1
|
Vartiainen V, Woodcock AA, Wilkinson A, Janson C, Björnsdóttir U, Haahtela T, Lehtimäki L. Thoughtful prescription of inhaled medication has the potential to reduce inhaler-related greenhouse gas emissions by 85. BMJ Open Respir Res 2024; 11:e001782. [PMID: 39222967 DOI: 10.1136/bmjresp-2023-001782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/28/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Both physicians and patients are increasingly aware of the environmental impacts of medication. The shift of treatment paradigm towards MART-treatment (Maintenance and Reliever Therapy) in asthma affects the treatment-related emissions. The carbon footprint of inhaled medication is also tied to the type of the device used. Today the most commonly used propellant-containing pressurised metered-dose inhalers (pMDIs) have a carbon footprint typically 20-40-fold higher than propellant-free dry powder inhalers (DPIs) and soft mist inhalers. METHODS We analysed the carbon footprint of inhaled medications in Europe using published life cycle analyses of marketed inhalers and comprehensive 2020 European sales data. In addition, we give an estimate on treatment-related emissions of different treatment regimens on Global Initiative for Asthma (GINA) step 2. RESULTS There is potential to reduce the carbon footprint of inhaled medications by 85% if DPIs are preferred over pMDIs. Emissions from pMDIs in the EU were estimated to be 4.0 megatons of carbon dioxide equivalent (MT CO2e) and this could be reduced to 0.6 MT CO2e if DPIs were used instead. In the treatment of moderate asthma with DPI, an as-needed combination of inhaled corticosteroid and long-acting beta-agonist in a single inhaler had a substantially lower annual carbon footprint (0.8 kg CO2e) than the more traditional maintenance therapy with an inhaled corticosteroid alone with as-needed short-acting beta-agonist (2.9 kg CO2e). DISCUSSION There has been an urgent call for healthcare to reduce its carbon footprint for appropriate patients with asthma and chronic obstructive pulmonary disease (COPD), changing to non-propellant inhalers can reduce the carbon footprint of their treatment by almost 20-fold.
Collapse
Affiliation(s)
- Ville Vartiainen
- Department of Pulmonary Medicine, Helsinki University Hospital Heart and Lung Center, Helsinki, Finland
| | - Ashley A Woodcock
- University NHS Foundation Trust, UK, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Alex Wilkinson
- Respiratory Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Unnur Björnsdóttir
- Department of Allergy and Pulmonary Medicine, University Hospital Iceland, Reykjavik, Iceland
| | - Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland
| |
Collapse
|
2
|
Thalberg K, Matilainen L, Heinonen E, Eriksson P, Husman-Piirainen J, Autio M, Lyberg AM, Göransson S, Kirjavainen M, Lähelmä S. Mixing energy as an adjustment tool for aerodynamic behaviour of an inhaled product: In-vitro and in-vivo effects. Int J Pharm 2024; 651:123755. [PMID: 38163524 DOI: 10.1016/j.ijpharm.2023.123755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/03/2024]
Abstract
This paper describes the development of a fixed dose dry powder combination of indacaterol maleate (Inda) and glycopyrronium bromide (Glyco) in Easyhaler® inhaler for a comparative pharmacokinetic (PK) study, as well as the outcome of such a study. The development aim was to produce formulations with three different in vitro dispersibility profiles for both Inda and Glyco. This so-called 'rake' approach allows for quantitation of the candidate formulations relative to the reference product Ultibro® Breezhaler® in terms of the key PK parameters. Three formulations (A, B and C) were produced based on the mixing energy concept. For both APIs, formulation A (lowest mixing energy) displayed the highest fine particle fractions and formulation C (highest mixing energy) the lowest. GMP manufacturing confirmed the performance of the three formulations. The candidate formulations were tested against the reference product in a single dose PK study in healthy volunteers. Clear differences in Inda plasma concentration profiles were observed between the treatments when administered concomitantly with charcoal, with Easyhaler A showing the highest Cmax value and Easyhaler C the lowest. Easyhaler B was bioequivalent to Ultibro Breezhaler with regard to the primary PK parameters of Inda, Cmax and AUC72h. For Glyco, Easyhaler formulations A, B and C provided lower peak concentrations than Ultibro Breezhaler. For AUC72h of Glyco, Easyhaler B was bioequivalent to the reference product. Additional measures for adjustment of formulation performance can be foreseen, whose effects can be predicted based on mixing energy theory.
