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Anzueto A, Cohen M, Echazarreta AL, Elassal G, Godoy I, Paramo R, Sayiner A, Torres-Duque CA, Acharya S, Aggarwal B, Erkus H, Levy G. Delphi Consensus on Clinical Applications of GOLD 2023 Recommendations in COPD Management: How Aligned are Recommendations with Clinical Practice? Pulm Ther 2024; 10:69-84. [PMID: 38112909 PMCID: PMC10881920 DOI: 10.1007/s41030-023-00248-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION The objective of this Delphi study was to understand and assess the level of consensus among respiratory experts on the clinical application of GOLD 2023 recommendations in management of patients with chronic obstructive pulmonary disease (COPD). METHODS The study comprised two online surveys and a participant meeting with 34 respiratory experts from 16 countries. Responses of 73 questions were recorded using a Likert scale ranging from 0 (disagreement) to 9 (agreement). The consensus threshold was 75%. RESULTS Survey 1 and survey 2 had 34 and 32 participants, respectively; and 25 attended the participant meeting. Consensus was reached on survey 1: 28/42; survey 2: 18/30 close-ended questions. A consensus was reached on the clinical relevance of most updates in definitions and diagnosis of COPD. Mixed results for the treatment recommendations by GOLD were noted: 74% agreed with the recommendation to initiate treatment with dual bronchodilators for group E patients; 63% agreed for including inhaled corticosteroids (ICS)/long-acting β2 agonist(LABA)/ Long-acting muscarinic receptor antagonists (LAMA) as a treatment option for GOLD B patients. Also, consensus lacked on removing ICS + LABA as an initial therapeutic option, in countries with challenges in access to other treatment option;. 88% agreed that they use GOLD recommendations in their daily clinical practice. CONCLUSIONS This Delphi study demonstrated a high level of consensus regarding key concepts of GOLD 2023 report, with most participants favoring recent updates in definitions, diagnosis, management, and prevention of COPD. More evidence on the etiotype based management and treatment options for group B and E are required which could further strengthen clinical application of the GOLD report.
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Affiliation(s)
- Antonio Anzueto
- University of Texas Health and South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Mark Cohen
- Hospital Centro Medico, Guatemala City, Guatemala
| | | | - Gehan Elassal
- Department of Pulmonology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Irma Godoy
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu Campus, Pneumology Area, São Paulo, Brazil
| | | | - Abdullah Sayiner
- Department of Chest Diseases, Faculty of Medicine, Ege University, Izmir, Turkey
| | | | | | | | | | - Gur Levy
- Emerging Markets, GSK, Panama City, Panama
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Wachtel H, Emerson-Stadler R, Langguth P, Hohlfeld JM, Ohar J. Aerosol Plumes of Inhalers Used in COPD. Pulm Ther 2024; 10:109-122. [PMID: 38194194 PMCID: PMC10881950 DOI: 10.1007/s41030-023-00249-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION The selection of inhaler device is of critical importance in chronic obstructive pulmonary disease (COPD) as the interaction between a patient's inhalation profile and the aerosol characteristics of an inhaler can affect drug delivery and lung deposition. This study assessed the in vitro aerosol characteristics of inhaler devices approved for the treatment of COPD, including a soft mist inhaler (SMI), pressurized metered-dose inhalers (pMDIs), and dry powder inhalers (DPIs). METHODS High-speed video recording was used to visualize and measure aerosol velocity and spray duration for nine different inhalers (one SMI, three pMDIs, and five DPIs), each containing dual or triple fixed-dose combinations of long-acting muscarinic receptor antagonists and long-acting β2-agonists, with or without an inhaled corticosteroid. Measurements were taken in triplicate at experimental flow rates of 30, 60, and 90 l/min. Optimal flow rates were defined based on pharmacopoeial testing requirements: 30 l/min for pMDIs and SMIs, and the rate achieving a 4-kPa pressure drop against internal inhaler resistance for DPIs. Comparison of aerosol plumes was based on the experimental flow rates closest to the optimal flow rates. RESULTS The Respimat SMI had the slowest plume velocity (0.99 m/s) and longest spray duration (1447 ms) compared with pMDIs (velocity: 3.65-5.09 m/s; duration: 227-270 ms) and DPIs (velocity: 1.43-4.60 m/s; duration: 60-757 ms). With increasing flow rates, SMI aerosol duration was unaffected, but velocity increased (maximum 2.63 m/s), pMDI aerosol velocity and duration were unaffected, and DPI aerosol velocity tended to increase, with a more variable impact on duration. CONCLUSIONS Aerosol characteristics (velocity and duration of aerosol plume) vary by inhaler type. Plume velocity was lower and spray duration longer for the SMI compared with pMDIs and DPIs. Increasing experimental flow rate was associated with faster plume velocity for DPIs and the SMI, with no or variable impact on plume duration, whereas pMDI aerosol velocity and duration were unaffected by increasing flow rate.
