Real-World Impact of Nonclinical Inhaler Regimen Switches on Asthma or COPD: A Systematic Review

Pharmaceutical, Clinical, and Regulatory Challenges of Reformulating Pressurized Metered-Dose Inhalers to Reduce Their Environmental Impact

The chlorofluorocarbons (CFCs) that were used as propellants in early pressurized metered-dose inhalers (pMDIs) had substantial ozone-depleting potential. Following the Montreal Protocol in 1987, the manufacture of a range of ozone-depleting substances, including CFCs, was gradually phased out, which required the propellants used in pMDIs to be replaced. Current pMDIs use hydrofluoroalkanes (HFAs) as propellants, such as 1,1,1,2-tetrafluoroethane (HFA-134a). Although these HFAs have no ozone-depleting potential, they have a high global warming potential (GWP), and consequently, their use is being phased down. One option for the discontinuation of HFA use in inhalers would be to discontinue all pMDIs, switching patients to dry powder inhalers (DPIs). However, a switch from pMDIs to DPIs may not be a clinically appropriate option for some patients; furthermore, the full lifecycle carbon footprint and the overall environmental impact of different inhalers should be considered. An alternative is therefore to reformulate the current HFA pMDIs to use low-GWP propellants, such as 1,1-difluoroethane (HFA-152a). This article summarizes the various steps and challenges associated with this change, illustrated using data from the inhaled triple combination of beclomethasone dipropionate, formoterol fumarate, and glycopyrronium bromide, a complex formulation of three molecules in a solution that contains liquid-phase propellant.

The carbon footprint of as-needed budesonide/formoterol in mild asthma: a post hoc analysis

INTRODUCTION

The use of pressurised metered-dose inhalers (pMDIs) and asthma exacerbations necessitating healthcare reviews contribute substantially to the global carbon footprint of healthcare. It is possible that a reduction in carbon footprint could be achieved by switching patients with mild asthma from salbutamol pMDI reliever-based therapy to inhaled corticosteroid-formoterol dry powder inhaler (DPI) reliever therapy, as recommended by the Global Initiative for Asthma.

METHODS

This post hoc analysis included all 668 adult participants in the Novel START trial, who were randomised 1:1:1 to treatment with as-needed budesonide/formoterol DPI, as-needed salbutamol pMDI or maintenance budesonide DPI plus as-needed salbutamol pMDI. The primary outcome was carbon footprint of asthma management, expressed as kilograms of carbon dioxide equivalent emissions (kgCO2e) per person-year. Secondary outcomes explored the effect of baseline symptom control and adherence (maintenance budesonide DPI arm only) on carbon footprint.

RESULTS

As-needed budesonide/formoterol DPI was associated with 95.8% and 93.6% lower carbon footprint compared with as-needed salbutamol pMDI (least-squares mean 1.1 versus 26.2 kgCO2e; difference -25.0, 95% CI -29.7 to -20.4; p<0.001) and maintenance budesonide DPI plus as-needed salbutamol pMDI (least-squares mean 1.1 versus 17.3 kgCO2e; difference -16.2, 95% CI -20.9 to -11.6; p<0.001), respectively. There was no statistically significant evidence that treatment differences in carbon footprint depended on baseline symptom control or adherence in the maintenance budesonide DPI arm.

CONCLUSIONS

The as-needed budesonide/formoterol DPI treatment option was associated with a markedly lower carbon footprint than as-needed salbutamol pMDI and maintenance budesonide DPI plus as-needed salbutamol pMDI.

Environmental, healthcare and societal impacts of asthma: a UK model-based assessment

Background

This study aimed to assess the broader environmental, healthcare and societal impacts across the entire asthma pathway from diagnosis to treatment in the UK.

Methods

A comprehensive cost-of-illness framework was developed considering the effects of the full asthma patient pathway, including greenhouse gas emissions generated from inhalers, National Health Service (NHS) costs, health-related quality of life and productivity losses. The model was based on published literature and clinical expert opinion to accurately estimate, in monetary terms, the net present value of the asthma pathway impacts for 2022-2031.

Results

The estimated net present value of the environmental, healthcare and societal impacts of the asthma pathway was £47 billion over the 2022-2031 period in the UK. Loss of disease control was a key contributor to higher greenhouse gas emissions and NHS costs. In 2022, a patient with non-severe uncontrolled asthma was estimated to incur 22% higher NHS costs than a patient with controlled asthma, while generating 0.1 t more of CO2 equivalent emissions. In the same year, the total direct impacts per patient with severe asthma were four times higher than for a patient with non-severe controlled asthma, with 0.54 t CO2 equivalent of greenhouse gas emissions. Moreover, as much as 77% of the total economic impact was driven by worsening health-related quality of life and productivity impacts occurring when patients' symptoms were uncontrolled.

