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Albanna AS, Alhajji M, Alsowayan W, Soliman MH. The impact of unsupervised and unconsented switch of inhalers in patients with controlled asthma - A targeted literature review. Ann Thorac Med 2023; 18:103-115. [PMID: 37663876 PMCID: PMC10473061 DOI: 10.4103/atm.atm_438_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/16/2023] [Accepted: 03/19/2023] [Indexed: 09/05/2023] Open
Abstract
Inhaler combination formulations consisting of an inhaled corticosteroid (ICS) (fluticasone propionate) and a long-acting β2 agonist (salmeterol xinafoate) are indicated as maintenance treatments for patients with asthma and/or for selected patients with chronic obstructive pulmonary disease. The emergence of generic equivalents to branded inhalers is expected to offer economic edge/savings; however, some may argue that cost advantages offered by generic inhalers may be offset by worsening outcomes due to improper inhaler use, reduced adherence, and consequently worse disease control. To understand how unsupervised and unconsented switch of dry-powder inhalers and/or metered-dose inhalers affects clinical and humanistic outcomes in asthma, comprehensive searches of Embase and MEDLINE were conducted to identify research articles published in the English language since 2011. Patients with asthma of any age who underwent an unsupervised and unconsented switch from an ICS/long-acting β2 agonist to another (brand-to-generic or brand-to-brand) for non-medical reasons were the target of this research. Relevant outcomes included asthma control, medication adherence, and healthcare resource utilization. In total, 11 studies were identified for review (ten non-interventional and one post hoc); cohorts ranged from 19 to 42,553 patients. Six studies indicated that unsupervised and unconsented inhaler switch had a negative impact on asthma control; six studies indicated reduced medication adherence post-switching; and five studies reporting healthcare resource utilization showed it was unchanged or increased post-switching. Findings from this targeted review support concerns that unsupervised and unconsented inhaler switch has a largely negative impact on asthma-associated outcomes. Additional studies are warranted to further explore unsupervised and unconsented switch in asthma.
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Affiliation(s)
- Amr S. Albanna
- Department of Medicine, Pulmonary Division, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Alhajji
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Waleed Alsowayan
- Pulmonary Division, Internal Medicine Department, Security Forces Hospital Program, Riyadh, Saudi Arabia
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Usmani OS, Bosnic-Anticevich S, Dekhuijzen R, Lavorini F, Bell J, Stjepanovic N, Swift SL, Roche N. Real-World Impact of Nonclinical Inhaler Regimen Switches on Asthma or COPD: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2624-2637. [PMID: 35750323 DOI: 10.1016/j.jaip.2022.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Switching inhaler regimens can be driven by poor disease control but also by nonclinical factors, such as cost and environmental impact. The consequences of switching for nonclinical reasons are largely unclear. OBJECTIVE To systematically review the real-world consequences of switching inhaler regimens for nonclinical reasons in asthma and/or chronic obstructive pulmonary disease patients. METHODS Embase, MEDLINE, EBM Reviews, and EconLit were searched to November 21, 2020. Conference searches and reference checking were also performed. Real-world studies of asthma and/or chronic obstructive pulmonary disease patients undergoing a switch in inhaler regimen for any reason apart from clinical need were included. Two reviewers screened and extracted data. Key outcomes included symptom control, exacerbations, and patient-doctor relationships. RESULTS A total of 8,958 records were screened and 21 studies included. Higher-quality (matched comparative) studies were prioritized. Five matched studies (6 datasets) reported on symptom control: 5 datasets (n = 7,530) with unclear patient consent reported improved disease control following switching, and 1 dataset (n = 1,648) with non-consented patients reported significantly worsened disease control. Three matched studies (5 datasets, n = 10,084) reported on exacerbation rate ratios; results were heterogeneous depending on the definition used. Two studies (n = 137) reported that switching inhaler regimens could have a negative impact on the doctor-patient relationship, especially when the switches were non-consented. Study quality was generally low. CONCLUSIONS Switching inhaler regimens is a complex issue that can have variable clinical consequences and can harm the patient-doctor relationship. Limited high-quality evidence was identified, and study designs were heterogeneous. A robust framework is needed to guide the personalized switching of inhalers.
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Affiliation(s)
- Omar S Usmani
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, UK
| | - Sinthia Bosnic-Anticevich
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Clinical Management, Woolcock Institute of Medical Research, Sydney, Australia
| | - Richard Dekhuijzen
- Faculty of Medical Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - John Bell
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | | | | | - Nicolas Roche
- Department of Respiratory Medicine, Cochin Hospital and Institute, APHP Centre University Paris Cité, Paris, France.