Collapse
Affiliation(s)
- Kyrre Thalberg
- Dept of Food Technology, Engineering and Nutrition, Lund University, Lund, Sweden; Emmace Consulting AB, Lund, Sweden.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Narrative Review of the Role of Patient-Reported Outcomes and Inhaler Handling Errors in the Control of Asthma and COPD. Curr Allergy Asthma Rep 2022; 22:151-161. [PMID: 36087251 PMCID: PMC9532287 DOI: 10.1007/s11882-022-01041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 12/02/2022]
Abstract
Purpose of Review Asthma and chronic obstructive pulmonary disease (COPD) are chronic respiratory diseases that remain uncontrolled in many patients, despite the wide range of therapeutic options available. This review analyzes the available clinical evidence on 3 budesonide/formoterol DPI devices, Spiromax®, Turbuhaler®, and Easyhaler®, in terms of patient-reported outcomes (PROs), inhaler errors, and asthma and COPD control. Recent Findings The effectiveness of dry powder inhalers (DPI) depends largely on the device and the patient’s inhaler technique. Equally important are the patient’s perception of the inhaler and adherence. Given the high burden of these diseases, it is important that efforts be made to select the best DPI for each patient and to analyze the impact of these variables to help improve the health and quality of life of our patients. Summary This review provides a comprehensive overview of the present knowledge about PROs, inhaler handling errors, and asthma and COPD control achieved by Spiromax®, Turbuhaler®, and Easyhaler®.
Collapse
|
4
|
Bickhardt J, Czupalla C, Bader U. [Reduction of greenhouse gas emissions by inhaler choice in the therapy of asthma and COPD patients]. Pneumologie 2022; 76:321-329. [PMID: 35453159 DOI: 10.1055/a-1771-5292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The global warming potential of inhaled medication depends on the applied inhaler. Pressurised metered dose inhalers (pMDI) contain green-house gases (GHG) and are associated with a 10 to 40 times higher CO2-footprint than GHG-free dry-powder inhalers (DPI). AIM Feasibility and relevance of prescription conversion from pMDI to DPI were investigated in a pulmonology outpatient clinic regarding the CO2-footprint and the economic costs under real-world conditions. METHODS Based on exemplary therapy regimens of different intensity for three patients, the annual CO2-footprint and daily therapy costs were investigated. The effect of converting from pMDI to DPI on CO2-footprint and economic costs were calculated on the basis of prescriptions during the first quarter of 2020 compared to the first quarter of 2021. RESULTS Conversion of a pMDI-based inhalative therapy of exemplary asthma and COPD patients to a DPI-based therapy saved between 115 and 480 kg CO2 equivalents (CO2e) per year and patient depending on intensity of therapy and GHG used. A total of 184,297 and 164,165 defined daily doses (DDD) were prescribed by the clinic for 2,610 (January-March 2020) and 2,693 (January-March 2021) patients, respectively. The proportion of DPI prescribed increased from 49 to 78% of total inhaler prescriptions. The increase in prescriptions for single-agent inhaled corticosteroids from 19.8 to 74.1% of total inhaler prescriptions was particularly striking. Due to the conversion, emissions were reduced by 35,000 to 40,000 kg CO2e between January-March 2020 and January-March 2021 in our clinic. During the same period, there was no increase in costs compared to nationwide costs. The relation of prescribed DPI and pMDI in the same period did not change among the pulmonologists in Saxony nor nationwide in Germany. If all ambulant pulmonologists in Germany would prescribe 75% DPI, CO2-emissions could be reduced by 11,650 tonnes CO2e per quarter and 46,600 tonnes CO2e per year, respectively. CONCLUSION The type of inhalers can be converted from pMDI to DPI in a real-world setting. Thereby, a significant reduction of GHG emissions is possible without increased costs.
