: 19 February 2024).
  9. Scottish Government, 2022. Polypharmacy: Manage Medicines - Respiratory Prescribing https://rightdecisions.scot.nhs.uk/respiratory-prescribing-in-development/ (Accessed 9 February 2024).
  10. Grol, R and Grimshaw, J. ‘From best evidence to best practice: effective implementation of change in patients' care’, The Lancet, Volume 362, Issue 9391, 2003, Pages 1225-1230, ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(03)14546-1 (Accessed 19 February 2024).
  11. Health Improvement Scotland, 2022. Why ask what matters? https://www.whatmatterstoyou.scot/ (Accessed 19 February 2024).
  12. Public Health Scotland, 2021. Dispenser payments and prescription cost analysis.  https://www.publichealthscotland.scot/publications/dispenser-payments-and-prescription-cost-analysis/dispenser-payments-and-prescription-cost-analysis-financial-year-2020-to-2021 (Accessed 19 February 2024).
  13. Sleight, H, Boxall, A and Toet, S. ‘Uptake of Pharmaceuticals by Crops: A Systematic Review and Meta-analysis’, 2023, Environmental Toxicology and Chemistry 42(10) 2091-2104 https://doi.org/10.1002/etc.5700 (Accessed 19 February 2024).
  14. SEPA and One Health Breakthrough Partnership, ‘Pharmaceuticals in the Water Environment’  https://informatics.sepa.org.uk/EnvironmentalPharmaceuticals/ (Accessed 16 February 2024).
  15. National Institute for Health and Clinical Excellence. Clinical Knowledge Summary- Asthma ‘What is the prevalence of Asthma’ (2022 update) https://cks.nice.org.uk/topics/asthma/background-information/prevalence/ (Accessed: 19 February 2024).
  16. Asthma and Lung UK, 2022. 'Transforming Asthma Care in the UK'.  https://www.asthmaandlung.org.uk/sites/default/files/Fighting%20back_V3.pdf (Accessed 19 February 2024).
  17. Inhaler technique: does age matter? A systematic review. Sarah Barbara, Vicky Kritikos, Sinthia Bosnic-Anticevich. European Respiratory Review Dec 2017, 26 (146) 170055; DOI: 10.1183/16000617.0055-2017. https://pubmed.ncbi.nlm.nih.gov/29212836/ (Accessed 19 February 2024).
  18. Health Improvement Scotland, 2021. Steroid emergency card to support early recognition of adrenal crisis in adults. https://www.healthcareimprovementscotland.scot/publications/steroid-emergency-card-to-support-early-recognition-and-treatment-of-adrenal-crisis-in-adults/ (Accessed 19 February 2024)
  19. National Institute for Health and Clinical Excellence, 2021. Clinical Knowledge Summary. Osteoporosis – prevention of fragility factures. https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/ (Accessed 19 February 2024).
  20. Nwaru BI, Ekstrom M, Hasvold P et al. Overuse of short-acting beta2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J 2023; 55(4): 1901872 DOI: 10.1183/13993003.01872-2019 (Accessed 19 February 2024)
  21. GSK, 2021. Asthma Control Test, 2021 https://www.asthmacontroltest.com/en-gb/welcome/ (Accessed 19 February 2024),
  22. Royal College of Physicians. National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014. https://www.rcplondon.ac.uk/projects/national-review-asthma-deaths (Accessed 19 February 2024).
  23. Primary Care Respiratory Society, 2022. Online Asthma Slide rule https://www.pcrs-uk.org/resource/online-asthma-slide-rule (Accessed 19 February 2024).
  24. Janson, C et al. An Overview of Short Acting B2 Agonist Use in Asthma in European Countries, Advances in Therapy 2020. March; 37 (3): p1124-1135, doi: 10.1007/s12325-020-01233-0.  https://pubmed.ncbi.nlm.nih.gov/31981105/ (Accessed 19 February 2024).
  25. General Pharmaceutical Council Patient safety spotlight, 2022. The risks of overprescribing Salbutamol inhalers for asthma https://www.pharmacyregulation.org/regulate/article/patient-safety-spotlight-risks-overprescribing-salbutamol-inhalers-asthma (Accessed 19 February 2024).
  26. Global Initiative for Asthma, 2023. GINA Difficult to treat & severe asthma Guide 2023. Available at https://ginasthma.org/reports/ (Accessed 19 February 2024).
