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Liao Q, Yuan S, Cao J, Tang K, Qiu Y, Seow HC, Man RC, Shao Z, Huang Y, Liang R, Chan JF, Yuen K, Lam JK. Inhaled Dry Powder Formulation of Tamibarotene, a Broad‐Spectrum Antiviral against Respiratory Viruses Including SARS‐CoV‐2 and Influenza Virus. ADVANCED THERAPEUTICS 2021. [DOI: 10.1002/adtp.202100059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Qiuying Liao
- Department of Pharmacology and Pharmacy LKS Faculty of Medicine The University of Hong Kong 21 Sassoon Road Pokfulam Hong Kong SAR China
| | - Shuofeng Yuan
- State Key Laboratory of Emerging Infectious Diseases Carol Yu Centre for Infection Department of Microbiology LKS Faculty of Medicine The University of Hong Kong Pokfulam Hong Kong SAR China
| | - Jianli Cao
- State Key Laboratory of Emerging Infectious Diseases Carol Yu Centre for Infection Department of Microbiology LKS Faculty of Medicine The University of Hong Kong Pokfulam Hong Kong SAR China
| | - Kaiming Tang
- State Key Laboratory of Emerging Infectious Diseases Carol Yu Centre for Infection Department of Microbiology LKS Faculty of Medicine The University of Hong Kong Pokfulam Hong Kong SAR China
| | - Yingshan Qiu
- Department of Pharmacology and Pharmacy LKS Faculty of Medicine The University of Hong Kong 21 Sassoon Road Pokfulam Hong Kong SAR China
| | - Han Cong Seow
- Department of Pharmacology and Pharmacy LKS Faculty of Medicine The University of Hong Kong 21 Sassoon Road Pokfulam Hong Kong SAR China
| | - Rico Chi‐Hang Man
- Department of Pharmacology and Pharmacy LKS Faculty of Medicine The University of Hong Kong 21 Sassoon Road Pokfulam Hong Kong SAR China
| | - Zitong Shao
- Department of Pharmacology and Pharmacy LKS Faculty of Medicine The University of Hong Kong 21 Sassoon Road Pokfulam Hong Kong SAR China
| | - Yaoqiang Huang
- State Key Laboratory of Emerging Infectious Diseases Carol Yu Centre for Infection Department of Microbiology LKS Faculty of Medicine The University of Hong Kong Pokfulam Hong Kong SAR China
| | - Ronghui Liang
- State Key Laboratory of Emerging Infectious Diseases Carol Yu Centre for Infection Department of Microbiology LKS Faculty of Medicine The University of Hong Kong Pokfulam Hong Kong SAR China
| | - Jasper Fuk‐Woo Chan
- State Key Laboratory of Emerging Infectious Diseases Carol Yu Centre for Infection Department of Microbiology LKS Faculty of Medicine The University of Hong Kong Pokfulam Hong Kong SAR China
- Department of Clinical Microbiology and Infection Control The University of Hong Kong‐Shenzhen Hospital Shenzhen Guangdong Province 518053 China
- Hainan Medical University‐The University of Hong Kong Joint Laboratory of Tropical Infectious Diseases Hainan Medical University Haikou Hainan Province 571199 China
| | - Kwok‐Yung Yuen
- State Key Laboratory of Emerging Infectious Diseases Carol Yu Centre for Infection Department of Microbiology LKS Faculty of Medicine The University of Hong Kong Pokfulam Hong Kong SAR China
- Department of Clinical Microbiology and Infection Control The University of Hong Kong‐Shenzhen Hospital Shenzhen Guangdong Province 518053 China
- Hainan Medical University‐The University of Hong Kong Joint Laboratory of Tropical Infectious Diseases Hainan Medical University Haikou Hainan Province 571199 China
| | - Jenny Ka‐Wing Lam
- Department of Pharmacology and Pharmacy LKS Faculty of Medicine The University of Hong Kong 21 Sassoon Road Pokfulam Hong Kong SAR China
- Advanced Biomedical Instrumentation Centre Hong Kong Science Park Shatin, New Territories, Hong Kong SAR China
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Designing enhanced spray dried particles for inhalation: A review of the impact of excipients and processing parameters on particle properties. POWDER TECHNOL 2021. [DOI: 10.1016/j.powtec.2021.02.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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53
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Davidson HE, Radlowski P, Han L, Shireman TI, Dembek C, Niu X, Gravenstein S. Clinical Characterization of Nursing Facility Residents With Chronic Obstructive Pulmonary Disease. Sr Care Pharm 2021; 36:248-257. [PMID: 33879286 DOI: 10.4140/tcp.n.2021.248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE AND DESIGN To describe clinical characteristics, medication use, and low peak inspiratory flow rate (PIFR) (< 60 L/min) prevalence in nursing facility residents with chronic obstructive pulmonary disease (COPD). PATIENTS AND SETTING Residents 60 years of age and older with a COPD diagnosis and≥ 6 months' nursing facility residence, were enrolled between December 2017 and February 2019 from 26 geographically varied United States nursing facilities. OUTCOME MEASURES Data, extracted from residents' charts, included demographic/clinical characteristics, COPD-related medications, exacerbations and hospitalizations within the past 6 months, and functional status from the most recent Minimum Data Set. At enrollment, residents completed the modified Medical Research Council (mMRC) Dyspnea Scale and COPD Assessment Test (CAT™). Spirometry and PIFR were also assessed. RESULTS Residents' (N = 179) mean age was 78.0 ± 10.6 years, 63.7% were female, and 57.0% had low PIFR. Most prevalent comorbidities were hypertension (79.9%), depression (49.2%), and heart failure (41.9%). The average forced expiratory volume in 1 second (FEV11) % predicted was 45.9% ± 20.9%. On the CAT, 78.2% scored≥ 10 and on the mMRC Dyspnea Scale, 74.1% scored≥ 2, indicating most residents had high COPD symptom burden. Only 49.2% were receiving a scheduled long-acting bronchodilator (LABD). Among those with low PIFR prescribed a LABD, > 80% used dry powder inhalers for medication delivery. CONCLUSION This study highlights underutilization of scheduled LABD therapy in nursing facility residents with COPD. Low PIFR was prevalent in residents while the majority used suboptimal medication delivery devices. The findings highlight opportunities for improving management and outcomes for nursing facility residents with COPD.
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Affiliation(s)
| | | | - Lisa Han
- 1Insight Therapeutics, LLC, Norfolk, Virginia
| | - Theresa I Shireman
- 2Brown University, Center for Gerontology and Health Care Research, Providence, Rhode Island
| | - Carole Dembek
- 3Sunovion Pharmaceuticals, Incorporated, Marlborough, Massachusetts
| | - Xiaoli Niu
- 3Sunovion Pharmaceuticals, Incorporated, Marlborough, Massachusetts
| | - Stefan Gravenstein
- 2Brown University, Center for Gerontology and Health Care Research, Providence, Rhode Island
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Alhajj N, O'Reilly NJ, Cathcart H. Leucine as an excipient in spray dried powder for inhalation. Drug Discov Today 2021; 26:2384-2396. [PMID: 33872799 DOI: 10.1016/j.drudis.2021.04.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/24/2021] [Accepted: 04/08/2021] [Indexed: 11/29/2022]
Abstract
Leucine is a promising excipient with several applications in the development of inhalable spray-dried powder of high- and low-dose drugs. The addition of leucine has exhibited significant enhancing effects on the aerosolization and physical stability of the produced particles. Here, we focus not only on the applications of leucine in inhalable spray-drying powders, but also on the underlying mechanisms by which the formulation and processing parameters dictate the behavior of leucine during the drying process and, therefore, its functionalities within the dried powder. Additionally, we highlight the current regulatory status of leucine. Such insights are important for more efficient utilization of leucine in the future, both for dry powder inhaler formulations and other pharmaceutical applications.
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Affiliation(s)
- Nasser Alhajj
- Pharmaceutical and Molecular Biotechnology Research Centre (PMBRC), Waterford Institute of Technology, Waterford, Ireland.
| | - Niall J O'Reilly
- Pharmaceutical and Molecular Biotechnology Research Centre (PMBRC), Waterford Institute of Technology, Waterford, Ireland; SSPC - The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland
| | - Helen Cathcart
- Pharmaceutical and Molecular Biotechnology Research Centre (PMBRC), Waterford Institute of Technology, Waterford, Ireland
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55
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de Wasseige S, Picotte K, Lavoie JP. Nebulized dexamethasone sodium phosphate in the treatment of horses with severe asthma. J Vet Intern Med 2021; 35:1604-1611. [PMID: 33817859 PMCID: PMC8162592 DOI: 10.1111/jvim.16113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
Background A study reported low systemic availability of injectable dexamethasone nebulized to healthy horses using the Flexineb mask. When used in horses with severe asthma and a different nebulizer, lack of efficacy and cortisol suppression were observed. Hypothesis Nebulized dexamethasone is as effective as PO administration for the treatment of severe asthma in horses. Animals Twelve horses with severe asthma from a research herd. Methods Randomized clinical trial. Horses were divided into 2 groups and received 5 mg of dexamethasone sodium phosphate by nebulization using a Flexineb mask (NE, n = 6) or PO (OR, n = 6) q24h for 7 days. Lung function and serum cortisol concentrations were evaluated at baseline, after 4 days of treatment (D4) and 1 day after the last treatment (D8). Data were analyzed using linear mixed models with Benjamini‐Hochberg adjustments. Results Lung resistance significantly improved at D4 (mean decrease ± SD, −1.5 ± 0.45 cm H₂O/L/s; 95% confidence interval [CI], −2; −0.6) and D8 (−1.4 ± 0.45 cm H₂O/L/s; 95% CI, −2.4; −0.5) compared to baseline in the OR group only (P = .004 and .01, respectively). Serum cortisol concentration was significantly decreased at D4 and D8 for both groups (maximum decrease, −1.2 ± 0.3 μg/dL; 95% CI, −1.9; −0.6 at D4 for NE group and −2.2 ± 0.3 μg/dL; 95% CI, −2.8; −1.6 at D8 for OR group; P < .001). Conclusions and Clinical Importance Oral, but not nebulized dexamethasone is an effective therapy for horses with severe asthma and both treatment modalities inhibit the hypothalamic‐pituitary‐adrenal axis.
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Affiliation(s)
- Selena de Wasseige
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, Quebec, Canada
| | - Khristine Picotte
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, Quebec, Canada
| | - Jean-Pierre Lavoie
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, Quebec, Canada
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Yaqoubi S, Chan HK, Nokhodchi A, Dastmalchi S, Alizadeh AA, Barzegar-Jalali M, Adibkia K, Hamishehkar H. A quantitative approach to predicting lung deposition profiles of pharmaceutical powder aerosols. Int J Pharm 2021; 602:120568. [PMID: 33812969 DOI: 10.1016/j.ijpharm.2021.120568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/19/2021] [Accepted: 03/30/2021] [Indexed: 12/11/2022]
Abstract
Dry powder inhalers (DPI) are widely used systems for pulmonary delivery of therapeutics. The inhalation performance of DPIs is influenced by formulation features, inhaler device and inhalation pattern. The current review presents the affecting factors with great focus on powder characteristics which include particle size, shape, surface, density, hygroscopicity and crystallinity. The properties of a formulation are greatly influenced by a number of physicochemical factors of drug and added excipients. Since available particle engineering techniques result in particles with a set of modifications, it is difficult to distinguish the effect of an individual feature on powder deposition behavior. This necessitates developing a predictive model capable of describing all influential factors on dry powder inhaler delivery. Therefore, in the current study, a model was constructed to correlate the inhaler device properties, inhalation flow rate, particle characteristics and drug/excipient physicochemical properties with the resultant fine particle fraction. The r2 value of established correlation was 0.74 indicating 86% variability in FPF values is explained by the model with the mean absolute errors of 0.22 for the predicted values. The authors believe that this model is capable of predicting the lung deposition pattern of a formulation with an acceptable precision when the type of inhaler device, inhalation flow rate, physicochemical behavior of active and inactive ingredients and the particle characteristics of DPI formulations are considered.