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Affiliation(s)
- Herbert Wachtel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
| | - Rachel Emerson-Stadler
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany
| | - Peter Langguth
- Institute for Pharmaceutical and Biomedical Sciences (IPBW), University of Mainz, Mainz, Germany
| | - Jens M Hohlfeld
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Jill Ohar
- Department of Internal Medicine, Section on Pulmonary Medicine, Critical Care, Allergy and Immunologic Diseases, Atrium Health Wake Forest Baptist, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Lavorini F, Usmani OS, Salvi S, Rote K, Gaur V, Gogtay J. A narrative review on the Synchrobreathe™: A novel breath-actuated pressurised metered-dose inhaler for the treatment of obstructive airway diseases. Respir Med 2023; 219:107435. [PMID: 38652077 DOI: 10.1016/j.rmed.2023.107435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 04/25/2024]
Abstract
Pressurised metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs), are widely used to deliver drugs for the treatment of asthma and chronic obstructive pulmonary disease (COPD). Incorrect use of inhalers is one of the main obstacles to achieving better clinical control. Indeed, with pMDIs, patients fail to synchronise actuation with inhalation due to a lack of coordination and with DPIs insufficient inspiratory effort compromises drug deposition in lungs. More than 50% of patients desire to switch their pMDIs and DPIs for a better device. This led to the development of pressurised breath-actuated inhalers (BAIs) with the aim of combining the beneficial features of pMDIs and DPIs and mitigating their problems. BAIs, e.g., Synchrobreathe™, are designed such that they are activated by a low inhalation effort and mechanically actuate the dose in synchrony to inspiration, thereby resolving the need to coordinate actuation with inspiration. BAIs have advantages, including ease of use, high lung deposition of medication, and greater patient preference. We discussed the design features, operating procedure, and clinical evidence of the Synchrobreathe™ device (Cipla Ltd, India), a BAI available with a wide range of drug combinations. Studies have shown that a higher number of patients (68.19%) used the Synchrobreathe™ without any error than the pMDI (56.21%), and that the vast majority of them (92%) found it easy to understand and use. The Synchrobreathe™ is an innovative, easy-to-use inhaler that may overcome many limitations associated with pMDIs and DPIs, thus potentially improving management of obstructive airway diseases and patients' quality of life.
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Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, Dovehouse Street, London, SW3 6LY, UK
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, Maharashtra, India; Faculty of Health Sciences, Symbiosis International (Deemed University), Pune, Maharashtra, India
| | - Kiran Rote
- Integrated Product Development, Cipla Ltd, Mumbai, Maharashtra, India
| | - Vaibhav Gaur
- Global Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India.
| | - Jaideep Gogtay
- Global Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
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Mahler DA, Halpin DMG. Personalizing Selection of Inhaled Delivery Systems in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:1389-1396. [PMID: 37499210 PMCID: PMC10559134 DOI: 10.1513/annalsats.202304-384cme] [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: 07/27/2023] [Indexed: 07/29/2023] Open
Abstract
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.