Conclusions

Uncontrolled asthma significantly impacts patients, the economy and the environment in the UK. Our results emphasise the need for a holistic approach in controlling asthma and should be carefully considered when developing policies to mitigate the overall burden of the disease.

Budesonide/Glycopyrrolate/Formoterol for the Management of COPD in a UK Primary Care Population: Real-World Use and Early Medication Success

Purpose

Real-life research is needed to evaluate the effectiveness of budesonide/glycopyrrolate/formoterol (BGF) in routine COPD primary care management. We assessed the frequency of medication success among patients with COPD who initiated BGF using real-world data.

Patients and Methods

Patients with a recorded diagnostic COPD code who started BGF with ≥2 prescriptions within 90-days were identified in the UK Optimum Patient Care Research Database and followed from first prescription until censoring at the end of follow-up (180-days), death, leaving database or end of data at 24/10/2022. The primary outcome was medication success at 90-days post-BGF initiation, defined as no major cardiac or respiratory event (ie no complicated COPD exacerbation, hospitalization for any respiratory event, myocardial infarction, new/hospitalized heart failure, and death) and no incidence of pneumonia. Medication success was also assessed at 180-days post-BGF initiation. Overall real-life medication success was claimed if the lower 95% confidence interval (CI) for the proportion of patients meeting the primary outcome was ≥70% (defined a priori).

Results

Two hundred eighty-five patients were included. Prior to BGF initiation, these patients often had severe airflow obstruction (mean ppFEV1: 54.5%), were highly symptomatic (mMRC ≥2: 77.9% (n = 205/263); mean CAT score: 21.7 (SD 7.8)), with evidence of short-acting β2-agonist (SABA) over-use (≥3 inhalers/year: 62.1%, n=179/285), repeat OCS prescriptions (≥2 courses/year: 33.0%, n = 95/285) and multiple primary care consultations (≥2 visits/year: 61.1%, n = 174/285). Overall, 39.6% of patients (n = 113/285) switched from previous triple therapies. Real-life medication success was achieved by 96.5% of patients (n = 275/285 [95% CI: 93.6, 98.3]) during 90-days treatment with BGF and by 91.8% (n = 169/184 [95% CI: 86.9, 95.4]) of patients at 180-days. The prescribed daily dose of SABA remained stable over the study period.

Conclusion

The majority of patients initiating BGF experienced real-life medication success reflecting the absence of severe cardiopulmonary events. These benefits were apparent after 90-days of treatment and sustained over 180-days.

Reducing short-acting beta-agonist use in asthma: Impact of national incentives on prescribing practices in England and the findings from SENTINEL Plus early adopter sites

Short-acting beta-agonist (SABA) over-use in asthma is harmful for patients and the environment. The Investment and Impact Fund (IIF) 2022/2023 financially rewarded English primary care networks that achieved specific targets, including reducing SABA over-use (RESP-02) and lowering the mean carbon footprint per salbutamol inhaler prescribed (ES-02). SENTINEL Plus is a co-designed quality improvement package that aims to improve asthma outcomes and reduce asthma's environmental impact by addressing SABA over-use. We investigated the impact of (i) the IIF incentives and (ii) SENTINEL Plus implementation on asthma prescribing. Using Openprescribing.net data, we demonstrate that IIF 2022-2023 had no significant impact on the total number of SABA prescribed in England (25,927,252 during 12-months pre- and 25,885,213 12-months post-IIF; 0.16% decrease; p=NS), but lower carbon footprint SABA inhaler use increased (Salamol™ prescribing increased from 5.1% to 19% of SABA prescriptions, p < 0.01). In contrast, SENTINEL Plus sites significantly reduced SABA prescribing post-implementation (5.43% decrease, p < 0.05).

Personalizing Selection of Inhaled Delivery Systems in Chronic Obstructive Pulmonary Disease

It can be challenging for healthcare professionals (HCPs) to prescribe inhaled therapy for patients with chronic obstructive pulmonary disease (COPD) because of the multiple individual and combinations of inhaled medications available in numerous delivery systems. Guidance on the selection of an inhaled delivery system has received limited attention compared with the emphasis on prescribing the class of the inhaled molecule(s). Although numerous recommendations and algorithms have been proposed to guide the selection of an inhaled delivery system for patients with COPD, no specific approach has been endorsed in COPD guidelines/strategies or by professional organizations. To provide recommendations for an inhaler selection strategy at initial and follow-up appointments, we examined the impact of patient errors using handheld inhalers on clinical outcomes and performed a focused narrative review to consider patient factors (continuity of the inhaled delivery system, cognitive function, manual function/dexterity, and peak inspiratory flow) when selecting an inhaled delivery system. On the basis of these findings, five questions are proposed for HCPs to consider in the initial selection of an inhaler delivery system and three questions to consider at follow-up. We propose that HCPs consider the inhaled medication delivery system as a unit and to match appropriate medication(s) with the unique features of the delivery system to individual patient factors. Assessment of inhaler technique and adherence together with patient outcomes/satisfaction at each visit is essential to determine whether the inhaled medication delivery system is providing benefits. Continued and repeated education on device features and correct technique is warranted to optimize efficacy.