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Ray SE, Boudewyns V, Davis C, Tzeng JP, Srivastava I, Oguntimein O, Conti DS, Feibus KB. Patient Perceptions of Switching to a Generic Dry Powder Inhaler – Increased Understanding Through Journey Mapping. Int J Chron Obstruct Pulmon Dis 2022; 17:1751-1768. [PMID: 35965841 PMCID: PMC9367651 DOI: 10.2147/copd.s362696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/23/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose This qualitative study explored patients’ attitudes about and perceptions of generic dry powder inhaler (DPI) substitution for the brand product and patients’ views of generic product quality, efficacy, design, and usability. Methods Forty COPD and asthma patients (36 adults, four adolescents), who were actively using a brand DPI product, participated in one of six focus groups. Participants completed a journey mapping exercise to assess attitudes and opinions about a scenario where they refill their prescription and unexpectedly receive a generic DPI instead of their brand DPI. The focus groups were audio recorded, transcribed, and analyzed thematically. Results The hypothetical scenario of unexpectedly receiving a generic DPI elicited mixed feelings including: happiness and relief about potential cost savings, confusion, disappointment, anger, and/or frustration with the unexpected switch. Participants in most groups anticipated anxiety or hesitation in using the generic DPI due to concerns about potential differences in usability, uncertainty about correct use, and questions about efficacy. Participants across all groups said they would ask a pharmacist or healthcare provider for information or answers to their questions, and some participants said they would use online resources. When participants held the brand and generic DPI devices, most preferred the brand DPI device and found it easier, less cumbersome, or more convenient to use (due to size and weight). However, many participants reiterated that the potential reduced cost of the generic DPI would be a primary factor in their decision-making related to generic DPI substitution for their brand DPI. Conclusion Patients experienced a mixture of positive and negative feelings when faced with an unexpected generic DPI substitution. Some patients have doubts about their ability to successfully navigate differences in generic device design, and most expressed the desire to participate in discussions and decision-making with their HCP about generic DPI sameness and substitution.
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Affiliation(s)
- Sarah E Ray
- Center for Communication Science, RTI International, Research Triangle Park, NC, USA
- Correspondence: Sarah E Ray, Center for Communication Science, RTI International, Research Triangle Park, NC, USA, Tel +1 770-407-4934, Email
| | - Vanessa Boudewyns
- Center for Communication Science, RTI International, Research Triangle Park, NC, USA
| | - Christine Davis
- Center for Communication Science, RTI International, Research Triangle Park, NC, USA
| | - Janice P Tzeng
- Center for Communication Science, RTI International, Research Triangle Park, NC, USA
| | - Ila Srivastava
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Oluwamurewa Oguntimein
- Office of Medication Error Prevention and Risk Management, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Denise S Conti
- Office of Safety and Clinical Evaluation, Office of Generic Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Karen B Feibus
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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Sulku J, Janson C, Melhus H, Ställberg B, Bröms K, Högman M, Lisspers K, Malinovschi A, Nielsen EI. Changes in critical inhaler technique errors in inhaled COPD treatment – A one-year follow-up study in Sweden. Respir Med 2022; 197:106849. [DOI: 10.1016/j.rmed.2022.106849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/28/2022] [Accepted: 04/06/2022] [Indexed: 12/01/2022]
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NUCERA F, BIANCO A, DAVID T, SALVATO I, ADCOCK IM, CARAMORI G. Treatable traits in COPD patients. Minerva Med 2022; 113:449-459. [DOI: 10.23736/s0026-4806.22.08001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Switching Inhalers: A Practical Approach to Keep on UR RADAR. Pulm Ther 2020; 6:381-392. [PMID: 33051824 PMCID: PMC7672131 DOI: 10.1007/s41030-020-00133-6] [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: 07/29/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022] Open
Abstract
The choice of an inhaler device is often as important as the medication put in it to achieve optimal outcomes for our patients with asthma and/or COPD. With a multitude of drug–device combinations available, optimization of respiratory treatment could well be established by switching devices rather than changing or even augmenting pharmacological or non-pharmacological therapies. Importantly, while notable between-device differences in release mechanism, particle size, drug deposition and required inspiratory flow exist, a patient uncomfortable with their device is unlikely to use it regularly and certainly will not use it properly. Switching requires a careful process and should not be done without patient consent. Switching devices entails several steps that need to be considered, which can be guided using the UR-RADAR mnemonic. It starts with (i) UncontRolled asthma/COPD (or UnaffoRdable device), followed by RADAR: (ii) review the patient’s condition (e.g. diagnosis, phenotype, co-morbidities) and address reasons for suboptimal control (e.g. triggers, smoking, non-adherence, poor inhaler technique) to be ruled out before switching; (iii) assess patient’s skills related to inhalation (e.g. inspiratory force); (iv) discuss inhaler switch options, patient preferences (e.g. size, daily regimen) and treatment goals; (v) allow patients input and use shared decision-making to decide final treatment choice, acknowledging individual patient skills, preferences and goals; and (vi) re-educate to the new device (at minimum, physical demonstration, verbal explanation and patient repetition, both verbally and physically) and prime the patient for the follow-up (i.e. explain the future patient journey, including multidisciplinary work flows with physicians, nurses and pharmacists).
