Rationalising inhaled drugs in palliative care

Follow the principles of medication rationalisation when rationalising inhaled drugs in palliative care.

As a patient’s condition declines, their maximal inspiratory flow, dexterity, coordination and ability to form a lip seal around the mouthpiece often reduces—consider switching inhalational drug delivery devices. A pressurised metered dose inhaler (pMDI) with spacer is easier for frail patients to use because it does not require strong inspiratory effort as with dry powder inhalers (DPIs). While this change may assist in reliable drug delivery, it is dependent upon the patient learning how to use a new device. See Managing common problems with inhalational devices for older adults for considerations to guide device choice, and Summary of inhalational drug delivery devices for a summary of inhalational devices in the Respiratory guidelines.

Make a management plan for when preventive inhalers are deprescribed, or when patients can no longer use them, including management of potential acute exacerbations of breathlessness. Consider anticipatory prescribing an as-required short-acting beta2 agonist (SABA) administered via pMDI with spacer (with or without mask), or via nebuliser.

Inhaled corticosteroids can be stopped in patients with stable chronic obstructive pulmonary disease (COPD) who take long-acting bronchodilator therapy and have not had any exacerbations in the past yearChalmers, 2020Nici, 2020. In these patients, inhaled corticosteroids can be stopped abruptly, without tapering; monitor for symptoms, and restart the inhaled corticosteroid if symptoms worsen. Deprescribing inhaled corticosteroids reduces polypharmacy and may reduce the risk of adverse effects (eg pneumonia, fractures, oropharyngeal candidiasis).

For patients with palliative care needs who have stable asthma, follow the advice on stepping down therapy in the Respiratory guidelines.

For principles of palliative care for patients with chronic respiratory disease, see Principles of palliative care for patients with chronic respiratory disease.