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Affiliation(s)
- Donald A. Mahler
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire
- Valley Regional Hospital, Claremont, New Hampshire; and
| | - David M. G. Halpin
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
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Miravitlles M, Acharya S, Aggarwal B, Fernandes FLA, Dreyse J, Jardim JR, Juthong S, Levy G, Sivori M. Clinical Concepts for Triple Therapy Use in Patients with COPD: A Delphi Consensus. Int J Chron Obstruct Pulmon Dis 2023; 18:1853-1866. [PMID: 37662490 PMCID: PMC10474219 DOI: 10.2147/copd.s424128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose Role of triple therapy in chronic obstructive pulmonary disease (COPD) management is supported by growing evidence, but consensus is lacking on various aspects. We conducted a Delphi survey in respiratory experts on the effects of triple therapy on exacerbation reduction, early optimization, pneumonia risk, and mortality benefits in COPD management. Methods The study comprised 2-round online surveys and a participant meeting with 21 respiratory experts from 10 countries. The 31-statement questionnaire was prepared using Decipher software after literature review. Responses were recorded using Likert scale ranging from 1 (disagreement) to 9 (agreement) with a consensus threshold of 75%. Results All experts participated in both surveys and 14/21 attended participant meeting. Consensus was reached on 13/31 questions in first survey and 4/14 in second survey on: mortality benefits of triple therapy; comparable pneumonia risk between single inhaler triple therapy (SITT) and multiple inhaler triple therapy (81%); preference of SITT for patients with high eosinophil count (95%); exacerbation risk reduction and healthcare cost benefits with early initiation of SITT post exacerbation-related hospitalization (<30 days) (86%). No consensus was reached on first line SITT use after first exacerbation resulting in COPD diagnosis (62%). Conclusion This study demonstrated that there is consensus among experts regarding many of the key concepts about appropriate clinical use and benefits of triple therapy in COPD. More evidence is required for evaluating the benefits of early optimisation of triple therapy.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | | | - Frederico L A Fernandes
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jorge Dreyse
- Internal Medicine and Critical Care Center Departments, Clínica Las Condes and School of Medicine, Universidad Finis Terrae, Santiago, Chile
| | - José R Jardim
- Respiratory Division, Escola Paulista de Medicina, Federal University of São Paulo, Sao Paulo, Brazil
| | - Siwasak Juthong
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Gur Levy
- Emerging Markets, GlaxoSmithKline, Panama City, Panama
| | - Martin Sivori
- Pneumonology University Center, School of Medicine, University of Buenos Aires, Argentina, Unit of Pneumonology Hospital “Dr.J.M. Ramos Mejia”, Buenos Aires, Argentina
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Erdelyi T, Lazar Z, Farkas Á, Furi P, Nagy A, Müller V. Modeling of pulmonary deposition of agents of open and fixed dose triple combination therapies through two different low-resistance inhalers in COPD: a pilot study. Front Med (Lausanne) 2023; 10:1065072. [PMID: 37215734 PMCID: PMC10196142 DOI: 10.3389/fmed.2023.1065072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 04/10/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Inhalation therapy is a cornerstone of treating patients with chronic obstructive pulmonary disease (COPD). Inhaler devices might influence the effectiveness of inhalation therapy. We aimed to model and compare the deposition of acting agents of an open and a fixed dose combination (FDC) triple therapy and examine their repeatability. Methods We recruited control subjects (Controls, n = 17) and patients with stable COPD (S-COPD, n = 13) and those during an acute exacerbation (AE-COPD, n = 12). Standard spirometry was followed by through-device inhalation maneuvers using a pressurized metered dose inhaler (pMDI) and a soft mist inhaler (SMI) to calculate deposition of fixed dose and open triple combination therapies by numerical modeling. Through-device inspiratory vital capacity (IVCd) and peak inspiratory flow (PIFd), as well as inhalation time (tin) and breath hold time (tbh) were used to calculate pulmonary (PD) and extrathoracic deposition (ETD) values. Deposition was calculated from two different inhalation maneuvers. Results There was no difference in forced expiratory volume in 1 s (FEV1) between patients (S-COPD: 42 ± 5% vs. AE-COPD: 35 ± 5% predicted). Spiriva® Respimat® showed significantly higher PD and lower ETD values in all COPD patients and Controls compared with the two pMDIs. For Foster® pMDI and Trimbow® pMDI similar PD were observed in Controls, while ETD between Controls and AE-COPD patients did significantly differ. There was no difference between COPD groups regarding the repeatability of calculated deposition values. Ranking the different inhalers by differences between the two deposition values calculated from separate maneuvers, Respimat® produced the smallest inter-measurement differences for PD. Discussion Our study is the first to model and compare PD using pMDIs and an SMI as triple combination in COPD. In conclusion, switching from FDC to open triple therapy in cases when adherence to devices is maintanined may contribute to better therapeutic effectiveness in individual cases using low resistance inhalers.