  27. Crossingham I, Turner S, Ramakrishnan S et al. Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database Syst Rev 2021; 5: CD013518 DOI: 10.1002/14651858.CD013518.pub2 (Accessed 19 February 2024).
  28. Conner J & Buck P. Improving Asthma Management: The Case for Mandatory Inclusion of Dose Counters on All Rescue Bronchodilators. Journal of Asthma 2013 Aug; 50 (6) :658-663 DOI: 3109/02770903.2013.789056 (Accessed 19 February 2024).
  29. Janson C, et al. The carbon footprint of respiratory treatment in Europe and Canada: an observational study from the CARBON programme. European Respiratory Journal 2022. June (60): DOI: 10.1183/13993003.02760-2021. https://erj.ersjournals.com/content/60/2/2102760 (Accessed 19 February 2024).
  30. WHO European Health Information Gateway, 2024.  https://gateway.euro.who.int/en/indicators/hfamdb_135-sdr-asthma-per-100-000/#id=29413&fullGraph=true) (Accessed 19 February 2024).
  31. Chiesi, 2019. Clenil® Modulite® 250 micrograms inhaler (with dose counter) SmPC. Available at https://www.medicines.org.uk/emc/product/6977/smpc (Accessed 19 February 2024).
  32. Kankaanranta, Hannu & Lahdensuo, Aarne & Moilanen, Eeva & Barnes, Peter. (2004). Add-on therapy options in asthma not adequately controlled by inhaled corticosteroids: A comprehensive review. Respiratory research. 5. 17. 10.1186/1465-9921-5-17. DOI: 10.1186/1465-9921-5-17 (Accessed 19 February 2024).
  33. Joint Formulary Committee, 2022. British National Formulary online. Montelukast updated 2022. https://bnf.nice.org.uk/drugs/montelukast/ (Accessed 19 February 2024).
  34. Medicines and Healthcare products Regulatory Agency, 2019. Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions. https://www.gov.uk/drug-safety-update/montelukast-singulair-reminder-of-the-risk-of-neuropsychiatric-reactions (Accessed 19 February 2024).
  35. European Medicines Agency, 2022. Scientific conclusions and grounds for the variation to the terms of the Marketing Authorisation- Montelukast July 2019. https://www.ema.europa.eu/en/documents/psusa/montelukast-cmdh-scientific-conclusions-and-grounds-variation-amendments-product-information-and-timetable-implementation-psusa00002087201807_en.pdf (Accessed 19 February 2024).
  36. National Institute for Clinical Excellence 2021: Asthma inhalers and climate change (patient decision aid) updated September 2022 Nice guideline [NG80] https://www.nice.org.uk/guidance/ng80/resources/inhalers-for-asthma-patient-decision-aid-pdf-6727144573 (Accessed 19 February 2024).
  37. Asthma UK, 2019. Living in Limbo: the scale of unmet need in difficult and severe asthma.  https://www.asthmaandlung.org.uk/sites/default/files/2023-03/living-in-limbo---the-scale-of-unmet-need-in-difficult-and-severe-asthma.pdf (Accessed 19 February 2024).
  38. PRECISION Scotland National Working Group. Severe asthma patient pathway for Scotland. March 2022 (funded by AstraZeneca and the PRECISION programme)
  39. Health Improvement Scotland Scottish Medicines Consortium, 2022. Omalizumab 7mg, 150mg solution for injection (Xolair) Advice, June 2011. Available at https://www.scottishmedicines.org.uk/medicines-advice/omalizumab-75mg-150mg-solution-for-injection-xolair-abbreviatedsubmission-70811/ (Accessed 19 February 2024).
  40. Health Improvement Scotland Scottish Medicines Consortium, 2022. Mepolizumab (Nucala) Advice, June https://www.scottishmedicines.org.uk/medicines-advice/mepolizumab-nucala-fullsubmission-114916 (Accessed 19 February 2024).
  41. Health Improvement Scotland / Scottish Medicines Consortium, 2022. Benralizumab (Fasenra) Advice, June 2019. https://www.scottishmedicines.org.uk/medicines-advice/benralizumab-fasenra-fullsubmission-smc2155/ (Accessed 19 February 2024).