Collapse
Affiliation(s)
- Jakob Bickhardt
- Pneumologische Gemeinschaftspraxis Dres. Bickhardt/Bader, Dresden, Germany
| | - Cornelia Czupalla
- Verordnungs- und Prüfwesen, Kassenärztliche Vereinigung Sachsen, Dresden, Germany
| | - Uta Bader
- Pneumologische Gemeinschaftspraxis Dres. Bickhardt/Bader, Dresden, Germany
| |
Collapse
|
5
|
Lavorini F, Chudek J, Gálffy G, Pallarés-Sanmartin A, Pelkonen AS, Rytilä P, Syk J, Szilasi M, Tamási L, Xanthopoulos A, Haahtela T. Switching to the Dry-Powder Inhaler Easyhaler ®: A Narrative Review of the Evidence. Pulm Ther 2021; 7:409-427. [PMID: 34581994 PMCID: PMC8477976 DOI: 10.1007/s41030-021-00174-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/07/2021] [Indexed: 02/07/2023] Open
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are major causes of morbidity and mortality worldwide. Optimal control of these conditions is a constant challenge for both physicians and patients. Poor inhaler practice is widespread and is a substantial contributing factor to the suboptimal clinical control of both conditions. The practicality, dependability, and acceptability of different inhalers influence the overall effectiveness and success of inhalation therapy. In this paper, experts from various European countries (Finland, Germany, Hungary, Italy, Poland, Spain, and Sweden) address inhaler selection with special focus on the Easyhaler® device, a high- or medium–high resistance dry-powder inhaler (DPI). The evidence examined indicates that use of the Easyhaler is associated with effective control of asthma or COPD, as shown by the generally accepted indicators of treatment success. Moreover, the Easyhaler is widely accepted by patients, is reported to be easy to learn and teach, and is associated with patient adherence. These advantages help patient education regarding correct inhaler use and the rational selection of drugs and devices. We conclude that switching inhaler device to the Easyhaler may improve asthma and COPD control without causing any additional risks. In an era of climate change, switching from pressurized metered-dose inhalers to DPIs is also a cost-effective way to reduce emissions of greenhouse gases. Enhanced feature (slides, video, animation) (MP4 43768 kb)
Collapse
Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland
| | | | | | - Anna S Pelkonen
- Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Paula Rytilä
- Global Medical Affairs, R&D, Orion Pharma, PO Box 65, 02101, Espoo, Finland.
| | - Jörgen Syk
- Academic Primary Health Care Centre, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Szilasi
- National Koranyi Institute of Pulmonology, Budapest, Hungary
| | - Lilla Tamási
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | - Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
6
|
Alvarez-Gutiérrez FJ, Gómez-Bastero Fernández A, Medina Gallardo JF, Campo Sien C, Rytilä P, Delgado Romero J. Preference for Easyhaler ® Over Previous Dry Powder Inhalers in Asthma Patients: Results of the DPI PREFER Observational Study. Patient Prefer Adherence 2021; 15:349-358. [PMID: 33628015 PMCID: PMC7897861 DOI: 10.2147/ppa.s295710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/30/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To study patient preference for and satisfaction with the Easyhaler® device and to assess ease of training and use of the inhaler in patients previously treated with a variety of dry powder inhalers (DPIs). METHODS We designed a non-interventional, cross-sectional, single-visit observational study of adult patients with persistent asthma referred to specialized care who had previously been treated with DPI inhalers for at least 3 months. Once clinical baseline data had been checked, patients filled in questionnaires on asthma control (GINA 2019), Feeling of Satisfaction with the Inhaler (FSI-10), and adherence (TAI and Morisky-Green questionnaires). Thereafter, all patients were trained in the use of Easyhaler. We assessed ease of use and satisfaction (FSI-10) with Easyhaler, as well as inhaler device preferences. RESULTS We recruited 502 patients (mean age, 50.2 ± 16.2 y; 63.1% female), of whom 485 were evaluable. In response to the main objective of the study, we compared the values of the self-completed adapted FSI-10, to measure satisfaction with the inhaler. A significantly higher score in each item of the questionnaire was recorded for Easyhaler. Overall, 38% of patients showed exclusive preference for Easyhaler (compared with 15% for the previous device) or were evenly matched in 46% of cases. CONCLUSION In the present study, Easyhaler achieved better patient ratings in terms of preference and satisfaction than previously used DPI devices. In order to improve asthma adherence strategies, patient preferences and device choice should be taken into account.