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Affiliation(s)
- Tamas Erdelyi
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Zsofia Lazar
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Árpád Farkas
- Environmental Physics Department, Centre for Energy Research, Budapest, Hungary
| | - Peter Furi
- Environmental Physics Department, Centre for Energy Research, Budapest, Hungary
| | - Attila Nagy
- Department of Applied and Nonlinear Optics, Wigner Research Centre for Physics, Budapest, Hungary
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
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Woodcock A, Beeh KM, Sagara H, Aumônier S, Addo-Yobo E, Khan J, Vestbo J, Tope H. The environmental impact of inhaled therapy: making informed treatment choices. Eur Respir J 2021; 60:13993003.02106-2021. [PMID: 34916263 PMCID: PMC9301054 DOI: 10.1183/13993003.02106-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/22/2021] [Indexed: 12/03/2022]
Abstract
When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual or organisation is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of carbon dioxide equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered-dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives. There is increasing interest regarding the carbon footprint of inhaled therapies; while efficacy, safety and patient preference should be prioritised, the increasingly available carbon footprint data may be factored into treatment decision makinghttps://bit.ly/3I6atV2
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Affiliation(s)
- Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK .,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Kai M Beeh
- Insaf Respiratory Research Institute, Wiesbaden, Germany
| | - Hironori Sagara
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University, Tokyo, Japan
| | | | - Emmanuel Addo-Yobo
- Department of Child Health, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Javaid Khan
- Section of Pulmonary and Critical Care Medicine, The Aga Khan University, Karachi, Pakistan
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Helen Tope
- Principal Consultant, Planet Futures, Melbourne, Australia
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Mahler DA, Ludwig-Sengpiel A, Ferguson GT, de la Hoz A, Ritz J, Shaikh A, Watz H. TRONARTO: A Randomized, Placebo-Controlled Study of Tiotropium/Olodaterol Delivered via Soft Mist Inhaler in COPD Patients Stratified by Peak Inspiratory Flow. Int J Chron Obstruct Pulmon Dis 2021; 16:2455-2465. [PMID: 34511891 PMCID: PMC8414074 DOI: 10.2147/copd.s324467] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/12/2021] [Indexed: 12/04/2022] Open
Abstract
Background Inhaled bronchodilator therapy is currently the mainstay of treatment for patients with chronic obstructive pulmonary disease (COPD). Some inhalers require patients to achieve certain inhalation efforts either to activate the device or to deliver medication to the site of action. For dry powder inhalers, low peak inspiratory flow (PIF) can result in poor medication delivery but the clinical significance of this is not well understood. Methods TRONARTO was a 4-week, randomized, double-blind, placebo-controlled, multicenter, parallel-group study which stratified patients with moderate-to-severe COPD according to their PIF against medium-low resistance at screening. Patients were randomized to receive tiotropium/olodaterol (5 μg/5 μg) or matched placebo delivered via the Respimat® Soft Mist™ inhaler (SMI). After 4 weeks of treatment, we assessed change from baseline in forced expiratory volume in 1 second (FEV1) area under the curve 0–3 hours (FEV1 AUC0–3h) and trough FEV1. Results Overall, 213 patients were randomized, of whom 106 received tiotropium/olodaterol (PIF <60 L/min, 55; PIF ≥60 L/min, 51) and 107 received placebo (PIF <60 L/min, 55; PIF ≥60 L/min, 52). For FEV1 AUC0–3h, the adjusted mean change from baseline versus placebo was 336 mL (95% confidence interval [CI] 246–425 mL; P<0.0001) in the PIF <60 L/min group and 321 mL (95% CI 233–409 mL; P<0.0001) in the PIF ≥60 L/min group. For trough FEV1, the adjusted mean change from baseline versus placebo was 201 mL (95% CI 117–286 mL; P<0.0001) in the PIF <60 L/min group and 217 mL (95% CI 135–299 mL; P<0.0001) in the PIF ≥60 L/min group. Conclusion In the TRONARTO study, which included patients with moderate-to-severe COPD and varying inspiratory flow abilities, treatment with tiotropium/olodaterol resulted in significant lung function improvements versus placebo. This SMI can be used irrespective of the PIF that a patient can generate.