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Ortsäter G, Borgström F, Soulard S, Miltenburger C. A Budget Impact Model to Estimate the Environmental Impact of Adopting RESPIMAT ® Re-usable in the Nordics and Benelux. Adv Ther 2019; 36:3435-3445. [PMID: 31625130 PMCID: PMC6860470 DOI: 10.1007/s12325-019-01114-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Indexed: 11/25/2022]
Abstract
Introduction The healthcare sector contributes 5–8% of the global greenhouse gas emissions. Global and regional organizations and governments have started to design and implement measures to reduce global greenhouse gas emissions in the healthcare sector, e.g. by green public procurement policies and inclusion of ecological considerations in the decision-making process for purchasing and funding of healthcare technologies. The objective of this study was to perform budget impact analysis of adopting RESPIMAT re-usable in the Nordics and Benelux that considered both the traditional healthcare costs as well as the environmental impact. Methods Inhaler costs and environmental impact over 5 years in the Nordics and Benelux in a scenario with RESPIMAT re-usable compared to a scenario without RESPIMAT re-usable were estimated using an budget impact model. RESPIMAT re-usable enables patients to re-use the inhaler device and its availability therefore reduces the number of inhalers and associated wastage. The carbon emissions were derived for each treatment pattern considering the whole life cycle (cradle-to-grave) of the inhaler product. The cost of carbon emissions was estimated using a societal cost per ton of carbon emission. Results Progressively introducing RESPIMAT re-usable in the Nordics and Benelux was estimated to decrease the number of inhalers used by 2023 by 7,466,621 compared to a scenario without RESPIMAT re-usable, which would result in a reduction of the environmental burden of inhaler use of 4717 tCO2e and a decrease in societal cost of €205,888. Conclusions Adopting RESPIMAT re-usable would lead to a substantial reduction in CO2 emissions, leading to savings from a societal perspective. Funding Boehringer Ingelheim. Electronic supplementary material The online version of this article (10.1007/s12325-019-01114-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Fredrik Borgström
- Quantify Research, Stockholm, Sweden
- LIME/MMC, Karolinska Institutet, Stockholm, Sweden
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McCabe H, Godman B, Kurdi A, Johnston K, MacBride-Stewart S, Lennon J, Hurding S, Bennie M, Morton A. Prescribing trends of inhaler treatments for asthma and chronic obstructive pulmonary disease within a resource-constrained environment in the Scottish national health service: findings and implications. Expert Rev Respir Med 2019; 13:679-689. [PMID: 31189394 DOI: 10.1080/17476348.2019.1624528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: There is an increasing prevalence of asthma and chronic obstructive pulmonary disease (COPD) worldwide, leading to increased inhaler use. However, there are concerns with inhaler compliance resulting in different patented inhalers and longer-acting formulations. As a result, inhalers are now among the highest expenditure items in ambulatory care in Scotland leading to multiple initiatives to keep within budget without compromising care. Method: This study assesses inhaler utilization and expenditure between 2001 and 2017 alongside health authority initiatives. Results: There was an increase by 137% in inhaler utilization between 2001 and 2017, and a two-fold increase in expenditure, driven by the increasing use of patented combination inhalers to address concerns. This is very different to the oral markets where expenditure on proton pump inhibitors, statins, and antihypertensives have fallen considerably recently despite increased volumes due to the increasing use of low-cost generics. However, inhaler expenditure has started to fall with an increasing use of lower cost combinations and initiatives to reduce the steroid burden alongside monitoring patient care. Conclusion: Challenges with using and changing inhalers has meant this market has not followed other high-volume drug classes following patent loss. This is starting to change, with the situation monitored to enhance efficient prescribing alongside continued good quality care.