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Affiliation(s)
- Shadi Yaqoubi
- Faculty of Pharmacy and Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ali Nokhodchi
- Pharmaceutics Research Laboratory, School of Life Sciences, University of Sussex, Brighton, UK
| | - Siavoush Dastmalchi
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Akbar Alizadeh
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Barzegar-Jalali
- Pharmaceutical Analysis Research Center, and Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khosro Adibkia
- Research Center for Pharmaceutical Nanotechnology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hamed Hamishehkar
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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Sulku J, Bröms K, Högman M, Janson C, Lisspers K, Malinovschi A, Melhus H, Ställberg B, Nielsen EI. Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations. NPJ Prim Care Respir Med 2021; 31:5. [PMID: 33563979 PMCID: PMC7873256 DOI: 10.1038/s41533-021-00218-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
A correct use of inhaler devices is essential in chronic obstructive pulmonary disease (COPD) treatment. Critical errors were studied by analysing 659 video-recorded demonstrations of inhaler technique from 364 COPD patients using six different inhaler device models. The majority of the included patients used two (55%) or more (20%) device models. Overall, 66% of the patients made ≥1 critical error with at least one device model. The corresponding numbers for patients using 1, 2 and ≥3 device models were 43%, 70% and 86%, respectively. The only factor associated with making ≥1 critical error was simultaneous use of two (adjusted odds ratios (aOR) 3.17, 95% confidence interval (95% CI) 1.81, 5.64) or three or more (aOR 8.97, 95% CI 3.93, 22.1) device models. In conclusion, the proportion of patients making critical errors in inhaler technique was substantial, particularly in those using several different device models. To obtain optimal COPD treatment, it is important to assess a patient's inhaler technique and to minimise the number of inhaler device models.
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Grants
- Uppsala-Örebro Regional Research Council, Centre for Research & Development, Uppsala university/Region Gävleborg, Bror Hjerpstedt Foundation, Uppsala County Association Against Heart and Lung Diseases
- Uppsala-Örebro Regional Research Council; Centre for Research & Development, Uppsala University/Region Gävleborg
- Uppsala-Örebro Regional Research Council; Centre for Research & Development, Uppsala University/Region Gävleborg; Swedish Heart-Lung Foundation
- Uppsala-Örebro Regional Research Council, County Council Dalarna
- Uppsala-Örebro Regional Research Council, Centre for Clinical Research, Uppsala University, the Swedish Heart-Lung Foundation, the Swedish Heart and Lung Association
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Affiliation(s)
- Johanna Sulku
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.
| | - Kristina Bröms
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Marieann Högman
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Clinical Pharmacogenomics and Osteoporosis, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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Malmberg LP, Pelkonen AS, Vartiainen V, Vahteristo M, Lähelmä S, Jõgi R. Patients with asthma or chronic obstructive pulmonary disease (COPD) can generate sufficient inspiratory flows via Easyhaler ® dry powder inhaler: a pooled analysis of two randomized controlled trials. J Thorac Dis 2021; 13:621-631. [PMID: 33717535 PMCID: PMC7947512 DOI: 10.21037/jtd-20-2112] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To evaluate whether patients of varying ages and lung function with asthma or those with chronic obstructive pulmonary disease (COPD) can achieve sufficient inspiratory flows for effective use of the fixed-dose combination of salmeterol-fluticasone propionate and budesonide-formoterol dispensed with the Easyhaler® (EH) device-metered, multi-dose dry powder inhaler (DPI). Methods A pooled analysis of two randomized, multicenter, crossover, open-label studies (NCT01424137; NCT009849061) was conducted to characterize inspiratory flow parameters across the EH, Seretide Diskus (DI) and Symbicort Turbuhaler (TH) inhalers in patients with asthma and/or COPD of varying severity. The primary endpoint was peak inspiratory flow (PIF) rate through the EH. Results The intent-to-treat population comprised 397 patients; 383 patients were included in the per-protocol (PP) population. The mean PIF (standard deviation) values through the EH in patients <18 and ≥18 years of age with asthma and in those with COPD, were similar: 61.4 (11.5), 69.7 (13.5), and 61.9 (13.2) L/min, respectively. These flow rates correspond to pressure drops of 5.05 (1.80), 6.52 (2.34) and 5.19 (2.07) kPa, respectively. In total, 380 (99.2%) of patients in the PP population were able to generate a PIF rate through the EH of ≥30 L/min, which is required to enable consistent dose delivery from the DPI; there was a moderate direct association between age and PIF in younger patients with asthma, but this was inverse and less apparent in adult patients with asthma and/or those with COPD. Height and weight were also moderately correlated with PIF. Stronger associations with PIF were observed for some lung function parameters, particularly native PIF and forced inspiratory vital capacity. Conclusions Over 99% of patients with asthma and/or COPD were able to inhale through the EH with an adequate PIF rate, irrespective of age, or severity of airway obstruction. This confirms that patients with asthma and/or COPD can achieve inspiratory flows via the EH DPI that are sufficient for its effective use.
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Affiliation(s)
- L Pekka Malmberg
- Unit of Clinical Physiology, Skin and Allergy Hospital, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Anna S Pelkonen
- Unit of Clinical Physiology, Skin and Allergy Hospital, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Satu Lähelmä
- Research and Development, Orion Corporation, Espoo, Finland
| | - Rain Jõgi
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
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Matera MG, Calzetta L, Ora J, Rogliani P, Cazzola M. Pharmacokinetic/pharmacodynamic approaches to drug delivery design for inhalation drugs. Expert Opin Drug Deliv 2021; 18:891-906. [PMID: 33412922 DOI: 10.1080/17425247.2021.1873271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: Inhaled drugs are important in the treatment of many lung pathologies, but to be therapeutically effective they must reach unbound concentrations at their effect site in the lung that are adequate to interact with their pharmacodynamic properties (PD) and exert the pharmacological action over an appropriate dosing interval. Therefore, the evaluation of pharmacokinetic (PK)/PD relationship is critical to predict their possible therapeutic effect.Areas covered: We review the approaches used to assess the PK/PD relationship of the major classes of inhaled drugs that are prescribed to treat pulmonary pathologies.Expert opinion: There are still great difficulties in producing data on lung concentrations of inhaled drugs and interpreting them as to their ability to induce the desired therapeutic action. The structural complexity of the lungs, the multiplicity of processes involved simultaneously and the physical interactions between the lungs and drug make any PK/PD approach to drug delivery design for inhalation medications extremely challenging. New approaches/methods are increasing our understanding about what happens to inhaled drugs, but they are still not ready for regulatory purposes. Therefore, we must still rely on plasma concentrations based on the axiom that they reflect both the extent and the pattern of deposition within the lungs.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigino Calzetta
- Unit of Respiratory Disease and Lung Function, Dept. Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Burkes RM, Panos RJ. Ultra Long-Acting β-Agonists in Chronic Obstructive Pulmonary Disease. J Exp Pharmacol 2020; 12:589-602. [PMID: 33364854 PMCID: PMC7751789 DOI: 10.2147/jep.s259328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/24/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Inhaled β-agonists have been foundational medications for maintenance COPD management for decades. Through activation of cyclic adenosine monophosphate pathways, these agents relax airway smooth muscle and improve expiratory airflow by relieving bronchospasm and alleviating air trapping and dynamic hyperinflation improving breathlessness, exertional capabilities, and quality of life. β-agonist drug development has discovered drugs with increasing longer durations of action: short acting (SABA) (4-6 h), long acting (LABA) (6-12 h), and ultra-long acting (ULABA) (24 h). Three ULABAs, indacaterol, olodaterol, and vilanterol, are approved for clinical treatment of COPD. PURPOSE This article reviews both clinically approved ULABAs and ULABAs in development. CONCLUSION Indacaterol and olodaterol were originally approved for clinical use as monotherapies for COPD. Vilanterol is the first ULABA to be approved only in combination with other respiratory medications. Although there are many other ULABA's in various stages of development, most clinical testing of these novel agents is suspended or proceeding slowly. The three approved ULABAs are being combined with antimuscarinic agents and corticosteroids as dual and triple agent treatments that are being tested for clinical use and efficacy. Increasingly, these clinical trials are using specific COPD clinical characteristics to define study populations and to begin to develop therapies that are trait-specific.
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Affiliation(s)
- Robert M Burkes
- University of Cincinnati Division of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, OH, USA
- Department of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati Veterans’ Affairs Medical Center, Cincinnati, OH, USA
| | - Ralph J Panos
- University of Cincinnati Division of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, OH, USA
- Department of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati Veterans’ Affairs Medical Center, Cincinnati, OH, USA
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Lee HY, Song JH, Won HK, Park Y, Chung KB, Lim HJ, Ahn YM, Lee BJ. Comparing Inhaler Use Technique Based on Inhaler Type in Elderly Patients with Respiratory Disease. Tuberc Respir Dis (Seoul) 2020; 84:46-54. [PMID: 32981292 PMCID: PMC7801805 DOI: 10.4046/trd.2020.0021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 09/28/2020] [Indexed: 11/24/2022] Open
Abstract
Background The aim of this study was to investigate inhaler device handling in elderly patients. Inhaler devices with respect to misuse and error correction were also compared. Methods Inhaler use technique was assessed using standardized checklists at the first visit and 3-month follow-up visit after retraining. The primary outcome was difference in the acceptable use ratio among inhaler devices. Secondary outcomes included differences in error correction, the most common step of misuse, and factors affecting the accuracy of inhaler use. Results A total of 251 patients (mean age, 76.4 years) were included. The handling of 320 devices was assessed in the study. All patients had been trained before. However, only 24.7% of them used inhalers correctly. Proportions of acceptable use for Evohaler, Respimat, Turbuhaler, Ellipta, and Breezhaler/Handihaler were 38.7%, 50.0%, 61.4%, 60.8%, and 43.2%, respectively (p=0.026). At the second visit, the acceptable use ratio had increased. There were no significant differences among inhaler types (Evohaler, 63.9%; Respimat, 86.1%; Turbuhaler, 74.3%; Ellipta, 64.6%; and Breezhaler/Handihaler, 65.3% [p=0.129]). In multivariate analysis, body mass index, Turbuhaler, and Ellipta showed positive correlations with acceptable use of inhalers, whereas Chronic Obstructive Pulmonary Disease Assessment Test score showed a negative correlation. Conclusion Although new inhalers have been developed, the accuracy of inhaler use remains low. Elderly patients showed more errors when using pressurized metered-dose inhalers than using dry powder inhalers and soft-mist inhalers. However, there were no significant differences in misuse among inhaler devices after individual training. Results of this study suggests that repeat training is more important than inhaler type.