A multicomponent nutraceutical (<i>Perilla frutescens</i>, quercetin, and vitamin D3) as add-on therapy in patients with grass pollen-induced mild persistent asthma and rhinitis

Background Allergic asthma is an inflammatory disease characterized by a type 2 immune response. Pollens are a common cause of seasonal asthma. Allergic rhinitis (AR) frequently associates with asthma. The treatment usually aims at controlling inflammation and relieving symptoms. Inhaled corticosteroids are the most effective controller and short-acting b2-agonists (SABA) as a reliever for asthma. Oral antihistamines and nasal corticosteroids (NC) are the mainstays for AR. A multicomponent nutraceutical containing perilla, quercetin, and vitamin D3 significantly prevented AR exacerbations in children. Thus, the current study explored the add-on use in adult patients with mild persistent asthma and AR due to grass pollen allergy. Methods The treatment lasted three months. Asthma and AR symptoms, asthma control test, spirometry, nasal eosinophils, and use of rescue medications (SABA and NC) were evaluated in the previous grass season and throughout the treatment. All patients were treated with ciclesonide (320 mcg/day) and cetirizine (10 mg/day). Patients were randomly stratified into Group A, taking the nutraceutical, and Group B using the predetermined therapy. Results 90 patients (13-59 years old) were enrolled, and 84 completed the trial. Group A significantly improved all outcomes (p<0.001). Group B did not achieve an improvement in AR symptoms, nasal eosinophils, and nasal steroid use. The intergroup analysis showed that Group A patients experienced less severe bronchial symptoms (- 32 %), AR symptoms (- 39 %), better asthma control (+ 38 %), higher FEV1 (+ 10 %), lower SABA (- 30 %) and NC use (- 41 %), and nasal eosinophils count (- 35 %) than Group B (p<0.0001 for all). No clinically relevant adverse events occurred. Conclusion A multicomponent nutraceutical containing perilla, quercetin, and vitamin D3, as an add-on treatment to inhaled ciclesonide and cetirizine, provided a clinically relevant benefit in patients with mild persistent asthma and AR due to grass pollen uncontrolled by standard therapy.

The importance of reminders and patient preferences to improve inhaler technique in older adults with COPD

Objectives: Medication non-adherence in patients with chronic obstructive pulmonary disease is common. The aim is to evaluate the efficacy of two interventions to improve the inhalation technique (IT) in patients with pulmonary disease is common. Also determine optimal IT reminder time and to test the role of preferences in the intervention selection. Method: 726 pulmonary disease in common patients (consecutive sampling) from two trials: 1) TECEPOC-study (patients' preference trial/comprehensive cohort design) 2) TIEPOC-study (randomised controlled trial). Interventions: intervention-A (ad-hoc leaflet with instructions about correct IT according Spanish Respiratory Society), intervention B (intervention A+ individual training by instructors). Four visits were performed (baseline, 3, 6 and 12 months). Data on IT, sociodemographic and clinical characteristics, quality of life and respiratory drugs were recorded. Analysis under intention to treat principle. Multivariate analysis was conducted to measure the potential modifying factors of improvement in the IT along follow-up. Results: 660 patients (90.9%) did not perform a correct IT at baseline 89.75% with Handihaler, 86.95% with Turbuhaler, 84.75% with Accuhaler and 87.35% with pMDI. At 12 months, 221 patients 29.9% performed correctly the IT; a decrease in the slope of the curve (correct IT) was detected at 3 months follow-up. Intervention B was the most effective in both trials compared to control group or intervention A, regardless of preferences: 1) TECEPOC Study (preference trial): Intervention B versus control group, NNT = 3.22 (IC95%, 2.27-5.52); and versus Intervention A, NNT = 3.57 (CI95%, 2.41-6.8). Preferences improved 6.7% in the correct IT without statistical significance. 2) TIEPOC Study (randomized controlled trial): Intervention B versus control group, NNT = 1.74 (IC95%, 1.47-2.17), and versus intervention A, NNT = 3.33 (CI 95%, 2.43-5.55). No differences were measured between Intervention A and control group. Conclusion: Individual training significantly improves IT. Reminders every 3 months are recommended. Preferences do not influence the intervention effectiveness.