Collapse
Affiliation(s)
- Francisco Javier Alvarez-Gutiérrez
- Unidad de Asma, Hospital Universitario Virgen del Rocio, Sevilla, Spain
- Correspondence: Francisco Javier Alvarez-Gutiérrez Unidad de Asma, Hospital Universitario Virgen del Rocio, Av. Manuel Siurot, S/n, Sevilla, 41013, Spain Email
| | | | | | | | | | | |
Collapse
|
7
|
Zhu RF, Gao YL, Robert SH, Gao JP, Yang SG, Zhu CT. Systematic review of the registered clinical trials for coronavirus disease 2019 (COVID-19). J Transl Med 2020; 18:274. [PMID: 32631442 PMCID: PMC7338108 DOI: 10.1186/s12967-020-02442-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Since the outbreak of coronavirus disease 2019 (COVID-19), many researchers in China have performed related clinical research. However, systematic reviews of the registered clinical trials are still lacking. Therefore, we conducted a systematic review of clinical trials for COVID-19 to summarize their characteristics. METHODS This study is based on the PRISMA recommendations in the Cochrane handbook. The Chinese Clinical Registration Center and the ClinicalTrials.gov databases were searched to identify registered clinical trials related to COVID-19. The retrieval inception date was February 9, 2020. Two researchers independently selected the literature based on the inclusion and exclusion criteria, extracted data, and evaluated the risk of bias. RESULTS A total of 75 registered clinical trials (63 interventional studies and 12 observational studies) for COVID-19 were identified. The majority of clinical trials were sponsored by Chinese hospitals. Only 11 trials have begun to recruit patients, and none of the registered clinical trials have been completed; 34 trials were early clinical exploratory trials or in the pre-experiment stage, 13 trials were phase III, and four trials were phase IV. The intervention methods included traditional Chinese medicine in 26 trials, Western medicine in 30 trials, and integrated traditional Chinese medicine and Western medicine in 19 trials. The subjects were primarily non-critical adult patients (≥ 18 years old). The median sample size of the trials was 100 (IQR: 60-200), and the median length of the trial periods was 179 d (IQR: 94-366 d). The main outcomes were clinical observation and examinations. Overall, the methodological quality of both the interventional trials and observational studies was low. CONCLUSIONS Intensive clinical trials on the treatment of COVID-19 using traditional Chinese medicine and Western medicine are ongoing or will be performed in China. However, based on the uncertain methodological quality, small sample size, and long trial duration, we will not be able to obtain reliable, high-quality clinical evidence regarding the treatment of COVID-19 in the near future. Improving the quality of study design, prioritizing promising drugs, and using different designs and statistical methods are worth advocating and recommending for clinical trials of COVID-19 in the future.
Collapse
Affiliation(s)
- Rui-Fang Zhu
- Editorial Department, First Hospital of Shanxi Medical University, No 85 Jiefang South Road, Taiyuan, Shanxi, China.
| | - Yu-Lu Gao
- Department of Laboratory Medicine, Kunshan Hospital Affiliated To Nanjing University of Traditional Chinese Medicine, Kunshan, Jiangsu, China
| | - Sue-Ho Robert
- Infection Service, University Hospital of Coventry and Warwickshire (UHCW) NHS Trust, Coventry, UK
| | - Jin-Ping Gao
- Editorial Department, First Hospital of Shanxi Medical University, No 85 Jiefang South Road, Taiyuan, Shanxi, China
| | - Shi-Gui Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chang-Tai Zhu
- Department of Transfusion Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No 600 Yishan Road, Shanghai, 200233, China.
| |
Collapse
|
8
|
Lehtimäki L, Björnsdóttir U, Janson C, Haahtela T. Minimising the environmental impact of inhaled therapies. Eur Respir J 2020; 55:55/5/2000721. [PMID: 32461339 DOI: 10.1183/13993003.00721-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/29/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Unnur Björnsdóttir
- Dept of Respiratory Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Christer Janson
- Dept of Medical Sciences, Respiratory, Allergy and Sleep Research Uppsala University, Uppsala, Sweden
| | - Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| |
Collapse
|