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Affiliation(s)
- Ha Youn Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Serim General Hospital, Incheon, Republic of Korea
| | - Jin Hwa Song
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Ha-Kyeong Won
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Yeonkyung Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Keun Bum Chung
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Hyo-Jeong Lim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Young Mee Ahn
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Byoung Jun Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
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Sanaullah T, Khan S, Masoom A, Mandokhail ZK, Sadiqa A, Malik MI. Inhaler Use Technique in Chronic Obstructive Pulmonary Disease Patients: Errors, Practices and Barriers. Cureus 2020; 12:e10569. [PMID: 33101814 PMCID: PMC7577299 DOI: 10.7759/cureus.10569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Inhaled medications are the main therapeutic treatment of chronic obstructive pulmonary disease (COPD) and inhaler technique remained important that can increase medication efficacy, reducing dose and side effects. Poor inhaler technique is multi-factorial and the quality of inhaler technique has not previously assessed in Pakistan. We conducted a study to examine a range of competing factors that impact COPD patient willingness, practices, and preference in using their inhalers. Methods A cross-sectional of 765 patients with COPD were interviewed and assessed by qualitative questionnaires. Objective inhalation technique and steps assessment was performed; satisfaction, preferences, perception, and practice of different types of inhaler devices were evaluated at a single cross-sectional visit at the study enrolment. Results The study included 765 participants of mean age 58.7 years (SD ±7.8); 32% males and 68% females. Almost all of the females were exposed to biomass fuel smoke exposure (99%) and pipe (Huka) smokers 53%, while most male participants were cigarette smokers (92%). Only 6.3% of participants were able to perform correct steps of inhaler use, and few educated patients completed 7-steps. 66% of patients were using dry powder inhalers (DPI) inhaler devices and mostly performed the steps 1, 2, and 4 (98%) correctly, while 44% who were using metered-dose inhalers (MDI) completed only steps 2 and 4 correctly (88%). The majority of participants reported the particular inhaler devices was prescribed by the visiting consultants (54%). Interestingly, they were using two inhalers together (47%) relieving symptoms of dyspnea (83%) and cough (73%). The inhaler use technique was demonstrated to most of the patients by the pharmacy salesman (38.4%), while 15.8% reported that their doctors taught them the inhaler technique. 54.2% reported reason for poor adherence to inhaler use as they understand it might not work lately and 75.2% were not aware of any side effects associated with the regular use of an inhaler. Conclusions Poor inhaler technique is highly prevalent and the associated errors did not appear to be dependent on device type. Most of the participants had not receive proper training about the correct use and were not involved in decision making about the choice of inhaler device.
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Affiliation(s)
- Tareen Sanaullah
- Pulmonary Medicine and Critical Care, FJ Chest Hospital, Bolan University of Medical and Health Sciences, Quetta, PAK
| | - Shereen Khan
- Pulmonary Medicine and Critical Care, Bolan University of Medical and Health Sciences, Quetta, PAK
| | - Aria Masoom
- Otolaryngology - Head and Neck Surgery, Bolan Medical Complex Hospital, Quetta, PAK
| | | | - Aisha Sadiqa
- Gynaecology & Obstetrics, Civil Provincial Hospital, Quetta, PAK
| | - Muhammad Irfan Malik
- Pulmonology, Postgraduate Medical Institute/Ameer-ud-Din Medical College (AMC) Lahore General Hospital, Lahore, PAK
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Ainali NM, Xanthopoulou E, Michailidou G, Zamboulis A, Bikiaris DN. Microencapsulation of Fluticasone Propionate and Salmeterol Xinafoate in Modified Chitosan Microparticles for Release Optimization. Molecules 2020; 25:molecules25173888. [PMID: 32859128 PMCID: PMC7503413 DOI: 10.3390/molecules25173888] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/23/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022] Open
Abstract
Chitosan (CS) is a natural polysaccharide, widely studied in the past due to its unique properties such as biocompatibility, biodegradability and non-toxicity. Chemical modification of CS is an effective pathway to prepare new matrices with additional functional groups and improved properties, such as increment of hydrophilicity and swelling rate, for drug delivery purposes. In the present study, four derivatives of CS with trans-aconitic acid (t-Acon), succinic anhydride (Succ), 2-hydroxyethyl acrylate (2-HEA) and acrylic acid (AA) were prepared, and their successful grafting was confirmed by FTIR and 1H-NMR spectroscopies. Neat chitosan and its grafted derivatives were fabricated for the encapsulation of fluticasone propionate (FLU) and salmeterol xinafoate (SX) drugs, used for chronic obstructive pulmonary disease (COPD), via the ionotropic gelation technique. Scanning electron microscopy (SEM) micrographs demonstrated that round-shaped microparticles (MPs) were effectively prepared with average sizes ranging between 0.4 and 2.2 μm, as were measured by dynamic light scattering (DLS), while zeta potential verified in all cases their positive charged surface. FTIR spectroscopy showed that some interactions take place between the drugs and the polymeric matrices, while X-ray diffraction (XRD) patterns exhibited that both drugs were encapsulated in MPs’ interior with a lower degree of crystallinity than the neat drugs. In vitro release studies of FLU and SX exposed a great amelioration in the drugs’ dissolution profile from all modified CS’s MPs, in comparison to those of neat drugs. The latter fact is attributed to the reduction in crystallinity of the active substances in the MPs’ interior.
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Inhaler devices in asthma and COPD patients - a prospective cross-sectional study on inhaler preferences and error rates. BMC Pulm Med 2020; 20:222. [PMID: 32819337 PMCID: PMC7439539 DOI: 10.1186/s12890-020-01246-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/27/2020] [Indexed: 01/10/2023] Open
Abstract
Background Inhalation therapy is the backbone of asthma and COPD control. However, inhaler adherence and device mishandling continue to be a problem in real life. Some studies have shown that using a patient-preferred inhaler may reduce device handling errors and improve adherence to prescribed chronic inhaler drug therapy. The aim of this study was to compare the preferences for commonly used inhaler devices in Germany in patients with chronic obstructive respiratory disease. We also pursued the question which properties of an inhaler device are particularly important to the user and what effects age, gender and type of disease (asthma or COPD) may have on device preference and handling errors. Methods Prospective, open-label cross-sectional study in which 105 patients with asthma (58%) or COPD (42%) participated. Validated checklists were used to objectively assess inhaler technique and errors with 10 different placebo devices. For each device, patients were asked to test the handling, to assess the device properties and to name the device that they would most or least prefer. Results Across the 10 placebo inhaler devices tested, patients needed an average of 1.22 attempts to error-free use. The device with the lowest mean number of attempts was the Turbohaler® (1.02), followed by the Nexthaler® (1.04), the Diskus® (1.07) and the Spiromax® (1.10). Patients over 60 years vs. younger age (p = 0.002) and COPD vs. asthma patients (p = 0.016) required more attempts to ensure correct use. 41% of the study participants chose one of the devices they already used as the most preferred inhaler. Overall, 20% opted for the Spiromax®, 15% for the Nexthaler® and 14% for the Turbohaler® or a pMDI. The least preferred device was the Elpenhaler® (0%). From a selection of 7 predefined inhaler attributes, patients stated easy handling as the most important for them. This was followed by short inhalation time and low inhalation resistance. Conclusions Patient preference may vary between inhaler devices. The lowest number of attempts to error-free use was reported for the Turbohaler® and the Nexthaler®. The Spiromax® and the Nexthaler® achieved the best overall ratings and were the devices most preferred by patients.
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Movia D, Prina-Mello A. Preclinical Development of Orally Inhaled Drugs (OIDs)-Are Animal Models Predictive or Shall We Move Towards In Vitro Non-Animal Models? Animals (Basel) 2020; 10:E1259. [PMID: 32722259 PMCID: PMC7460012 DOI: 10.3390/ani10081259] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/18/2022] Open
Abstract
Respiratory diseases constitute a huge burden in our society, and the global respiratory drug market currently grows at an annual rate between 4% and 6%. Inhalation is the preferred administration method for treating respiratory diseases, as it: (i) delivers the drug directly at the site of action, resulting in a rapid onset; (ii) is painless, thus improving patients' compliance; and (iii) avoids first-pass metabolism reducing systemic side effects. Inhalation occurs through the mouth, with the drug generally exerting its therapeutic action in the lungs. In the most recent years, orally inhaled drugs (OIDs) have found application also in the treatment of systemic diseases. OIDs development, however, currently suffers of an overall attrition rate of around 70%, meaning that seven out of 10 new drug candidates fail to reach the clinic. Our commentary focuses on the reasons behind the poor OIDs translation into clinical products for the treatment of respiratory and systemic diseases, with particular emphasis on the parameters affecting the predictive value of animal preclinical tests. We then review the current advances in overcoming the limitation of animal animal-based studies through the development and adoption of in vitro, cell-based new approach methodologies (NAMs).
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Affiliation(s)
- Dania Movia
- Laboratory for Biological Characterisation of Advanced Materials (LBCAM), Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College, The University of Dublin, Dublin D8, Ireland;
| | - Adriele Prina-Mello
- Laboratory for Biological Characterisation of Advanced Materials (LBCAM), Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College, The University of Dublin, Dublin D8, Ireland;
- AMBER Centre, CRANN Institute, Trinity College, The University of Dublin, Dublin D2, Ireland
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Stephenson JJ, Dembek C, Caldwell-Tarr A, Conto RM, Paullin M, Kerwin EM. Observational Real-World Study to Assess Clinical Characteristics and Device Satisfaction in Patients with COPD Treated with Glycopyrrolate/eFlow ® CS. Int J Chron Obstruct Pulmon Dis 2020; 15:1713-1727. [PMID: 32764916 PMCID: PMC7369372 DOI: 10.2147/copd.s248760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/12/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess clinical characteristics and device satisfaction of patients with chronic obstructive pulmonary disease (COPD) treated with glycopyrrolate/eFlow® Closed System (CS) nebulizer (further referred to as eFlow) under real-world conditions. Participants and Methods Patients with COPD currently using eFlow were identified by the study sponsor. Consenting patients who met study inclusion criteria completed a cross-sectional survey that included a device satisfaction questionnaire. Means, medians, and standard deviations were calculated. Results Sixty-six patients met inclusion criteria and completed the survey. Participants' mean ± standard deviation age was 64.9 ± 11.9 years and the majority were white (86.4%) and female (59.1%). Almost two-thirds were former smokers. Thirty-nine (59.1%) reported their COPD to be severe/very severe and 38 (57.6%) reported a COPD exacerbation resulting in a hospitalization, ER visit, or medication modification over the past 12 months. Among 55 participants who had previously used another type of nebulizer, 44 (80%) were overall "much more"/"somewhat more" satisfied with the eFlow compared with their previous nebulizer(s). Regardless of prior nebulizer use, 60 (90.9%) participants were "satisfied"/"very satisfied" overall with the eFlow. Assembly and disassembly, operation, and cleaning were perceived as being "easy"/"very easy" by at least 65% of participants. Among all participants, 57 (86.4%) were "confident"/"very confident" of glycopyrrolate administration. On a Likert scale of 1 ("I don't like it") to 7 ("I like it a lot"), mean scores were at least 5.9 for portability, ease of cleaning, size, weight, short administration time, and relative silence of the device. Over 80% of participants said they "probably"/"definitely" would continue to use eFlow. Conclusion Based on this real-world study, the majority of patients were highly satisfied with, and confident in, using eFlow.