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Affiliation(s)
- Holly McCabe
- a Department of Management Science , Strathclyde Business School, University of Strathclyde , Glasgow , UK
| | - Brian Godman
- b Strathclyde Institute of Pharmacy and Biomedicial Sciences , University of Strathclyde , Glasgow , UK.,c Division of Clinical Pharmacology , Karolinska Institutet, Karolinska University Hospital , Huddinge , Sweden.,d Department of Public Health Pharmacy and Management , School of Pharmacy, Sefako Makgatho Health Sciences University , Garankuwa , South Africa
| | - Amanj Kurdi
- b Strathclyde Institute of Pharmacy and Biomedicial Sciences , University of Strathclyde , Glasgow , UK.,e Department of pharmacology , College of Pharmacy, Hawler Medical University , Erbil , Iraq
| | - Katie Johnston
- f Prescribing Advisor Primary Care , NHS , Edinburgh , UK
| | | | - Janey Lennon
- g Pharmacy Service , NHS Greater Glasgow and Clyde , Glasgow , UK
| | - Simon Hurding
- h Therapeutics Branch , Scottish Government , Edinburgh , UK
| | - Marion Bennie
- b Strathclyde Institute of Pharmacy and Biomedicial Sciences , University of Strathclyde , Glasgow , UK
| | - Alec Morton
- a Department of Management Science , Strathclyde Business School, University of Strathclyde , Glasgow , UK
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Backer V, Bjermer L, Refvem OK, Søderman A, Jones S. A multicenter, open-label, noninterventional study to evaluate the impact on clinical effects, user-friendliness and patients' acceptance of AirFluSal Forspiro in the treatment of asthma under real-life conditions (ASSURE). Pragmat Obs Res 2019; 10:29-39. [PMID: 31213944 PMCID: PMC6541794 DOI: 10.2147/por.s200654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background: The design of inhaler devices may potentially influence adherence/persistence and outcomes in asthma. Objective: The primary objective was to assess asthma control and any change in the quality of life in patients using an intuitive dry powder inhaler containing fluticasone propionate/salmeterol (AirFluSal® Forspiro®) for the treatment of asthma in everyday practice. Methods: ASSURE was a multicenter, noninterventional, open-label, prospective study in patients with asthma, aged ≥12 years and treated with the Forspiro device in Denmark, Sweden and Norway. Patients’ opinions of their asthma control were assessed by the Asthma Control Test (ACT) questionnaire and asthma-related quality of life by the Mini Asthma Quality of Life Questionnaire (miniAQLQ) at baseline and at two follow-up visits (approximately 4–8-week intervals). Results: Of 321 patients enrolled in the study, 299 received at least one dose of fluticasone propionate/salmeterol via the Forspiro device and 204 had evaluable data at the baseline visit and at least one later visit. Patients showed improvements in asthma control and quality of life during the study. The mean sum score of ACT increased from 18.0 (SD 4.5) at visit 1 to 19.9 (4.2) at visit 2 and 20.5 (4.3) at visit 3. Overall, 38.2% of patients improved by the minimal clinically important difference (MCID) of ≥3 points (45.6% among those with a baseline score below 23 [ie, not already well controlled]). The mean score on the miniAQLQ increased from 5.16 (SD 1.24) at visit 1 to 5.58 (SD 1.20) at visit 2 and 5.82 (SD 1.04) at visit 3. Overall, 42.6% of patients improved by the MCID of ≥0.5. Conclusion: This real-life study suggests that treatment with fluticasone propionate/salmeterol via the Forspiro device can improve asthma symptom control and quality of life.
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Affiliation(s)
- Vibeke Backer
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen University, 48 2400 Copenhagen, Denmark
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, 221 85 Lund, Sweden
| | | | - Andreas Søderman
- Medical Affairs Nordics, Sandoz AS, Copenhagen, DK-2300, Denmark
| | - Spencer Jones
- Global Medical Affairs, Sandoz International GmbH, Holzkirchen, D-83607, Germany
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Rönmark P, Jagorstrand B, Safioti G, Menon S, Bjermer L. Comparison of correct technique and preference for Spiromax®, Easyhaler® and Turbuhaler®: a single-site, single-visit, crossover study in inhaler-naïve adult volunteers. Eur Clin Respir J 2018; 5:1529536. [PMID: 30370020 PMCID: PMC6201814 DOI: 10.1080/20018525.2018.1529536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/14/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022] Open
Abstract
Background: Many patients do not use inhalers correctly. Inhalers associated with good technique have the potential to improve symptom control and are often preferred by patients. Methods: Inhaler-naïve, adult volunteers were randomized to use empty Spiromax®, Easyhaler®, and Turbuhaler® dry powder inhalers (DPIs) in one of six possible sequences in this single-site, single-visit, crossover study conducted in Sweden. Randomization was stratified by age and gender. Participants attempted to use each device intuitively (no instructions) and after reading the instructions for use from the patient information leaflet. Device preference was surveyed after using all devices. Mastery of device handling (i.e. dose preparation) or inhalation was defined as having no healthcare-professional-observed errors. The primary endpoint was mastery of device handling after reading the instructions. Results: More participants mastered device handling with Spiromax vs Easyhaler or Turbuhaler, both intuitively (44%, 0%, and 10%, respectively) and after reading the instructions (99%, 56%, and 81%, respectively). Fewer participants had ≥1 device-handling error with Spiromax than with the other devices. The percentage of participants still showing inhalation errors after reading the instructions ranged between 21% for Spiromax and 40% for Easyhaler. After reading instructions, mastery of handling and inhalation was numerically lower among older (aged >60 years) vs younger participants across all devices. Most participants preferred Spiromax for device handling (59%) and intuitiveness/ease of use (61%). Conclusion: These findings highlight that important differences exist between DPI devices, which could have implications for disease control when selecting a device for a patient.