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Section of Pulmonary Medicine, Valley Regional Hospital, Claremont, NH, USA
| | | | - Gary T Ferguson
- Department of Medicine, Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Alberto de la Hoz
- Cardio-Metabolism and Respiratory, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - John Ritz
- Biostatistics, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Asif Shaikh
- Clinical Development & Medical Affairs, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
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Matera MG, Calzetta L, Ora J, Rogliani P, Cazzola M. Pharmacokinetic/pharmacodynamic approaches to drug delivery design for inhalation drugs. Expert Opin Drug Deliv 2021; 18:891-906. [PMID: 33412922 DOI: 10.1080/17425247.2021.1873271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: Inhaled drugs are important in the treatment of many lung pathologies, but to be therapeutically effective they must reach unbound concentrations at their effect site in the lung that are adequate to interact with their pharmacodynamic properties (PD) and exert the pharmacological action over an appropriate dosing interval. Therefore, the evaluation of pharmacokinetic (PK)/PD relationship is critical to predict their possible therapeutic effect.Areas covered: We review the approaches used to assess the PK/PD relationship of the major classes of inhaled drugs that are prescribed to treat pulmonary pathologies.Expert opinion: There are still great difficulties in producing data on lung concentrations of inhaled drugs and interpreting them as to their ability to induce the desired therapeutic action. The structural complexity of the lungs, the multiplicity of processes involved simultaneously and the physical interactions between the lungs and drug make any PK/PD approach to drug delivery design for inhalation medications extremely challenging. New approaches/methods are increasing our understanding about what happens to inhaled drugs, but they are still not ready for regulatory purposes. Therefore, we must still rely on plasma concentrations based on the axiom that they reflect both the extent and the pattern of deposition within the lungs.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigino Calzetta
- Unit of Respiratory Disease and Lung Function, Dept. Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Cvetkovski B, Hespe C, Tan R, Kritikos V, Azzi E, Bosnic-Anticevich S. General Practitioner Use of Generically Substitutable Inhaler Devices and the Impact of Training on Device Mastery and Maintenance of Correct Inhaler Technique. Pulm Ther 2020; 6:315-331. [PMID: 33038005 PMCID: PMC7672138 DOI: 10.1007/s41030-020-00131-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Generic substitution of inhaler devices is a relatively new phenomenon. The best patient outcomes associated with generic substitution occur when prescribers obtain consent from their patients to prescribe a generic inhaler and also teach their patient how to correctly use the new device. To date, no prospective observational study has assessed the level of training required for general practitioners (GPs) to demonstrate correct inhaler technique using two dry powder inhaler devices delivering fixed-dose combination budesonide/formoterol therapy. This study aims to (1) determine the level of training required for GPs to master and maintain correct IT when using two different dry powder inhalers that are able to be substituted in clinical practice and (2) determine the number and types of errors made by GPs on each device and inhaler device preference at each training visit. METHOD A randomized, parallel-group cross-over study design was used to compare the inhaler technique of participants with a Spiromax® placebo device and a Turbuhaler® placebo device. This study consisted of two visits with each participant over a period of 4 ± 1 weeks (visit 1 and visit 2). A total of six levels of assessment and five levels of training were implemented as required. Level 1, no instruction; level 2, following use of written instruction; level 3, following viewing of instructional video; level 4, expert tuition from the researcher; level 5/level 6, repeats of expert tuition from the researcher when required. Participants progressed through each level and stopped at the point at which they demonstrated device mastery. At each level, trained researchers assessed the inhaler technique of the participants. Participants were also surveyed about their previous inhaler use and training. RESULTS In total, 228 GPs participated in this study by demonstrating their ability to use a Turbuhaler® and a Spiromax® device. There was no significant difference between the proportion of participants who demonstrated device mastery with the Turbuhaler® compared with the Spiromax® at level 1, (no instruction), (119/228 (52%) versus 131/228 (57%), respectively, n = 228, p = 0.323 (McNemar's test of paired data). All but one participant had demonstrated correct inhaler technique for both devices by level 3(instructional video). There was a significant difference between the proportion of participants who demonstrated maintenance of device mastery with the Turbuhaler® compared with the Spiromax® at visit 2, level 1 (127/177 (72%) versus 151/177 (85%) respectively, p = 0.003; McNemar's test of paired data). All but two participants achieved device mastery by level 3, visit 2. More participants reported previous training with the Turbuhaler® than with Spiromax®. DISCUSSION This study demonstrates that GPs are able to equally demonstrate correct use of the Turbuhaler® and Spiromax® devices, even though most had not received training on a Spiromax® device prior to this study. The significance of being able to demonstrate correct technique on these two devices equally has ramifications on practice and supported generic substitution of inhaler devices at the point of prescribing, as the most impactful measure a GP can take to ensure effective use of inhaled medicine is the correct demonstration of inhaler technique.