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Affiliation(s)
| | | | | | | | | | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
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Gangemi A, Kim V, Criner G. Customer is always right: optimising inhaler design to fit patient preferences in obstructive lung disease. Thorax 2020; 75:711-712. [PMID: 32631931 DOI: 10.1136/thoraxjnl-2020-215238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Andrew Gangemi
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Gerard Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Correlation of Inhaled Long-Acting Bronchodilators With Adverse Cardiovascular Outcomes in Patients With Stable COPD: A Bayesian Network Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2020; 74:255-265. [PMID: 31306366 DOI: 10.1097/fjc.0000000000000705] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A majority of existing studies have focused on the efficacy of inhaled long-acting bronchodilators (ILABs), such as long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs), and LABAs combined with LAMAs in treating chronic obstructive pulmonary disease (COPD). The current meta-analysis aimed to investigate the correlation of ILABs with specific cardiovascular adverse events (CAEs). Five electronic databases, including PubMed, Embase, Cochrane Library, Scopus, and Web of Science were systematically retrieved. Finally, 16 randomized controlled trials were enrolled into the current meta-analysis. Typically, the efficacy of 3 major classes of drugs (LABAs, LAMAs, and LABAs combined with LAMAs), and 7 specific drugs (including formoterol, glycopyrrolate, indacaterol, olodaterol, Salmeterol, tiotropium, and vilanterol) for 4 CAEs, including myocardial infarction, cardiac failure (CF), ischemic heart disease (IHD), and stroke in stable COPD patients, was examined. All the pooled results were analyzed through the odds ratios (ORs) with the corresponding 95% confidence intervals (CIs). The direct meta-analysis results suggested that LABAs could increase the risk of CF in patients with stable COPD compared with placebo controls (OR 1.70, 95% CI, 1.00-2.90). In addition, network meta-analysis results indicated that LAMAs combined with LABAs would result in an increased risk of CF in patients with stable COPD (OR 2.31, 95% CI, 1.10-5.09). According to the ILABs specific drug analysis, formoterol may potentially have protective effects on IHD compared with placebo controls (OR 0.45, 95% CI, 0.18-1.00). In conclusion, among these 3 kinds of ILABs, including LAMAs, LABAs, and LABAs/LAMAs, for stable COPD patients, LAMAs and LABAs are associated with the least possibility to induce myocardial infarction and stroke, respectively. However, the application of LABAs will probably increase the risk of CF; they should be used with caution for stable COPD patients with CF. In addition, in specific-drug analysis, the use of formoterol can reduce the risk of treatment-related IHD. Nevertheless, more studies on different drug doses are needed in the future to further validate this conclusion.
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Efficacy of Budesonide/Glycopyrronium/Formoterol Fumarate Metered Dose Inhaler (BGF MDI) Versus Other Inhaled Corticosteroid/Long-Acting Muscarinic Antagonist/Long-Acting β 2-Agonist (ICS/LAMA/LABA) Triple Combinations in COPD: A Systematic Literature Review and Network Meta-analysis. Adv Ther 2020; 37:2956-2975. [PMID: 32335859 PMCID: PMC7467454 DOI: 10.1007/s12325-020-01311-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Triple inhaled corticosteroid/long-acting muscarinic antagonist/long-acting β2-agonist (ICS/LAMA/LABA) combination therapy is recommended for patients with chronic obstructive pulmonary disease (COPD) who experience further exacerbations/symptoms on dual LAMA/LABA or ICS/LABA therapy. The relative efficacy of budesonide/glycopyrronium/formoterol fumarate metered dose inhaler 320/18/9.6 µg (BGF MDI) in COPD was compared with other ICS/LAMA/LABA fixed-dose and open combination therapies in a network meta-analysis (NMA). METHODS A systematic literature review was conducted to identify randomized controlled trials of at least 10-week duration, including at least one fixed-dose or open combination triple therapy arm, in patients with moderate to very severe COPD. Studies were assessed for methodological quality and risk of bias. A three-level hierarchical Bayesian NMA model was used to determine the exacerbation rate per patient per year as well as the following outcomes at week 24: changes from baseline in pre-dose trough forced expiratory volume in 1 s (FEV1), post-dose peak FEV1, and St. George's Respiratory Questionnaire (SGRQ) total score; proportion of SGRQ responders; and Transition Dyspnea Index focal score. Change from baseline in rescue medication use over weeks 12-24 was also analyzed. Meta-regression and sensitivity analyses were used to assess heterogeneity across studies. RESULTS Eighteen studies (n = 29,232 patients) contributed to the NMA. ICS/LABA dual combinations were combined as a single treatment group to create a connected network. Across all outcomes, there were no statistically significant differences between BGF MDI and other triple ICS/LAMA/LABA fixed-dose (fluticasone furoate/umeclidinium/vilanterol and beclomethasone dipropionate/glycopyrronium/formoterol fumarate) and open combinations with data available within the network. Results from sensitivity analyses and meta-regression were consistent with the base-case scenario. CONCLUSION This NMA suggested that BGF MDI has comparable efficacy to other ICS/LAMA/LABA fixed-dose and open triple combination therapies in reducing exacerbations and improving lung function and symptoms in patients with moderate to very severe COPD. Further research is warranted as additional evidence regarding triple therapies, especially fixed-dose combinations, becomes available.
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Michailidou G, Ainali NM, Xanthopoulou E, Nanaki S, Kostoglou M, Koukaras EN, Bikiaris DN. Effect of Poly(vinyl alcohol) on Nanoencapsulation of Budesonide in Chitosan Nanoparticles via Ionic Gelation and Its Improved Bioavailability. Polymers (Basel) 2020; 12:polym12051101. [PMID: 32408557 PMCID: PMC7285374 DOI: 10.3390/polym12051101] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 12/13/2022] Open
Abstract
Chitosan (CS) is a polymer extensively used in drug delivery formulations mainly due to its biocompatibility and low toxicity. In the present study, chitosan was used for nanoencapsulation of a budesonide (BUD) drug via the well-established ionic gelation technique and a slight modification of it, using also poly(vinyl alcohol) (PVA) as a surfactant. Scanning electron microscopy (SEM) micrographs revealed that spherical nanoparticles were successfully prepared with average sizes range between 363 and 543 nm, as were measured by dynamic light scattering (DLS), while zeta potential verified their positive charged surface. X-ray diffraction (XRD) patterns revealed that BUD was encapsulated in crystalline state in nanoparticles but with a lower degree of crystallinity than the neat drug, which was also proven by differential scanning calorimetry (DSC) and melting peak measurements. This could be attributed to interactions that take place between BUD and CS, which were revealed by FTIR and by an extended computational study. An in vitro release study of budesonide showed a slight enhancement in the BUD dissolution profile, compared to the neat drug. However, drug release was substantially increased by introducing PVA during the nanoencapsulation procedure, which is attributed to the higher amorphization of BUD on these nanoparticles. The release curves were analyzed using a diffusion model that allows estimation of BUD diffusivity in the nanoparticles.
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Affiliation(s)
- Georgia Michailidou
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (G.M.); (N.M.A.); (E.X.); (S.N.)
| | - Nina Maria Ainali
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (G.M.); (N.M.A.); (E.X.); (S.N.)
| | - Eleftheria Xanthopoulou
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (G.M.); (N.M.A.); (E.X.); (S.N.)
| | - Stavroula Nanaki
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (G.M.); (N.M.A.); (E.X.); (S.N.)
| | - Margaritis Kostoglou
- Laboratory of Inorganic Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece;
| | - Emmanuel N. Koukaras
- Laboratory of Quantum and Computational Chemistry, Department of Chemistry, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece;
| | - Dimitrios N. Bikiaris
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (G.M.); (N.M.A.); (E.X.); (S.N.)
- Correspondence: ; Tel.: +30-2310-997812; Fax: +30-2310-997667
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McCarthy SD, González HE, Higgins BD. Future Trends in Nebulized Therapies for Pulmonary Disease. J Pers Med 2020; 10:E37. [PMID: 32397615 PMCID: PMC7354528 DOI: 10.3390/jpm10020037] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/15/2022] Open
Abstract
Aerosol therapy is a key modality for drug delivery to the lungs of respiratory disease patients. Aerosol therapy improves therapeutic effects by directly targeting diseased lung regions for rapid onset of action, requiring smaller doses than oral or intravenous delivery and minimizing systemic side effects. In order to optimize treatment of critically ill patients, the efficacy of aerosol therapy depends on lung morphology, breathing patterns, aerosol droplet characteristics, disease, mechanical ventilation, pharmacokinetics, and the pharmacodynamics of cell-drug interactions. While aerosol characteristics are influenced by drug formulations and device mechanisms, most other factors are reliant on individual patient variables. This has led to increased efforts towards more personalized therapeutic approaches to optimize pulmonary drug delivery and improve selection of effective drug types for individual patients. Vibrating mesh nebulizers (VMN) are the dominant device in clinical trials involving mechanical ventilation and emerging drugs. In this review, we consider the use of VMN during mechanical ventilation in intensive care units. We aim to link VMN fundamentals to applications in mechanically ventilated patients and look to the future use of VMN in emerging personalized therapeutic drugs.
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Affiliation(s)
- Sean D. McCarthy
- Anaesthesia, School of Medicine, National University of Ireland Galway, H91 TK33 Galway, Ireland; (S.D.M.); (H.E.G.)
- Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, H91 TK33 Galway, Ireland
| | - Héctor E. González
- Anaesthesia, School of Medicine, National University of Ireland Galway, H91 TK33 Galway, Ireland; (S.D.M.); (H.E.G.)
- Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, H91 TK33 Galway, Ireland
| | - Brendan D. Higgins
- Physiology, School of Medicine, National University of Ireland Galway, H91 TK33 Galway, Ireland
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Sorino C, Negri S, Spanevello A, Visca D, Scichilone N. Inhalation therapy devices for the treatment of obstructive lung diseases: the history of inhalers towards the ideal inhaler. Eur J Intern Med 2020; 75:15-18. [PMID: 32113944 DOI: 10.1016/j.ejim.2020.02.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 01/04/2023]
Abstract
Inhalation therapy allows conveying drugs directly into the airways. The devices used to administer inhaled drugs play a crucial role in the management of obstructive lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). To ensure high bronchial deposition of the drug, a device should deliver a high proportion of fine particles, be easy to use, and provide constant and accurate doses of the active substance. Nowadays, four different types of inhalers are widely used: nebulizers, dry powder inhalers (DPIs), pressurized metered-dose inhalers (pMDIs), and soft mist inhalers (SMIs). Nebulizers can be used by patients unable to use other inhalers. However, they require long times of administration and do not ensure precise dosages. The first pMDIs became popular since they were small, inexpensive, fast, and silent. Their performance was improved by spacers and then by new technologies which reduced the delivery speed. In DPIs, micronized drug particles are attached to larger lactose carrier particles. No coordination between actuation and inhalation is required. However, the patient is supposed to produce an adequate inspiratory flow to extract the drug and disaggregate it from the carrier. In SMIs, the medication is dissolved in an aqueous solution, without propellant, and it is dispensed as a slow aerosol cloud thanks to the energy of a spring. Smart inhalers, connected to smartphones, are promising tools that can provide information about patient's adherence and their inhaler technique. Inhalation has also been proposed as a route of administration for several systemic drugs.