  42. Health Improvement Scotland / Scottish Medicines Consortium, 2022. Dupilumab (Dupixent) Advice, April 2021. https://www.scottishmedicines.org.uk/medicines-advice/dupilumab-dupixent-full-smc2317/ (Accessed 19 February 2024).
  43. Oxford Academic Health Science Network Accelerated Access Collaborative. Understanding opportunities to improve Severe Asthma Care in England: A National Benchmarking Exercise, March 2022.  https://www.healthinnovationoxford.org/ (Accessed 19 February 2024).
  44. Sustainable Healthcare Coalition, 2019. Care pathway for Monoclonal Antibody Therapy June 2018.  https://shcoalition.org/care-pathway-for-monoclonal-antibody-therapy-2/ (Accessed 19 February 2024).
  45. British Lung Foundation, 2022. Chronic obstructive pulmonary disease (COPD) statistics.  https://statistics.blf.org.uk/copd (Accessed 19 February 2024).
  46. National Institute of Clinical Excellence, 2018 Chronic Obstructive Pulmonary Disease in over 16s: diagnosis and management. NICE guideline [NG115] 2018. Update July 2019.  https://www.nice.org.uk/guidance/ng115 (Accessed 19 February 2024).
  47. Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2024. Global Strategy for prevention, diagnosis and management of COPD: 2024 Report. https://goldcopd.org/2024-gold-report/ (Accessed 19 February 2024).
  48. National Institute of Health and Care Excellence, 2018 Chronic Obstructive Pulmonary Disease (acute exacerbation): antimicrobial prescribing. NICE guideline [NG114] 2018.  https://www.nice.org.uk/guidance/ng114 (Accessed 19 February 2024).
  49. Smith D. et al. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax 2020; 0:1–35. doi:10.1136/thoraxjnl-2019-213929.  https://thorax.bmj.com/content/75/5/370 (Accessed 19 February 2024).
  50. Experts in COPD supported by GSK, 2022. The COPD Assessment Test (CAT) August 2022.  https://www.catestonline.org/hcp-homepage.html (Accessed 19 February 2024).
  51. Medical Research Council, 2016. MRC Breathlessness Scale 1959.  https://www.ukri.org/publications/mrc-breathlessness-scales-1952-and-1959/ (Accessed 19 February 2024).
  52. Healthcare Improvement Scotland / Scottish Antimicrobial Prescribing Group, 2022. Penicillin Allergy De-labelling guidance. https://www.sapg.scot/guidance-qi-tools/quality-improvement-tools/penicillin-allergy-de-labelling/ (Accessed 19 February 2024).
  53. Tamondong-Lachica DR, Skolnik N, Hurst JR, Marchetti N, Rabe APJ, Montes de Oca M, Celli BR. GOLD 2023 Update: Implications for Clinical Practice. Int J Chron Obstruct Pulmon Dis. 2023 May 5;18:745-754. doi: 10.2147/COPD.S404690. PMID: 37180752; PMCID: PMC10168197. (Accessed 19 February 2024).
  54. Poole P, Sathananthan K, Fortescue R. Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. May 2019. Issue 5.  https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001287.pub6/full (Accessed 19 February 2024).
  55. Novartis Pharmaceuticals UK Ltd. Enezair® Breezhaler® April 2022.  https://www.medicines.org.uk/emc/product/11886 (Accessed 19 February 2024).
  56. GlaxoSmithKline UK. Trelegy Ellipta 92/55/22 micrograms inhalation powder, pre-dispensed.  https://www.medicines.org.uk/emc/product/8666 (Accessed 19 February 2024).
  57. Chiesi Limited. Trimbow pMDI 87/5/9/ micrograms pressurised inhalation. July 2022.  https://www.medicines.org.uk/emc/product/761/smpc (Accessed 19 February 2024).
  58. Chiesi Limited. Trimbow pMDI 172/5/9/ micrograms pressurised inhalation, July 2022.  https://www.medicines.org.uk/emc/product/13816/smpc (Accessed 19 February 2024).
  59. Chiesi Limited. Trimbow NEXThaler (DPI) 88/5/9 micrograms per actuation. July 2022.  https://www.medicines.org.uk/emc/product/12829/smpc (Accessed 19 February 2024).
  60. AstraZeneca UK Limited. Trixeo Aerosphere 5/ 7.2/ 160 micrograms pressurised inhalation, suspension, March 2021. https://www.medicines.org.uk/emc/product/12028 (Accessed 19 February 2024).