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Affiliation(s)
- Per Rönmark
- Stadsfjӓrden Health Center, Praktikertjänst AB, Nykӧping, Sweden
| | | | - Guilherme Safioti
- Global Medical Affairs, Teva Pharmaceuticals, Amsterdam, The Netherlands
| | - Sreedevi Menon
- Cognub Decision Solutions (formerly known as Kreara Solutions Pvt Ltd), Trivandrum, India
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Institute of Clinical Science, Lund University, Lund, Sweden
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Rhee CK, van Boven JFM, Yau Ming SW, Park HY, Kim DK, Park HS, Ling JZJ, Yoo KH, Price DB. Does Changing Inhaler Device Impact Real-Life Asthma Outcomes? Clinical and Economic Evaluation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:934-942. [PMID: 30292924 DOI: 10.1016/j.jaip.2018.09.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 09/07/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Inhaler usability and deposition differ between devices. Change of device may therefore have an impact on clinical and economic outcomes. OBJECTIVE To characterize clinical and economic asthma outcomes surrounding the change from a dry powder inhaler (DPI) to a pressurized metered-dose inhaler (pMDI) for fixed-dose combination inhaled corticosteroid/long-acting β agonist (FDC ICS/LABA) treatment. METHODS Three retrospective cohort substudies using 2010 to 2015 data from the Korean Health Insurance and Review Assessment Service database were performed. Patients with asthma who received an FDC ICS/LABA pMDI for the first time after initially being on FDC ICS/LABA DPI were included. The following outcomes were assessed: (1) persistence of change to pMDI over 6 months, (2) clinical outcomes during the year after the change compared with the baseline year; and (3) noninferiority comparison of costs and effectiveness between patients changing to a pMDI and matched patients who continued their DPI. RESULTS Patients who change inhalers seem to represent a more severe subpopulation. Fifty-eight percent of patients (95% CI, 56-60) persisted with the change. After the change in therapy, an increased proportion of patients (58.3%) remained free from severe exacerbations compared with the year before (47.4%; P < .001). Patients who changed to pMDIs had significantly less severe exacerbations, acute respiratory events, and lower short-acting β agonist inhaler average daily dose, but higher average ICS daily dose (all P < .05), compared with matched patients remaining on a DPI. Total costs were similar between patients who changed to pMDI therapy compared with those remaining on a DPI. CONCLUSION Changing from a DPI to a pMDI for FDC ICS/LABA asthma treatment can be as effective and cost-effective as remaining on a DPI.
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Affiliation(s)
- Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Job F M van Boven
- Department of General Practice and Elderly Care Medicine, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | | | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyun Kwan University School of Medicine, Seoul, Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Seoul National University, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hae-Sim Park
- Allergy and Clinical Immunology Department, Ajou University Medical Center, Seoul, Korea
| | | | - Kwang-Ha Yoo
- Division of Pulmonary and Allergy, Department of Internal Medicine, School of Medicine, Konkuk University, Seoul, Korea.
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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Abstract
PURPOSE OF REVIEW In this review, we herein describe the progress in management of severe asthma, evolving from a 'blockbuster approach' to a more personalized approach targeted to the utilization of endotype-driven therapies. RECENT FINDINGS Severe asthma characterization in phenotypes and endotypes, by means of specific biomarkers, have led to the dichotomization of the concepts of 'personalized medicine' and 'precision medicine', which are often used as synonyms, but actually have conceptual differences in meaning. The recent contribute of the omic sciences (i.e. proteomics, transcriptomics, metabolomics, genomics, …) has brought this initially theoretic evolution into a more concrete level. SUMMARY This step-by-step transition would bring to a better approach to severe asthmatic patients as the personalization of their therapeutic strategy would bring to a better patient selection, a more precise endotype-driven treatment, and hopefully to better results in terms of reduction of exacerbation rates, symptoms, pulmonary function and quality of life.
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13
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Luczak-Wozniak K, Dabrowska M, Domagala I, Miszczuk M, Lubanski W, Leszczynski A, Krenke R. Mishandling of pMDI and DPI inhalers in asthma and COPD - Repetitive and non-repetitive errors. Pulm Pharmacol Ther 2018; 51:65-72. [PMID: 29964174 DOI: 10.1016/j.pupt.2018.06.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/23/2018] [Accepted: 06/28/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pharmacological treatment of asthma and chronic obstructive pulmonary disease (COPD) is based mainly on inhaled medications. There is a continuous need to examine and train patients in their inhalation technique. The objective of the presented study is to determine whether the errors which patients made during inhalations are repetitive, and therefore easier to eradicate, or rather accidental, hence require more attention and effort from the health care professionals. METHODS It was a prospective, cohort study which included adults with asthma or COPD, who have used at least one inhaler daily on a regular basis. Inhalation technique was evaluated twice in a six months interval basing on a list of the most common errors in the inhalation technique. There was no training of inhalation skills between visits. RESULTS There were 92 patients (46 asthmatics, 46 with COPD; median age 66 years, median duration of the disease 10 years) included into the analysis. 92% of patients made at least one error during their inhalation. Among pMDI users the most common device mishandlings were: no or too short breath-holding after inhalation (60% of the patients during the first visit; 50% during the 2nd), too rapid and too forceful inhalation (52%; 61%) and lack of exhalation before the use of the medicine (48%; 43%). Among the DPI users, the most numerous errors were: no or too short (less than 3 s) breath-holding after inhalation (62%; 55%) and slow and not forceful enough inhalation (38%; 36%). When comparing the mishandlings in the inhalation technique conducted during the first and second visit the majority of the errors conducted by the patients were repetitive. However, some errors such as too early termination of inhalation (p = 0.016), inhalation through the nose during actuation (p = 0.002) among pMDI users and lack of expiration before inhalation (p = 0.027) among DPI users, were non-permanent. CONCLUSIONS Improper inhalation technique is very common and the majority of errors made in inhalation technique are repetitive. This emphasizes the role of an ongoing verification and training of a proper inhalation technique in all patients that are regularly treated with inhalers.