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Affiliation(s)
- Claudio Sorino
- Division of Pulmonology, Sant'Anna Hospital, Como, Italy; University of Insubria, Faculty of Medicine and Surgery, Varese, Italy.
| | - Stefano Negri
- University of Insubria, Faculty of Medicine and Surgery, Varese, Italy
| | - Antonio Spanevello
- University of Insubria, Faculty of Medicine and Surgery, Varese, Italy; Division of Pulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
| | - Dina Visca
- University of Insubria, Faculty of Medicine and Surgery, Varese, Italy; Division of Pulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
| | - Nicola Scichilone
- Division of Respiratory Medicine, Department PROMISE, "Giaccone" University Hospital, University of Palermo, Italy
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Barnes CN, Mahler DA, Ohar JA, Lombardi DA, Crater GD. Peak Inspiratory Flows: Defining Repeatability Limits and a Predictive Equation for Different Inhalers. Chest 2020; 158:1413-1419. [PMID: 32343967 DOI: 10.1016/j.chest.2020.03.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/23/2020] [Accepted: 03/27/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Peak inspiratory flow (PIF) has been proposed as a measure to assess a patient's ability to use dry powder inhalers (DPIs). However, robust quality criteria to determine a repeatability limit for measuring PIF are lacking. RESEARCH QUESTIONS What are the repeatability limits for measuring PIF? What is the relationship between PIF measured using the In-Check DIAL device at Diskus (GlaxoSmithKline; PIFD) and HandiHaler (Boehringer Ingelheim; PIFHH) resistances? STUDY DESIGN AND METHODS Data from a randomized, controlled, phase 3 trial (study 0149; see Clinical Trial Registration data) were used to define repeatability limits for PIF. In addition, a model to characterize the relationship between PIF measured with the In-Check DIAL device at PIFD and PIFHH was defined using data from two randomized, controlled, phase 3 trials (studies 0128 and 0149). RESULTS In study 0128, the mean values (SD) for PIF at zero resistance and PIFHH were 84.6 (33.4) and 57.3 (26.1) L/min, respectively. In study 0149, the mean values (SD) for PIFD and PIFHH were 42.4 (11.2) and 29.0 (8.3) L/min, respectively. At the mean level, the mean difference between measurement attempts for PIFD and PIFHH was small, < 5 and < 3 L/min, respectively. The repeatability limit was determined as 10 and 5 L/min for PIFD and PIFHH, respectively. Modeling the relationship between PIFD and PIFHH, after controlling for significant covariates, demonstrated that a PIFD value of 60 L/min was approximately equivalent to PIFHH of 40 L/min. INTERPRETATIONS This analysis demonstrated that the two highest values of PIF using the In-Check DIAL device among three inspiratory efforts, met the repeatability limit. Altogether, these data provide guidance for measuring PIF against the simulated resistance of a specific DPI in clinical practice and research studies. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; Nos.: NCT02518139 (study 0128) and NCT03095456 (study 0149); URL: www.clinicaltrials.gov.
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Affiliation(s)
| | | | - Jill A Ohar
- Wake Forest University Medical Center, Winston-Salem, NC
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Chiner Vives E, Fernández Fabrellas E, Agüero Balbín R, Martínez García MÁ. Aerosolterapia. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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75
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Lavorini F, Bianco A, Blasi F, Braido F, Corsico AG, Di Marco F, Gentile A, Paggiaro PL, Pegoraro V, Pelaia G, Rogliani P, Santus P, Scichilone N, Soldi A, Canonica GW. What drives inhaler prescription for asthma patients? Results from a real-life retrospective analysis. Respir Med 2020; 166:105937. [PMID: 32250870 DOI: 10.1016/j.rmed.2020.105937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/27/2020] [Accepted: 03/17/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The choice of inhaler device for asthma patients depends upon multiple attributes. We investigated factors that may drive general practitioners (GPs) and respiratory specialists in the prescription of inhaler devices for asthma patients who initiated inhalation therapy. METHODS We retrospectively analysed prescriptions by GPs and respiratory specialists to asthma patients commencing inhaled corticosteroid/long-acting β2-agonist combination therapy available as both pressurised metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs). Patient characteristics were compared by device and multivariate analysis was used to model the likelihood of receiving a pMDI as opposed to a DPI in order to identify drivers for prescription. A sample of the respiratory specialists completed an ad-hoc survey of their perceived success in achieving asthma control in their patients and barriers to attaining full control. RESULTS Prescription of a particular inhaler device was unrelated to the characteristics of the patients. Multivariate analysis revealed that the main driver for the choice of inhaler device was the medication (Odds Ratio and 95% Confidence Interval, respectively for GPs and specialists: 0.19 [0.16-0.23]; 0.17 [0.08-0.37]). Specialists perceived asthma as being inadequately controlled in 41% of their patients, and considered patients' difficulties in using DPIs and pMDIs as instrumental in this, citing a need for a novel, more effective inhaler technology. CONCLUSION Physicians choose inhaler devices according to the prescribed drugs and not to the characteristics of the individual patient. This may reflect a lack of confidence in existing inhaler devices and underlines the need for technologies, which are more reliable and easier to use by patients.
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Affiliation(s)
- F Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - A Bianco
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - F Blasi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - F Braido
- Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genova, Azienda Policlinico IRCCs San Martino, Genoa, Italy
| | - A G Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation - Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - F Di Marco
- Department of Health Sciences, University of Milan, Italy - Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - A Gentile
- Mundipharma Pharmaceuticals, Milan, Italy
| | - P L Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Italy
| | | | - G Pelaia
- Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - P Rogliani
- Respiratory Medicine Department of Experimental Medicine, University of Rome "Tor Vergata" - Respiratory Unit, Policlinico Tor Vergata, Rome, Italy
| | - P Santus
- Department of Biomedical and Clinical Sciences (DIBIC) - University of Milan. Division of Respiratory Diseases - "L. Sacco" University Hospital - ASST Fatebenefratelli Sacco - Milan, Italy
| | - N Scichilone
- PROMISE Department, University of Palermo, Palermo, Italy
| | - A Soldi
- Mundipharma Pharmaceuticals, Milan, Italy
| | - G W Canonica
- Personalized Medicine, Asthma and Allergy Clinic, Humanitas Research Hospital - Department of Biomedical Sciences, Humanitas University, Milan, Italy
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76
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Cazzola M, Cavalli F, Usmani OS, Rogliani P. Advances in pulmonary drug delivery devices for the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Deliv 2020; 17:635-646. [DOI: 10.1080/17425247.2020.1739021] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Mario Cazzola
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Francesco Cavalli
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Omar S. Usmani
- Imperial College London and Royal Brompton Hospital, Airways Disease Section, National Heart and Lung Institute (NHLI), London, UK
| | - Paola Rogliani
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
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Singh M, Duarte AG, Hsu ES, Kuo YF, Sharma G. Trends and Factors Associated with Nebulized Therapy Prescription in Older Adults with Chronic Obstructive Pulmonary Disease from 2008 to 2015. J Aerosol Med Pulm Drug Deliv 2020; 33:161-169. [PMID: 32017642 DOI: 10.1089/jamp.2019.1582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Medical management of patients with chronic obstructive pulmonary disease (COPD) includes nebulized therapy as an option for inhalational drug delivery. A broad variety of short- and long-acting bronchodilators and inhaled corticosteroids in the nebulized form are available. Despite this, limited information exists on the pattern and predictors of nebulized prescription. We examined the trend and factors associated with prescription of nebulized therapy among Medicare beneficiaries with COPD. Methods: A retrospective cross-sectional study of 5% Medicare beneficiaries with COPD (n = 66,032) who were enrolled in parts A, B, and D and received nebulized prescription from 2008 to 2015 was conducted. This sample has shown to be representative of the entire fee-for-service Medicare population. The primary outcome was a prescription of nebulized medications. Reliever nebulized medications included short-acting beta agonist (SABA), short-acting muscarinic agents (SAMAs), and a combination of SABA and SAMA, while maintenance nebulized medications included long-acting beta agonists, long-acting muscarinic agents, and corticosteroid solutions as well as combinations of these agents. The secondary outcome was prescription of other inhaler respiratory medications not administered with a nebulizer. Results: Overall, 38.9% patients were prescribed nebulized medication and their prescription significantly declined from 42.4% in 2008 to 35.1% in 2015, majority of which was related to decreased prescriptions of nebulized relievers. Factors associated with the prescription of nebulized medications include female gender (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.02-1.09), dual eligibility or low-income subsidy beneficiaries (OR = 1.49; CI = 1.44-1.53), hospitalization for COPD in the previous year (OR = 1.29; CI = 1.25-1.34), home oxygen therapy (OR = 2.29; CI = 2.23-2.36), pulmonary specialist visit (OR = 1.24; CI = 1.20-1.27), and moderate (OR = 1.61; CI = 1.57-1.65) or high (OR = 1.52; CI = 1.46-1.59) severity of COPD. Conclusion: Between 2008 and 2015, prescriptions for nebulized therapy for COPD declined among Medicare beneficiaries, probably related to increase in use of maintenance non-nebulized medications.
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Affiliation(s)
- Mandeep Singh
- Division of Pulmonary Critical Care & Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Alexander G Duarte
- Division of Pulmonary Critical Care & Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - En-Shuo Hsu
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas
| | - Gulshan Sharma
- Division of Pulmonary Critical Care & Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
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78
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Rogliani P, Matera MG, Facciolo F, Page C, Cazzola M, Calzetta L. Beclomethasone dipropionate, formoterol fumarate and glycopyrronium bromide: Synergy of triple combination therapy on human airway smooth muscle ex vivo. Br J Pharmacol 2020; 177:1150-1163. [PMID: 31660611 DOI: 10.1111/bph.14909] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/11/2019] [Accepted: 10/12/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Combining inhaled corticosteroids (ICSs), long-acting β2 -adrenoceptor agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) is recommended to treat severe forms of asthma and chronic obstructive pulmonary disease (COPD). Clinical benefits have been demonstrated for ICS/LABA/LAMA combinations. This study characterized the interaction between the ICS beclomethasone dipropionate, the LABA formoterol fumarate and the LAMA glycopyrronium bromide in human airways. EXPERIMENTAL APPROACH Human passively sensitized airways and bronchi from COPD donors were stimulated with histamine or carbachol. Tissues were incubated overnight with beclomethasone and then treated with formoterol and glycopyrronium, alone or in triple combination. The interaction was assessed by using Bliss Independence and Unified Theory theorems. KEY RESULTS Beclomethasone/formoterol/glycopyrronium combination synergistically relaxed medium bronchi and small airways. Beclomethasone/formoterol/glycopyrronium combination at 100:6:12.5 combination ratio was a balanced drug mixture leading to very strong synergistic effect on relaxation of medium bronchi (Combination Index: from 0.042 to 0.96) and middle to very strong synergy in small airways (Combination Index: from 0.018 to 0.310). The synergy was related with the activation of intracellular glucocorticoid receptors and Gsα subunit G-protein of β2 -adrenoceptors, leading to the modulation of cyclic AMP-dependent PKA pathway. CONCLUSION Triple beclomethasone/formoterol/glycopyrronium combination induces synergistic bronchorelaxant effect in medium and small human airways, at least in ex vivo experiments. Further research is needed to confirm these findings in clinical studies in patients with asthma or COPD.
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Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Facciolo
- Thoracic Surgery Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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79
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Ari A, Fink JB. Recent advances in aerosol devices for the delivery of inhaled medications. Expert Opin Drug Deliv 2020; 17:133-144. [PMID: 31959028 DOI: 10.1080/17425247.2020.1712356] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Aerosolized medications are commonly prescribed for the treatment of patients with pulmonary diseases, and there has been an increased interest in the development of aerosol delivery devices over the years. Technical innovations have advanced device design, novel features such as breath actuation, dose tracking, portability, and feedback mechanism during treatment that improved the performance of aerosol devices, and effectiveness of inhalation therapy.Areas covered: The purpose of this paper is to review recent advances in aerosol devices for delivery of inhaled medications.Expert opinion: Drug formulations and device designs are rapidly evolving to make more consistent dosing across a broad range of inspiratory efforts, to maximize dose and target specific areas of the diseased lung.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA
| | - James B Fink
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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80
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Ruessel K, Luecke E, Schreiber J. Inhaler Devices in a Geriatric Patient Population: A Prospective Cross-Sectional Study on Patient Preferences. Patient Prefer Adherence 2020; 14:1811-1822. [PMID: 33116426 PMCID: PMC7548293 DOI: 10.2147/ppa.s262057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The aim of this study was to examine the perception and preference of geriatric patients for commonly used inhaler devices in Germany. PATIENTS AND METHODS This was a prospective, open-label cross-sectional study with inpatient inhaler-naïve geriatric volunteers (age ≥ 70 years). All 106 participants were interviewed and subjected to a geriatric examination for cognitive, motor and fine motor skills before demonstrating the use of nine inhalers in random order. For each device, patients were asked to test the handling, to assess the device properties and to name the device that they would most or least prefer. RESULTS The mean age of the patients was 80.8 years. From a selection of 7 predefined general inhaler attributes, ease of use, discrete handling and inhalation resistance were the most important for the geriatric participants. Across all inhaler devices, the volunteers needed an average of 2.47 attempts to error-free use. The device with the lowest mean number of attempts was the Nexthaler® (1.75; SD ± 0.903), followed by Spiromax® (1.96; SD ± 0.965) and Genuair® (2.05; SD ± 1.027). There was a weak to moderate correlation between the number of attempts required to ensure the correct use of these three inhalers and the patient's cognitive and fine motor skills. Fifty-nine patients (56%) chose the Nexthaler as the inhalation device that they would most prefer (p<0.001 vs other devices). This was followed by Spiromax (n=23; 22%) and Genuair (n=12; 11%). The device that was least favored was the Elpenhaler® (p<0.001 vs other devices). CONCLUSION Patient preference and frequency of inhaler handling-errors may vary between inhaler devices. The Nexthaler was the easiest-to-use and most popular device among inhaler-naïve patients.