  61. University of Dundee / NHS Tayside. Bronchiectasis Severity Index.  http://www.bronchiectasisseverity.com/15-2/ (Accessed 19 February 2024).
  62. Hill AT, Sullivan AL, Chalmers JD, et al. 2018. ‘Guideline for Bronchiectasis in Adults’, Thorax 2019;74 (Suppl 1):1–69. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/bronchiectasis-in-adults/ (Accessed 19 February 2024).
  63. Polverino E, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J 2017; 50: 1700629. https://pubmed.ncbi.nlm.nih.gov/28889110/ (Accessed 19 February 2024).
  64. British Thoracic Society, Vol10 Issue 3, 2019. ILD Registry Annual Report 2019. https://www.acprc.org.uk/Data/Resource_Downloads/BTSILDRegistryAnnualReport2019.pdf?date=01/04/2022%2011:41:01 (Accessed 19 February 2024).
  65. National Institute for Health and Care Excellence, 2021, ‘Nintedanib for treating progressive fibrosing interstitial lung diseases.’ https://www.nice.org.uk/guidance/ta747 (Accessed 19 February 2024).
  66. Health Improvement Scotland / Scottish Medicines Consortium, 2022. Nintedanib (Ofev®) Advice. https://www.scottishmedicines.org.uk/medicines-advice/nintedanib-ofev-fullsubmission-107615/ (Accessed 19 February 2024).
  67. Health Improvement Scotland / Scottish Medicines Consortium, 2022. Pirfenidone (Esbriet®) Advice August 213. https://www.scottishmedicines.org.uk/medicines-advice/pirfenidone-esbriet-resubmission-83513/ (Accessed 19 February 2024).
  68. National Institute for Care and Health Excellence, British National Formulary, ‘Nintedanib’, 2024. https://bnf.nice.org.uk/drugs/nintedanib/ (Accessed 19 February 2024)
  69. National Institute for Care and Health Excellence, British National Formulary, ‘Pirfenidone’, 2024. https://bnf.nice.org.uk/drugs/pirfenidone/ (Accessed 19 February 2024)
  70. National Institute for Health and Care Excellence, 2013. ‘Idiopathic pulmonary fibrosis in adults: diagnosis and management.’ NICE guideline [CG163] Update May 2017. https://www.nice.org.uk/guidance/CG163/chapter/1-Recommendations#management (Accessed 19 February 2024).
  71. National Institute for Clinical Excellence, 2018. Pirfenidone for treating Idiopathic pulmonary fibrosis. February 2018. Technology Appraisal guidance [TA504]. https://www.nice.org.uk/guidance/ta504 (Accessed 19 February 2024).
  72. National Institute for Clinical Excellence, 2016. Nintedanib for treating Idiopathic pulmonary fibrosis. January 2016. Technology Appraisal guidance [TA379]. https://www.nice.org.uk/guidance/ta379 (Accessed 19 February 2024).
  73. Health Improvement Scotland / Scottish Medicines Consortium, 2022. Patient Access Schemes. https://www.scottishmedicines.org.uk/making-a-submission/companies/patient-access-schemes/ (Accessed 19 February 2024).
  74. Scottish Government, 2022. Chief Medical Officer – Annual report: 2020-2021 March 2021. https://www.gov.scot/publications/cmo-annual-report-2020-21/pages/6/ (Accessed 19 February 2024).
  75. Lavorini F, Corrigan CJ, Barnes PJ, Dekhuijzen PR, Levy ML, Pedersen S, Roche N, Vincken W, Crompton GK; Aerosol Drug Management Improvement Team. ‘Retail sales of inhalation devices in European countries: so much for a global policy.’ Respir Med. 2011 Jul;105(7):1099-103. https://pubmed.ncbi.nlm.nih.gov/21489771/ (Accessed 19 February 2024).
  76. British Thoracic Society. Position Statement Environment and Lung Health March 2020. https://www.brit-thoracic.org.uk/about-us/position-statements/ (Accessed 19 February 2024).
  77. Green Inhaler, 2022 The problem with Inhalers. https://greeninhaler.org/the-problem-with-inhalers/ (Accessed 19 February 2024).