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Affiliation(s)
| | - Marta Dabrowska
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland.
| | - Izabela Domagala
- Students' Research Group "Alveolus", Medical University of Warsaw, Poland
| | - Marta Miszczuk
- Students' Research Group "Alveolus", Medical University of Warsaw, Poland
| | - Wojciech Lubanski
- Students' Research Group "Alveolus", Medical University of Warsaw, Poland
| | | | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland
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14
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Bosnic-Anticevich SZ, Cvetkovski B, Azzi EA, Srour P, Tan R, Kritikos V. Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management. Pulm Ther 2018; 4:1-12. [PMID: 32026244 PMCID: PMC6966926 DOI: 10.1007/s41030-018-0051-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 12/24/2022] Open
Abstract
Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the 'luxury' of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient's make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient's making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.
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Affiliation(s)
- Sinthia Z Bosnic-Anticevich
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia.
- Woolcock Emphysema Centre, University of Sydney, Sydney, Australia.
- Sydney Local Health District, Sydney, Australia.
| | - Biljana Cvetkovski
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Elizabeth A Azzi
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Pamela Srour
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachel Tan
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
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15
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Bender BG, Hernandez Vecino RA, McGrath K, Jones S. Comparative Analysis of Persistence to Treatment among Patients with Asthma or COPD Receiving AirFluSal Forspiro or Seretide Diskus Salmeterol/Fluticasone Propionate Combination Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 4:884-9. [PMID: 27587319 DOI: 10.1016/j.jaip.2016.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/24/2016] [Accepted: 07/07/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low adherence and persistence to inhaled therapy result in poor outcomes in patients with asthma and chronic obstructive pulmonary disease (COPD). Although adherence has been widely studied, growing awareness of the large number of patients who abandon their asthma treatment suggests that persistence to treatment may be more relevant for longer term outcomes. OBJECTIVE The objective of this study was to compare persistence to salmeterol/fluticasone propionate combination treatment as AirFluSal Forspiro with persistence to Seretide Diskus in patients with asthma or COPD aged 12 years and above. METHODS This study analyzed dispensing data from a large German pharmacy database. Male and female patients who were prescribed AirFluSal Forspiro were randomly paired with those who were prescribed Seretide Diskus controlling for month of treatment initiation (to limit potential seasonality effects), age groups, and gender. Matched patient pair analysis was conducted on a total of 11,774 patients (45.1% male) to compare persistence between the 2 products. RESULTS The survival probability estimates at 12 months were 0.229 (0.02 standard error) for AirFluSal Forspiro versus 0.105 (0.025 standard error) for Seretide Diskus. The Renyi family of tests demonstrated a statistically significant difference (P = .01) in persistence to AirFluSal Forspiro compared with Seretide Diskus in the overall survival experience of the 2 populations. CONCLUSIONS In this large retrospective pharmacy database analysis, patients using AirFluSal Forspiro were more likely to persist with treatment compared with those using Seretide Diskus as demonstrated by the overall survival experience of the 2 populations (12-month study period). These new data provide a basis for further research to better understand persistence behavior and to develop strategies to address poor persistence.
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Affiliation(s)
- Bruce G Bender
- Department of Pediatrics, National Jewish Health, Denver, Colo.
| | | | - Kevin McGrath
- Health Informatics, Healthcare at Home Ltd., Burton upon Trent, East Staffordshire, United Kingdom
| | - Spencer Jones
- Global Medical Affairs, Sandoz International GmbH, Holzkirchen, Germany
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16
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Mayers I, Bhutani M. Considerations in establishing bioequivalence of inhaled compounds. Expert Opin Drug Deliv 2017; 15:153-162. [PMID: 28918665 DOI: 10.1080/17425247.2018.1381084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Generic inhalers are often perceived as inferior to their branded counterparts; however, they are safe and effective if they can meet the regulatory requirements. The approach to assess bioequivalence (BE) in oral dosage form products is not sufficient to address the complexities of inhalational products (e.g., patient-device interface); hence, more considerations are needed and caution should be applied in determining BE of inhaled compounds. AREAS COVERED This review outlines the evaluation process for generic inhalers, explores the regulatory approaches in BE assessment, and highlights the considerations and challenges in the current in vitro and in vivo approaches (lung deposition, pharmacokinetic, pharmacodynamic/clinical studies, and patient-device interface) for establishing BE of inhaled compounds. EXPERT OPINION The ultimate goals in this field are to establish uniformity in the regulatory approaches to speed the drug submission process in different regions, clear physicians' misconception of generic inhalers, and have meaningful clinical endpoints such as improvement in patient quality of life when compared to placebo and brand name drugs. As inhalational drugs become more common for other indications such as antibiotics, the technologies developed for inhaled compounds in the treatment of chronic pulmonary diseases may be extrapolated to these other agents.