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Affiliation(s)
- Katharina Ruessel
- Department of Pneumonology, Otto-Von-Guericke University, Magdeburg, Germany
| | - Eva Luecke
- Department of Pneumonology, Otto-Von-Guericke University, Magdeburg, Germany
| | - Jens Schreiber
- Department of Pneumonology, Otto-Von-Guericke University, Magdeburg, Germany
- Correspondence: Jens Schreiber Department of Pneumonology, Otto-Von-Guericke University, Leipziger Strasse 44, Magdeburg39120, GermanyTel +49 391 67 15421Fax +49 391 67 13356 Email
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81
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A particle technology approach toward designing dry-powder inhaler formulations for personalized medicine in respiratory diseases. ADV POWDER TECHNOL 2020. [DOI: 10.1016/j.apt.2019.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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82
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Navaie M, Dembek C, Cho-Reyes S, Yeh K, Celli BR. Device use errors with soft mist inhalers: A global systematic literature review and meta-analysis. Chron Respir Dis 2020; 17:1479973119901234. [PMID: 31984767 PMCID: PMC6985977 DOI: 10.1177/1479973119901234] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/28/2019] [Indexed: 11/30/2022] Open
Abstract
Inhaled bronchodilators are the cornerstone of treatment for chronic obstructive pulmonary disease (COPD). Soft mist inhalers (SMIs) are devices that deliver bronchodilators. Although correct device use is paramount to successful medication delivery, patient errors are common. This global systematic literature review and meta-analysis examined device use errors with SMIs among patients with obstructive lung diseases. PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify studies published between 2010 and 2019 that met the following inclusion criteria: (a) English language; (b) a diagnosis of COPD, bronchitis, or emphysema; and (c) reported device use errors among adults receiving long-acting bronchodilator treatment with Respimat® SMI (i.e. Spiriva®, Stiolto®, Spiolto®, and Striverdi®). Descriptive statistics examined sociodemographics, clinical characteristics, and device use errors. Meta-analysis techniques were employed with random-effects models to generate pooled mean effect sizes and 95% confidence intervals (CIs) for overall and step-by-step errors. The I2 statistic measured heterogeneity. Twelve studies (n = 1288 patients) were included in this meta-analysis. Eighty-eight percent of patients had COPD, and most had moderate/very severe airflow limitation (Global Initiative for Chronic Obstructive Lung Disease spirometric stages II to IV). Aggregate results revealed that 58.9% (95% CI: 42.4-75.5; I2 = 92.8%) of patients made ≥1 device use errors. Among 11 studies with step-by-step data, the most common errors were failure to (1) exhale completely and away from the device (47.8% (95% CI: 33.6-62.0)); (2) hold breath for up to 10 seconds (30.6% (95% CI: 17.5-43.7)); (3) take a slow, deep breath while pressing the dose release button (27.9% (95% CI: 14.5-41.2)); (4) hold the inhaler upright (22.6% (95% CI: 6.2-39.0)); and (5) turn the base toward the arrows until it clicked (17.6% (95% CI: 3.0-32.2)). Device use errors occurred in about 6 of 10 patients who used SMIs. An individualized approach to inhalation device selection and ongoing training and monitoring of device use are important in optimizing bronchodilator treatment.
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Affiliation(s)
- Maryam Navaie
- Advance Health Solutions, LLC, New York, NY, USA
- School of Professional Studies, Columbia University, New York, NY, USA
| | - Carole Dembek
- Global Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | | | - Karen Yeh
- Advance Health Solutions, LLC, New York, NY, USA
| | - Bartolome R Celli
- Chronic Obstructive Pulmonary Disease Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Calzetta L, Matera MG, Cazzola M, Rogliani P. Optimizing the Development Strategy of Combination Therapy in Respiratory Medicine: From Isolated Airways to Patients. Adv Ther 2019; 36:3291-3298. [PMID: 31654332 PMCID: PMC6860506 DOI: 10.1007/s12325-019-01119-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Indexed: 12/16/2022]
Abstract
The current recommendations for the treatment of chronic obstructive pulmonary disease (COPD) are pushing towards triple combination therapy based on the combination of an inhaled corticosteroid (ICS) associated with two bronchodilator agents. However, dual bronchodilation remains the cornerstone for the treatment of most COPD patients. Combining a long-acting β2 adrenoceptor agonist (LABA) with a long-acting muscarinic antagonist (LAMA) induces appreciable synergistic bronchorelaxant effect in human airways, especially when the medications are combined at isoeffective concentrations. Thus, each LABA/LAMA combination is characterized by a specific range of concentration-ratio at which the drug mixture may induce sustained synergistic interaction. Results of a recent randomized controlled trial (RCT, NCT00696020) and evidences from pre-clinical studies in human isolated airways poses the question whether combining tiotropium 5 μg with olodaterol 5 μg is the best combination option: tiotropium/olodaterol 5/5 μg has the same efficacy profile of tiotropium/olodaterol 5/2 μg, and it is less effective than tiotropium/olodaterol 5/10 μg. Furthermore, tiotropium/olodaterol 5/2 μg, 5/5 μg, and 5/10 μg combinations are generally characterized by the same safety profile. Indeed tiotropium/olodaterol 5/5 μg is effective and safe in COPD, but a different development strategy based on solid data obtained from human isolated airways would have driven towards a better-balanced FDC to be tested in Phase III RCTs. Accurate bench-to-bedside plans are needed also in the development of triple combination therapies for asthma and COPD, in which the presence of an ICS in the formulation may further modulate the beneficial interaction between the LABA and the LAMA.
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Affiliation(s)
- Luigino Calzetta
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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84
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Zhang L, Zhang X, Li J, Beck-Broichsitter M, Muenster U, Wang X, Zhao J, Mao S. Optimization of budesonide-loaded large-porous microparticles for inhalation using quality by design approach. J Drug Deliv Sci Technol 2019. [DOI: 10.1016/j.jddst.2019.101140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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85
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Lindh A, Theander K, Arne M, Lisspers K, Lundh L, Sandelowsky H, Ställberg B, Westerdahl E, Zakrisson A. Errors in inhaler use related to devices and to inhalation technique among patients with chronic obstructive pulmonary disease in primary health care. Nurs Open 2019; 6:1519-1527. [PMID: 31660180 PMCID: PMC6805258 DOI: 10.1002/nop2.357] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/25/2019] [Accepted: 07/10/2019] [Indexed: 11/27/2022] Open
Abstract
AIM The aim of this study was to describe inhaler use in primary health care patients with chronic obstructive pulmonary disease (COPD) and to categorize these patients into those making errors related to devices, those making errors related to inhalation technique and those making errors related to both. DESIGN Observational study. METHODS COPD nurses used a checklist to assess the use of inhalers by patients with spirometry-verified COPD (N = 183) from primary healthcare centres. The STROBE checklist has been used. RESULTS The mean age of the patients was 71 (SD 9) years. Almost half of them (45%) made at least one error; of these, 50% made errors related to devices, 31% made errors related to inhalation technique and 19% made errors related both to devices and to inhalation technique.
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Affiliation(s)
- Annika Lindh
- Faculty of Medicine and Health, School of Health SciencesÖrebro UniversityÖrebroSweden
- Centre for Clinical ResearchRegion VärmlandKarlstadSweden
| | | | - Mats Arne
- Centre for Clinical ResearchRegion VärmlandKarlstadSweden
- Department of Medical Sciences, Respiratory, Allergy & Sleep ResearchUppsala UniversityUppsalaSweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive MedicineUppsala UniversityUppsalaSweden
| | - Lena Lundh
- Academic Primary Health Care CentreStockholmSweden
- Division of Family Medicine and Primary CareKarolinska Institutet, NVSStockholmSweden
| | - Hanna Sandelowsky
- Academic Primary Health Care CentreStockholmSweden
- Division of Family Medicine and Primary CareKarolinska Institutet, NVSStockholmSweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive MedicineUppsala UniversityUppsalaSweden
| | - Elisabeth Westerdahl
- Faculty of Medicine and Health, School of Health SciencesÖrebro UniversityÖrebroSweden
- Faculty of Medicine and HealthUniversity Health Care Research Centre, Örebro UniversityÖrebroSweden
| | - Ann‐Britt Zakrisson
- Faculty of Medicine and HealthUniversity Health Care Research Centre, Örebro UniversityÖrebroSweden
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86
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Dal Negro RW, Turco P, Povero M. Patients' usability of seven most used dry-powder inhalers in COPD. Multidiscip Respir Med 2019; 14:30. [PMID: 31528340 PMCID: PMC6743127 DOI: 10.1186/s40248-019-0192-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/07/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction Inhalation devices affect both the effectiveness and the therapeutic outcomes in persistent airway obstruction, and the effects are largely independent of the drug(s) assumed. Usability is a complex and comprehensive indicator of inhalation devices’ performance. The Global Usability Score (GUS) Questionnaire is an investigational tool designed to assess objectively the patients’-related and unrelated domains of devices’ usability. Methods The GUS questionnaire was administered to all consecutive COPD patients referring for three months to the Lung Unit of CEMS Specialist Centre (Verona, Italy). The usability of seven Dry Powder Inhalers (DPIs) indicated as appropriate in COPD was tested and compared: Breezhaler, Diskus, Ellipta, Genuair, Nexthaler, Spiromax, and Turbohaler. Patients were divided in two groups, checked separately, according to their DPIs previous experience. A Bayesian Indirect Comparison (IC) model was built to assess “global usability” ranking. Results A total of 103 patients were investigated: 74 patients already instructed in DPI use and 29 naive to DPIs. IC analysis proved Ellipta as the device characterized by the highest usability, while Breezhaler the device with the lowest usability in both groups of COPD patients (both with probability > 90%). Moreover, Turbohaler ranked second according to the Bayesian pooling, followed by Diskus, Spiromax, Nexthaler, and Genuair in patients already instructed in DPI use, while the ranking order was not as much well defined in naïve patients, likely due to their too small sample. Conclusions Usability is a multifaceted indicator that contributes to assess the factual DPIs’ convenience in real life. DPIs are characterized by different levels of real-life usability, which can be checked, compared and ranked by means of the GUS score. Electronic supplementary material The online version of this article (10.1186/s40248-019-0192-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roberto W Dal Negro
- National Centre for Respiratory Pharmacoeconomics and Pharmacoepidemiology, Verona, Italy
| | - Paola Turco
- Research & Clinical Governance, Verona, Italy
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87
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Park JH, Kim Y, Choi S, Jang EJ, Kim J, Lee CH, Yim JJ, Yoon HI, Kim DK. Risk for pneumonia requiring hospitalization or emergency room visit according to delivery device for inhaled corticosteroid/long-acting beta-agonist in patients with chronic airway diseases as real-world evidence. Sci Rep 2019; 9:12004. [PMID: 31427602 PMCID: PMC6700062 DOI: 10.1038/s41598-019-48355-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/02/2019] [Indexed: 12/22/2022] Open
Abstract
A fixed-dose combination of inhaled corticosteroid and long-acting beta agonist (ICS/LABA) may increase the risk of pneumonia in patients with chronic airway diseases including chronic obstructive pulmonary disease and asthma. Although lung deposition of ICS/LABA is dependent on the inhaler device and inhalation technique, there have been few studies comparing the risk for pneumonia according to the type of device used to deliver ICS/LABA in real-world practice. A retrospective cohort study was performed using the National Health Insurance Database of the Korean Health Insurance Review & Assessment Service. New users who began ICS/LABA were selected and followed-up 180 days after ICS/LABA initiation. The risk for pneumonia requiring emergency room (ER) visit or admission was compared according to inhaler device used-pressurized metered-dose inhaler (pMDI) or dry powder inhaler (DPI)-after individual exact matching (1:5). Among the eligible cohort of 245,477 new ICS/LABA users, 7,942 patients who used pMDI only were matched with 39,690 patients who used DPI only. The incidence of pneumonia was higher in the pMDI group (1.6%) than the DPI group (1.1%); the adjusted hazard ratio (HR) for pneumonia was 1.6 (95% CI 1.3-2.0; p < 0.0001). In subgroup analyses, a significantly higher risk for pneumonia was found in the pMDI group compared with the DPI group regardless of the presence of history of pneumonia (HR 1.7 [95% CI 1.2-2.3]; p = 0.002), COPD (HR 1.6 [95% CI 1.2-2.0]; p = 0.0007), or asthma (HR 1.6 [95% CI 1.2-2.2]; p = 0.0008). In analyses of real-world data, pMDI users incurred a higher risk for pneumonia requiring hospitalization or ER visit compared with DPI users.