  78. Woodcock, A et al. Effects of switching from a metered dose inhaler to a dry powder inhaler on climate emissions and asthma control: post-hoc analysis. Thorax 2022 O;1-6. https://thorax.bmj.com/content/early/2022/01/12/thoraxjnl-2021-218088 (Accessed 19 February 2024).
  79. Vartiainen VA, Federico Lavorini, Anna C Murphy & Klaus F Rabe (2023) High inhaler resistance does not limit successful inspiratory manoeuvre among patients with asthma or COPD, Expert Opinion on Drug Delivery, 20:3, 385-393, DOI: 10.1080/17425247.2023.2179984 (Accessed 19 February 2024).
  80. Koura, 2021 Zephex® 152a: reducing the carbon footprint of asthma inhalers. https://www.zephex.com/ (Accessed 19 February 2024).
  81. Honeywell International Inc, 2022. ‘Honeywell Begins Production of Near-Zero Global-Warming – Potential Medical Propellant.’ Press release: October 2022. https://www.honeywell.com/us/en/press/2022/10/honeywell-begins-production-of-near-zero-global-warming-potential-medical-propellant (Accessed 19 February 2024).
  82. PrescQIPP Community Interest Company, 2018. Bulletin 295: Inhaler carbon footprint. https://www.prescqipp.info/our-resources/bulletins/bulletin-295-inhaler-carbon-footprint/ (Accessed 19 February 2024).
  83. PrescQIPP Community Interest Company. Hot Topics – Lowering the carbon footprint update. https://www.prescqipp.info/news/hot-topics-lowering-the-inhaler-carbon-footprint-update/ (Accessed 19 February 2024).
  84. Greener Practice, 2022. ‘Why Environmentally Sustainable Practice?’ https://www.greenerpractice.co.uk/information-and-resources/why-environmentally-sustainable-practice/ (Accessed 19 February 2024).
  85. Scottish Government, 2022. Effective Prescribing and Therapeutics Division. National Therapeutic Indicators – Respiratory. Update March 2022. Available at: https://scotland.shinyapps.io/nhs-prescribing-nti/ (Accessed 19 February 2024).
  86. Usmani O, Capstick T, Saleem A. Choosing an appropriate inhaler device for the treatment of adults with asthma or COPD. MGP guidelines. 2020. https://www.medscape.co.uk/viewarticle/choosing-appropriate-inhaler-device-treatment-adults-asthma-2022a10025xw (Accessed 19 February 2024)
  87. Ramadan WH, Sarkis AT. ‘Patterns of use of dry powder inhalers versus pressurized metered-dose inhalers devices in adult patients with chronic obstructive pulmonary disease or asthma: an observational comparative study.’ Chron Respir Dis. 2017; 14:309-320. https://doi.org/10.1177/1479972316687209 (Accessed 19 February 2024).
  88. Usmani, O.S., Lavorini, F., Marshall, J. et al. ‘Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes.’ Respir Res 19, 10 (2018). https://doi.org/10.1186/s12931-017-0710-y (Accessed 19 February 2024).
  89. Starup-Hansen, J, Dunne, H, Sadler, J, Jones, A, Okorie, M. ‘Climate change in healthcare: Exploring the potential role of inhaler prescribing.’ Pharmacol Res Perspect. 2020; 8: e00675. https://doi.org/10.1002/prp2.675 (Accessed 19 February 2024).
  90. Chen, SY., Huang, CK., Peng, HC. et al. ‘Inappropriate Peak Inspiratory Flow Rate with Dry Powder Inhaler in Chronic Obstructive Pulmonary Disease.’ Sci Rep 10, 7271 (2020). https://doi.org/10.1038/s41598-020-64235-6 (Accessed 19 February 2024).
  91. Small, M., Anderson, P., Vickers, A. et al. ‘Importance of inhaler-device satisfaction in asthma treatment: Real-world observations of physician-observed compliance and clinical/patient-reported outcomes.’ Adv Therapy 28, 202–212 (2011). https://doi.org/10.1007/s12325-010-0108-4 (Accessed 19 February 2024).
  92. Keeley, D and Attar-Zadeh, D. ‘Shared decision making for greener healthcare: guidance on making safe and clinically appropriate changes to inhalers.’ PCRS, 22 :14. 2021. https://www.pcrs-uk.org/sites/default/files/pcru/articles/2021-July-Issue-22-GHC_ChangingInhalersSharedDecisions.pdf (Accessed 19 February 2024).