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Affiliation(s)
- Irvin Mayers
- a Division of Pulmonary Medicine, Department of Medicine , University of Alberta , Edmonton , AB , Canada
| | - Mohit Bhutani
- a Division of Pulmonary Medicine, Department of Medicine , University of Alberta , Edmonton , AB , Canada
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17
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Sangiorgi D, Perrone V, Buda S, Degli Esposti L. Exacerbations in COPD patients treated with Inhaled Corticosteroids/Long-acting β2 agonists combinations, switching to another combination drugs or inhaler device: A “real – world” study. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1304873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Diego Sangiorgi
- CliCon S.r.l. Health, Economics & Outcomes Research, Via Salara, 36, 48100 Ravenna, Italy
| | - Valentina Perrone
- CliCon S.r.l. Health, Economics & Outcomes Research, Via Salara, 36, 48100 Ravenna, Italy
| | - Stefano Buda
- CliCon S.r.l. Health, Economics & Outcomes Research, Via Salara, 36, 48100 Ravenna, Italy
| | - Luca Degli Esposti
- CliCon S.r.l. Health, Economics & Outcomes Research, Via Salara, 36, 48100 Ravenna, Italy
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18
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Generic medications in precision medicine in asthma. Curr Opin Pulm Med 2017; 23:1-2. [PMID: 27902500 DOI: 10.1097/mcp.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Senna G, Caminati M, Bovo C, Canonica GW, Passalacqua G. The role of the pharmacy in the management of bronchial asthma: A literature-based evaluation. Ann Allergy Asthma Immunol 2016; 118:161-165. [PMID: 27887807 DOI: 10.1016/j.anai.2016.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/16/2016] [Accepted: 10/20/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pharmacists play a relevant role in the real-life management of asthma because they are a first-line referral for patients. In fact, the role of pharmacies has been underlined and evidenced also in guidelines. Nonetheless, the true effect of pharmacy-based management of asthma has been assessed in only a few studies. We review the available literature on asthma management in a territorial pharmacy setting. DATA SOURCES The literature was searched for the keywords pharmacy, bronchial asthma, control, and management. STUDY SELECTIONS The available studies were subdivided into observational and interventional and described. RESULTS Seven observational studies and 14 interventional trials were found, involving approximately 20,000 individuals. Most of those studies were performed in Europe and Australia. A high proportion of patients had poorly controlled asthma in the observational studies. The active involvement of pharmacists, in the interventional trials, consistently led to an improvement of the quality of life, a better inhalation technique, and a reduction of exacerbations. CONCLUSION The literature analysis confirms the relevance of the role of pharmacists in the real-life management of bronchial asthma and underlines the need for a more specific training for those health care professionals.
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Affiliation(s)
- Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Marco Caminati
- Asthma Center and Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Clara Bovo
- Medical Direction, University Hospital of Verona, Verona, Italy
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital, IST, University of Genoa, Genoa, Italy
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital, IST, University of Genoa, Genoa, Italy.
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20
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Rogueda P, Traini D. The future of inhalers: how can we improve drug delivery in asthma and COPD? Expert Rev Respir Med 2016; 10:1041-4. [PMID: 27545190 DOI: 10.1080/17476348.2016.1227246] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Philippe Rogueda
- a Aedestra ltd , Kowloon , Hong Kong.,b Respiratory Technology , Woolcock Institute of Medical Research , Sydney , Australia.,c Discipline of Pharmacology, Sydney Medical School , University of Sydney , Sydney , Australia
| | - Daniela Traini
- b Respiratory Technology , Woolcock Institute of Medical Research , Sydney , Australia.,c Discipline of Pharmacology, Sydney Medical School , University of Sydney , Sydney , Australia
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21
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Pirozynski M, Sosnowski TR. Inhalation devices: from basic science to practical use, innovative vs generic products. Expert Opin Drug Deliv 2016; 13:1559-1571. [PMID: 27267298 DOI: 10.1080/17425247.2016.1198774] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Inhalation therapy is a convenient method of treating respiratory diseases. The key factors required for inhalation are the preparation of drug carriers (aerosol particles) allowing reproducible dosing during administration. These technical challenges are accomplished with a variety of inhalation devices (inhalers) and medicinal formulations, which are optimized to be easily converted into inhalable aerosols. Areas covered: This review is focused on the most important, but often overlooked, effects, which are required for the reliable and reproducible inhalable drug administration. The effects of patient-related issues that influence inhalation therapy, such as proper selection of inhalers for specific cases is discussed. We also discuss factors that are the most essential if generic inhalation product should be considered equivalent to the drugs with the clinically confirmed efficacy. Expert opinion: Proper device selection is crucial in clinical results of inhalation therapy. The patients' ability to coordinate inhalation with actuation, generation of optimal flow through the device, use of optimal inspiratory volume, all produces crucial effects on disease control. Also the severity of the disease process effects proper use of inhalers. Interchanging of inhalers can produce potentially conflicting problem regarding efficacy and safety of inhalation therapy.