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Affiliation(s)
- Ju-Hee Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Yunjung Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Seongmi Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
- National Health Insurance Service, Wonju, Republic of Korea
| | - Eun Jin Jang
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
- Department of Information Statistics, College of Natural Science, Andong National University, Andong, Republic of Korea
| | - Jimin Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
- Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Il Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Republic of Korea.
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea.
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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88
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Athamneh T, Amin A, Benke E, Ambrus R, Leopold CS, Gurikov P, Smirnova I. Alginate and hybrid alginate-hyaluronic acid aerogel microspheres as potential carrier for pulmonary drug delivery. J Supercrit Fluids 2019. [DOI: 10.1016/j.supflu.2019.04.013] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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89
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Matera MG, Rinaldi B, Calzetta L, Rogliani P, Cazzola M. Pharmacokinetics and pharmacodynamics of inhaled corticosteroids for asthma treatment. Pulm Pharmacol Ther 2019; 58:101828. [PMID: 31349002 DOI: 10.1016/j.pupt.2019.101828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/07/2019] [Accepted: 07/22/2019] [Indexed: 11/27/2022]
Abstract
The differences in the pharmacokinetic (PK) characteristics of inhaled corticosteroids (ICSs) critically influence the profile of each of them, but also the significant differences in glucocorticoid receptor selectivity, potency, and physicochemical properties are critical in defining the pharmacodynamic (PD) profile of an ICS. The PK and PD properties of ICSs used in asthma and the importance of their interrelationship have been reviewed. The differences among the ICSs in PK and PD must be considered when an ICS should be prescribed to an asthmatic patient because a better understanding of the PK/PD interrelationship of ICSs could be important to better fit with the between-patient variability and within-patient repeatability in the response to ICSs that often complicate the therapeutic approach to the asthmatic patient. The role of the device in influencing the PK profile of an ICS must be always considered because it is crucial. Also patient-related factors and disease severity affect pulmonary deposition of ICS.
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Affiliation(s)
- Maria Gabriella Matera
- University of Campania "Luigi Vanvitelli", Department of Experimental Medicine, Naples, Italy
| | - Barbara Rinaldi
- University of Campania "Luigi Vanvitelli", Department of Experimental Medicine, Naples, Italy
| | - Luigino Calzetta
- University of Rome "Tor Vergata", Department of Experimental Medicine, Rome, Italy
| | - Paola Rogliani
- University of Rome "Tor Vergata", Department of Experimental Medicine, Rome, Italy
| | - Mario Cazzola
- University of Rome "Tor Vergata", Department of Experimental Medicine, Rome, Italy.
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90
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Alatrash A, Mehri R, Ogrodnik N, Matida E, Fiorenza F. Experimental Study of Spiriva Respimat Soft Mist Inhaler Spray Characterization: Size Distributions and Velocity. J Aerosol Med Pulm Drug Deliv 2019; 32:293-302. [PMID: 31259646 DOI: 10.1089/jamp.2018.1501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Respiratory illnesses such as asthma, bronchitis, and chronic obstructive pulmonary disease (COPD) are considered to be debilitating diseases. A variety of inhalation devices have been used to deliver aerosol medication to patients in the treatment of those diseases. Soft Mist Inhalers (SMIs, for example, the Spiriva Respimat) are a new generation of propellant-free inhalers. In this type of inhalation device, inhalable droplets are generated from an aqueous solution. Droplet size and velocity are two of the most substantial factors that impact the deposition of SMI aerosol medication into the patient lungs. Methods: In this study, size and velocity of droplets generated from the Spiriva Respimat inhaler were measured using phase Doppler anemometry (PDA). Measurements were taken at four locations along the centerline of the Spiriva Respimat inhaler, in addition to three cross sections (free-spray configuration). In addition, measurements were also performed at a single cross section in confined spray configurations using two separate idealized mouth cavities. Results and Conclusions: Measurements along the centerline of the aerosol mist generated using the Spiriva Respimat inhaler (6.5, 25, 100, and 125 mm downstream of the inhaler nozzle' orifice) showed that droplets at the mouthpiece have the highest velocity of 10.95 m/s, decreasing to 1.33 m/s at the 125 mm location away from the nozzle. The mean diameter D10 values ranged from 3.97 to 3.67 μm at 6.5 and 125 mm locations, respectively. In addition, of the three probability density functions (PDFs) that were tested, the log-normal PDF showed better curve fitting for the empirical data (droplet size distributions) that were measured. The effect of spray confinement using two idealized mouth cavities shows that there was a drop in the particles' velocity for both models on each axes compared with the open-air environment (free-spray configuration).
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Affiliation(s)
- Abubaker Alatrash
- Department of Mechanical & Aerospace Engineering, Carleton University, Ottawa, Canada
| | - Rym Mehri
- Department of Mechanical & Aerospace Engineering, Carleton University, Ottawa, Canada
| | - Nicholas Ogrodnik
- Department of Mechanical & Aerospace Engineering, Carleton University, Ottawa, Canada
| | - Edgar Matida
- Department of Mechanical & Aerospace Engineering, Carleton University, Ottawa, Canada
| | - Frank Fiorenza
- Product Development, McArthur Medical Sales, Inc., Rockton, Canada.,Respiratory Therapy Department, University of Ottawa Heart Institute, Ottawa, Canada
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91
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D'Urzo A, Chapman KR, Donohue JF, Kardos P, Maleki-Yazdi MR, Price D. Inhaler Devices for Delivery of LABA/LAMA Fixed-Dose Combinations in Patients with COPD. Pulm Ther 2019; 5:23-41. [PMID: 32026426 PMCID: PMC6967354 DOI: 10.1007/s41030-019-0090-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Indexed: 02/07/2023] Open
Abstract
Inhaled fixed-dose combinations (FDCs) of a long-acting β-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) have become the cornerstone for the maintenance treatment of symptomatic COPD patients. In this regard, global COPD treatment guidelines have recognized the importance of inhaler devices as integral contributors to the effectiveness of LABA/LAMA FDCs and recommend regular assessment of inhaler device use by the patients in order to improve long-term clinical outcomes. Optimal disease control is also highly dependent upon patient preferences and adherence to inhaler devices. This review objectively examines and compares the major inhaler devices used to deliver different LABA/LAMA FDCs, discusses the inhaler device characteristics that determine drug deposition in the airways, real-life preference for inhaler devices, and handling of inhaler devices that impact the results of the long-term management of COPD. The introduction of new LABA/LAMA FDCs, new inhaler devices, and more clinical studies have created confusion among physicians in choosing the optimal inhaled therapy for COPD patients; in this context, this review attempts to provide an evidence-based framework for informed decision-making with a particular focus on the inhaler devices.Funding. The preparation of this manuscript was funded by Novartis Pharma AG.
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Affiliation(s)
- Anthony D'Urzo
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Kenneth R Chapman
- Asthma and Airway Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - James F Donohue
- Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Peter Kardos
- Group Practice and Centre for Allergy, Respiratory and Sleep Medicine, Red Cross Maingau Hospital, Frankfurt, Germany
| | - M Reza Maleki-Yazdi
- Division of Respiratory Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore, Singapore
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92
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Calzetta L, Rogliani P, Page C, Rinaldi B, Cazzola M, Matera MG. Pharmacological characterization of the interaction between tiotropium bromide and olodaterol on human bronchi and small airways. Pulm Pharmacol Ther 2019; 56:39-50. [DOI: 10.1016/j.pupt.2019.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/08/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022]
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93
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Li C, Cheng W, Guo J, Guan W. Relationship of inhaled long-acting bronchodilators with cardiovascular outcomes among patients with stable COPD: a meta-analysis and systematic review of 43 randomized trials. Int J Chron Obstruct Pulmon Dis 2019; 14:799-808. [PMID: 31114181 PMCID: PMC6489598 DOI: 10.2147/copd.s198288] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/22/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Long-acting muscarinic antagonists (LAMAs) and long-acting β2–agonists (LABAs) are the mainstay of maintenance therapy for chronic obstructive pulmonary disease (COPD). Although previous studies have supported inhaled long-acting bronchodilators (ILABs) for overall cardiovascular safety, the risk of specific cardiovascular outcomes such as arrhythmia, heart failure and stroke is still unknown. Materials and methods: We systematically searched from PubMed, the Embase database and the Cochrane Library for published studies on ILABs and COPD, from its inception to November 10, 2018, with no language restrictions. The RRs and corresponding 95% CIs were pooled to evaluate ILAB/placebo. Results: Finally, 43 randomized controlled trials were included. Compared with placebo, ILABs do not increase the risk of overall and specific cardiovascular adverse events (AEs); on the contrary, they can reduce the incidence of hypertension (RR 0.73, 95% CI 0.55–0.98;I219.9%; P= 0.221). However, when stratified according to the specific agents of ILABs, olodaterol might reduce the risk of overall cardiovascular adverse events (OCAEs) (RR 0.65, 95% CI 0.49–0.88;I227.5%; P= 0.000), and the protective effect of lowing blood pressure disappeared. Similarly, the use of inhaled LABA might increase the risk of cardiac failure (RR 1.71, 95% CI 1.04–2.84;I20%; P= 0.538), but this risk disappeared when stratified according to the specific agents of LABA. Besides, formoterol might decrease the risk of cardiac ischemia (RR 0.53, 95% CI 0.32–0.91; I20%; P= 0.676). Conclusions: Overall, the use of ILABs was not associated with overall cardiovascular AEs in patients with stable COPD. When stratified according to the specific agents of LABA, olodaterol might reduce the risk of OCAE; and formoterol might decrease the risk of cardiac ischemia. LABA might reduce the incidence of hypertension, but might increase the risk of heart failure. Therefore, COPD patients with a history of heart failure should use it with caution.
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Affiliation(s)
- Chenxi Li
- Department of Respiratory, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
| | - Wenke Cheng
- Department of Cardiology, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
| | - Jin Guo
- Department of Respiratory, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
| | - Wei Guan
- Department of Respiratory, Affiliated Hospital of Qinghai University, Xining, People's Republic of China
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94
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Handling forces for the use of different inhaler devices. Int J Pharm 2019; 560:315-321. [DOI: 10.1016/j.ijpharm.2019.01.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/23/2019] [Accepted: 01/25/2019] [Indexed: 11/22/2022]
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95
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Price DB, Yang S, Ming SWY, Hardjojo A, Cabrera C, Papaioannou AI, Loukides S, Kritikos V, Bosnic-Anticevich SZ, Carter V, Dorinsky PM. Physiological predictors Of peak inspiRatory flow using Observed lung function resultS (POROS): evaluation at discharge among patients hospitalized for a COPD exacerbation. Int J Chron Obstruct Pulmon Dis 2018; 13:3937-3946. [PMID: 30587952 PMCID: PMC6296178 DOI: 10.2147/copd.s174371] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Peak inspiratory flow (PIF) as generated through the resistance of a dry powder inhaler (DPI) device is a critical patient-dependent maneuver impacting the success of DPI medication delivery. Despite its importance, it is not routinely measured in clinical practice. Little is currently known about the relationship, if any, between PIF through DPI devices, routine spirometry and disease outcomes. Aim The aim of this study was to identify potential predictors of PIF for different DPIs from spirometric parameters and patient characteristics and explore the association between PIF and follow-up events. Patients and methods A retrospective observational study at discharge among patients hospitalized for a COPD exacerbation at Attikon hospital, Athens, Greece. Spirometry was performed using an Easy on-PC™ spirometer. PIF was measured through four DPI resistances using the In-Check™ DIAL. Regression analyses were used to investigate the association between PIF through resistances and spirometric parameters obtained at discharge, comorbidities and demographic parameters. Results Forty-seven COPD patients (mean [±SD], age 71 [±9] years, 72% males, 51% current smokers) were included in this study. Overall, 85% and 15% were classified as GOLD (2017) groups D and C, respectively. Most prevalent comorbidities were hypertension (70%) and cardiovascular disease (53%). In the final regression model, higher PIF was significantly associated with the following: higher FEV1 and % predicted peak expiratory flow (PEF) for Turbohaler® (R-squared value 0.374); higher FEV1 and diagnosis of gastroesophageal reflux disease (GERD) for Aerolizer® (R-squared value 0.209) and higher FEV1, younger age and diagnosis of ischemic heart disease (IHD) for Diskus® (R-squared value 0.350). However, R-squared values for all three devices were weak (<0.4). Conclusion The study did not provide evidence to support the use of surrogate measurements for PIF through device resistance, which could assist in determining the appropriateness of inhaler device type. Although PIF measurement is feasible in patients at discharge and could be a valuable addition to the standard of care in COPD management, it needs to be measured directly.
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Affiliation(s)
- David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore, .,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK,
| | - Sen Yang
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore,
| | - Simon Wan Yau Ming
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore,
| | - Antony Hardjojo
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore,
| | - Claudia Cabrera
- Global Medical Affairs, AstraZeneca R and D, Mölndal, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Andriana I Papaioannou
- 2nd Respiratory Medicine Department, Medical School, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, Medical School, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - Vicky Kritikos
- Woolcock Institute of Medical Research, Quality Use of Respiratory Medicines Group, School of Medical Sciences, University of Sydney, Glebe, Australia
| | - Sinthia Z Bosnic-Anticevich
- Woolcock Institute of Medical Research, Quality Use of Respiratory Medicines Group, School of Medical Sciences, University of Sydney, Glebe, Australia
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96
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Matera MG, Rinaldi B, Page C, Rogliani P, Cazzola M. Pharmacokinetic considerations concerning the use of bronchodilators in the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Metab Toxicol 2018; 14:1101-1111. [DOI: 10.1080/17425255.2018.1530215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Barbara Rinaldi
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King’s College London, London, UK
| | - Paola Rogliani
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
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97
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Rogliani P, Calzetta L, Braido F, Cazzola M, Clini E, Pelaia G, Rossi A, Scichilone N, Di Marco F. LABA/LAMA fixed-dose combinations in patients with COPD: a systematic review. Int J Chron Obstruct Pulmon Dis 2018; 13:3115-3130. [PMID: 30323582 PMCID: PMC6174911 DOI: 10.2147/copd.s170606] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the current evidence for long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combinations (FDCs) in the treatment of COPD. MATERIALS AND METHODS A systematic literature search of randomized controlled trials published in English up to September 2017 of LABA/LAMA FDCs vs LABA or LAMA or LABA/inhaled corticosteroid (ICS) FDCs in COPD patients was performed using PubMed, Embase, Scopus, and Google Scholar. Outcomes including forced expiratory volume in 1 second (FEV1), Transition Dyspnea Index (TDI) scores, St George's Respiratory Questionnaire (SGRQ) scores, exacerbations, exercise tolerance (endurance time [ET]), inspiratory capacity (IC), and rescue medication use were evaluated. RESULTS In total, 27 studies were included in the review. LABA/LAMA FDCs significantly improved lung function (FEV1) at 12 weeks compared with LABA or LAMA or LABA/ICS. These effects were maintained over time. Significant improvements with LABA/LAMA FDCs vs each evaluated comparator were also observed in TDI and SGRQ scores, even if significant differences between different LABA/LAMA FDCs were detected. Only the LABA/LAMA FDC indacaterol/glycopyrronium has shown superiority vs LAMA and LABA/ICS for reducing exacerbation rates, while olodaterol/tiotropium and indacaterol/glycopyrronium have been shown to improve ET and IC vs the active comparators. Rescue medication use was significantly reduced by LABA/LAMA FDCs vs the evaluated comparators. LABA/LAMA FDCs were safe, with no increase in the risk of adverse events with LABA/LAMA FDCs vs the monocomponents. CONCLUSION Evidence supporting the efficacy of LABA/LAMA FDCs for COPD is heterogeneous, particularly for TDI and SGRQ scores, exacerbation rates, ET, and IC. So far, indacaterol/glycopyrronium is the LABA/LAMA FDC that has the strongest evidence for superiority vs LABA, LAMA, and LABA/ICS FDCs across the evaluated outcomes. LABA/LAMA FDCs were safe; however, more data should be collected in a real-world setting to confirm their safety.
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Affiliation(s)
- Paola Rogliani
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy,
| | - Luigino Calzetta
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy,
| | - Fulvio Braido
- Department of Internal Medicine, IRCCS San Martino Genoa University Hospital, Genoa, Italy
| | - Mario Cazzola
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy,
| | - Enrico Clini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Girolamo Pelaia
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, Magna Græcia University, Catanzaro, Italy
| | - Andrea Rossi
- Pulmonary Unit, University of Verona, Verona, Italy
| | - Nicola Scichilone
- Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università degli Studi di Milano, Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
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98
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Wallin M, Tagami T, Chen L, Yang M, Chan HK. Pulmonary drug delivery to older people. Adv Drug Deliv Rev 2018; 135:50-61. [PMID: 29197631 DOI: 10.1016/j.addr.2017.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 12/20/2022]
Abstract
Pulmonary diseases, such as asthma and chronic obstructive pulmonary disease (COPD), are common in older people. Treatment principles are well established in this group of patients; however, inadequate training and improper inhaler techniques often results in poor treatment outcomes. Healthcare professionals often do not have the required knowledge about the most common inhaler devices. Age-related conditions like cognitive ability and physical strength would also impact on the inhaler usage. Pharmacokinetics and pharmacodynamics may be affected by physiological changes, like impaired renal and hepatic functions and reduced lung functions. Adjusting and optimizing the inhaler device to the patient preferences, improvement of the drug formulation and inhalers, and using different adherence strategies might improve the treatment outcomes in elderly patients.
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99
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Xu PY, Kankala RK, Pan YJ, Yuan H, Wang SB, Chen AZ. Overcoming multidrug resistance through inhalable siRNA nanoparticles-decorated porous microparticles based on supercritical fluid technology. Int J Nanomedicine 2018; 13:4685-4698. [PMID: 30154654 PMCID: PMC6103603 DOI: 10.2147/ijn.s169399] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In recent times, the co-delivery therapeutics have garnered enormous interest from researchers in the treatment of cancers with multidrug resistance (MDR) due to their efficient delivery of multiple agents, which result in synergistic effects and capable of overcoming all the obstacles of MDR in cancer. However, an efficient delivery platform is required for the conveyance of diverse agents that can successfully devastate MDR in cancer. METHODS Initially, short-interfering RNA-loaded chitosan (siRNA-CS) nanoparticles were synthesized using the ionic gelation method. Further, the siRNA-CS nanoparticles and doxorubicin hydrochloride (DOX) were co-loaded in poly-L-lactide porous microparticles (PLLA PMs) (nano-embedded porous microparticles, [NEPMs]) by the supercritical anti-solvent (SAS) process. RESULTS AND DISCUSSION The NEPM formulation exhibited an excellent aerodynamic performance and sustained release of DOX, which displayed higher anticancer efficacy in drug-resistant cells (human small cell lung cancer, H69AR cell line) than those treated with either free DOX and DOX-PLLA PMs due to the siRNA from CS nanoparticles silenced the MDR gene to DOX therapy. CONCLUSION This eco-friendly process provides a convenient way to fabricate such innovative NEPMs co-loaded with a chemotherapeutic agent and a gene, which can devastate MDR in cancer through the co-delivery system.
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Affiliation(s)
- Pei-Yao Xu
- College of Chemical Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, P. R. China,
| | - Ranjith Kumar Kankala
- College of Chemical Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Fujian Provincial Key Laboratory of Biochemical Technology (Huaqiao University), Xiamen 361021, P. R. China,
| | - Yu-Jing Pan
- College of Chemical Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, P. R. China,
| | - Hui Yuan
- College of Chemical Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, P. R. China,
| | - Shi-Bin Wang
- College of Chemical Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Fujian Provincial Key Laboratory of Biochemical Technology (Huaqiao University), Xiamen 361021, P. R. China,
| | - Ai-Zheng Chen
- College of Chemical Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Institute of Biomaterials and Tissue Engineering, Huaqiao University, Xiamen 361021, P. R. China,
- Fujian Provincial Key Laboratory of Biochemical Technology (Huaqiao University), Xiamen 361021, P. R. China,
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100
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Dosing challenges in respiratory therapies. Int J Pharm 2018; 548:659-671. [PMID: 30033395 DOI: 10.1016/j.ijpharm.2018.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/20/2018] [Accepted: 07/01/2018] [Indexed: 01/16/2023]
Abstract
The pulmonary route of administration has been commonly used for local lung conditions such as asthma and chronic obstructive pulmonary disease (COPD). Recently, with the advent of new technologies available for both formulation and device design, molecules usually delivered at high doses, such as antibiotics and insulin to treat cystic fibrosis (CF) and diabetes, respectively, can now be delivered by inhalation as a dry powder. These molecules are generally delivered in milligrams instead of traditional microgram quantities. High dose delivery is most commonly achieved via dry powder inhalers (DPIs), breath activated devices designed with a formulated powder containing micronized drug with aerodynamic diameters between 1 and 5 µm. The powder formulation may also contain other excipients and/or carrier particles to improve the flowability and aerosol dispersion of the powder. A drawback with high doses is that the formulation contains a great number of fine particles, leading to a greater degree of cohesive forces, producing strongly bound agglomerates. With greater cohesive forces holding fine particles together, higher dispersion forces are needed for efficient de-agglomeration and aerosolisation. This requirement of greater dispersion forces has led to different dry powder formulations and vastly different inhaler designs. The purpose of this review is to evaluate the different formulation types, various DPI devices currently available, and how these affect the aerosolisation process and delivery of high dosed inhalable dry powder formulations to the lungs.
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