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Affiliation(s)
- Michal Pirozynski
- a Allergy and Pulmonology Department , Postgraduate Center for Medical Education , Warsaw , Poland
| | - Tomasz R Sosnowski
- b Faculty of Chemical and Process Engineering , Warsaw University of Technology , Warsaw , Poland
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22
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Carsin A, Dubus JC. Dispensation of Spacer Devices/Nebulizers to the Patient: There Is Still Some Way to Go …. J Aerosol Med Pulm Drug Deliv 2016; 29:534-535. [PMID: 27149431 DOI: 10.1089/jamp.2016.1296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ania Carsin
- Pediatric Pulmonology Unit, University Hospital of La Timone-Enfants , Marseille, France
| | - Jean-Christophe Dubus
- Pediatric Pulmonology Unit, University Hospital of La Timone-Enfants , Marseille, France
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23
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Roggeri A, Micheletto C, Roggeri DP. Inhalation errors due to device switch in patients with chronic obstructive pulmonary disease and asthma: critical health and economic issues. Int J Chron Obstruct Pulmon Dis 2016; 11:597-602. [PMID: 27051283 PMCID: PMC4807897 DOI: 10.2147/copd.s103335] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Different inhalation devices are characterized by different techniques of use. The untrained switching of device in chronic obstructive pulmonary disease (COPD) and asthma patients may be associated with inadequate inhalation technique and, consequently, could lead to a reduction in adherence to treatment and limit control of the disease. The aim of this analysis was to estimate the potential economic impact related to errors in inhalation in patients switching device without adequate training. METHODS An Italian real-practice study conducted in patients affected by COPD and asthma has shown an increase in health care resource consumption associated with misuse of inhalers. Particularly, significantly higher rates of hospitalizations, emergency room visits (ER), and pharmacological treatments (steroids and antimicrobials) were observed. In this analysis, those differences in resource consumption were monetized considering the Italian National Health Service (INHS) perspective. RESULTS Comparing a hypothetical cohort of 100 COPD patients with at least a critical error in inhalation vs 100 COPD patients without errors in inhalation, a yearly excess of 11.5 hospitalizations, 13 ER visits, 19.5 antimicrobial courses, and 47 corticosteroid courses for the first population were revealed. In the same way, considering 100 asthma patients with at least a critical error in inhalation vs 100 asthma patients without errors in inhalation, the first population is associated with a yearly excess of 19 hospitalizations, 26.5 ER visits, 4.5 antimicrobial courses, and 21.5 corticosteroid courses. These differences in resource consumption could be associated with an increase in health care expenditure for INHS, due to inhalation errors, of €23,444/yr in COPD and €44,104/yr in asthma for the considered cohorts of 100 patients. CONCLUSION This evaluation highlights that misuse of inhaler devices, due to inadequate training or nonconsented switch of inhaled medications, is associated with a decrease in disease control and an increase in health care resource consumption and costs.
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Braido F, Lavorini F, Blasi F, Baiardini I, Canonica GW. Switching treatments in COPD: implications for costs and treatment adherence. Int J Chron Obstruct Pulmon Dis 2015; 10:2601-8. [PMID: 26664108 PMCID: PMC4671757 DOI: 10.2147/copd.s79635] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Inhaled therapy is key to the management of chronic obstructive pulmonary disease (COPD). New drugs and inhalers have recently been launched or will soon become available, and the expiry of patent protection covering several currently used inhaled bronchodilators and corticosteroids will be accompanied by the development of bioequivalent, generic inhaled drugs. Consequently, a broader availability of branded and generic compounds will increase prescription opportunities. Given the time course of COPD, patients are likely to switch drugs and inhalers in daily practice. Switching from one device to another, if not accompanied by appropriate training for the patient, can be associated with poor clinical outcomes and increased use of health care resources. In fact, while it seems reasonable to prescribe generic inhaled drugs to reduce costs, inadequate use of inhaler devices, which is often associated with a poor patient–physician or patient–pharmacist relationship, is one of the most common reasons for failure to achieve COPD treatment outcomes. Further research is needed to quantify, as in asthma, the impact of inappropriate switching of inhalers in patients with COPD and show the outcomes related to the effect of using the same device for delivering inhaled medications.
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Affiliation(s)
- Fulvio Braido
- Respiratory and Allergy Diseases Clinic, Department of Internal Medicine, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Baiardini
- Respiratory and Allergy Diseases Clinic, Department of Internal Medicine, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Giorgio Walter Canonica
- Respiratory and Allergy Diseases Clinic, Department of Internal Medicine, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
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