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Affiliation(s)
- Biljana Cvetkovski
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Rachel Tan
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Elizabeth Azzi
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Sinthia Bosnic-Anticevich
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Local Health District, Sydney, Australia
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11
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Sanaullah T, Khan S, Masoom A, Mandokhail ZK, Sadiqa A, Malik MI. Inhaler Use Technique in Chronic Obstructive Pulmonary Disease Patients: Errors, Practices and Barriers. Cureus 2020; 12:e10569. [PMID: 33101814 PMCID: PMC7577299 DOI: 10.7759/cureus.10569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Inhaled medications are the main therapeutic treatment of chronic obstructive pulmonary disease (COPD) and inhaler technique remained important that can increase medication efficacy, reducing dose and side effects. Poor inhaler technique is multi-factorial and the quality of inhaler technique has not previously assessed in Pakistan. We conducted a study to examine a range of competing factors that impact COPD patient willingness, practices, and preference in using their inhalers. Methods A cross-sectional of 765 patients with COPD were interviewed and assessed by qualitative questionnaires. Objective inhalation technique and steps assessment was performed; satisfaction, preferences, perception, and practice of different types of inhaler devices were evaluated at a single cross-sectional visit at the study enrolment. Results The study included 765 participants of mean age 58.7 years (SD ±7.8); 32% males and 68% females. Almost all of the females were exposed to biomass fuel smoke exposure (99%) and pipe (Huka) smokers 53%, while most male participants were cigarette smokers (92%). Only 6.3% of participants were able to perform correct steps of inhaler use, and few educated patients completed 7-steps. 66% of patients were using dry powder inhalers (DPI) inhaler devices and mostly performed the steps 1, 2, and 4 (98%) correctly, while 44% who were using metered-dose inhalers (MDI) completed only steps 2 and 4 correctly (88%). The majority of participants reported the particular inhaler devices was prescribed by the visiting consultants (54%). Interestingly, they were using two inhalers together (47%) relieving symptoms of dyspnea (83%) and cough (73%). The inhaler use technique was demonstrated to most of the patients by the pharmacy salesman (38.4%), while 15.8% reported that their doctors taught them the inhaler technique. 54.2% reported reason for poor adherence to inhaler use as they understand it might not work lately and 75.2% were not aware of any side effects associated with the regular use of an inhaler. Conclusions Poor inhaler technique is highly prevalent and the associated errors did not appear to be dependent on device type. Most of the participants had not receive proper training about the correct use and were not involved in decision making about the choice of inhaler device.
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Affiliation(s)
- Tareen Sanaullah
- Pulmonary Medicine and Critical Care, FJ Chest Hospital, Bolan University of Medical and Health Sciences, Quetta, PAK
| | - Shereen Khan
- Pulmonary Medicine and Critical Care, Bolan University of Medical and Health Sciences, Quetta, PAK
| | - Aria Masoom
- Otolaryngology - Head and Neck Surgery, Bolan Medical Complex Hospital, Quetta, PAK
| | | | - Aisha Sadiqa
- Gynaecology & Obstetrics, Civil Provincial Hospital, Quetta, PAK
| | - Muhammad Irfan Malik
- Pulmonology, Postgraduate Medical Institute/Ameer-ud-Din Medical College (AMC) Lahore General Hospital, Lahore, PAK
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12
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Abstract
Introduction Chronic obstructive pulmonary disease (COPD) is a progressive disease requiring maintenance therapy. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report, bronchodilation with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs), administered via inhalers, is currently the mainstay of COPD treatment. Combined LAMA/LABA therapies have been shown to improve patient health status, lung function and breathlessness. Here, we wanted to report patient satisfaction with the Respimat® Soft Mist™ inhaler (SMI). Methods This was a pooled analysis of SPIRIT® (NCT02675517) and OTIVACTO® (NCT02719639), two open-label, single-arm, non-interventional studies of physical function in patients with COPD. Patients were treated with tiotropium/olodaterol 5/5 μg for approximately 6 weeks via the SMI. SPIRIT was conducted in Germany; OTIVACTO was conducted in nine European countries. The primary endpoints have been reported previously. Here, we assess patient satisfaction with inhalation and handling, and patient adherence to treatment with the tiotropium/olodaterol SMI in patients with COPD. These were assessed through self-reported questionnaires and physician general assessments. Results Baseline data were collected from 9180 patients from the SPIRIT and OTIVACTO studies. The majority of patients were GOLD group A (25.59%) or B (46.12%). After 6 weeks of treatment with tiotropium/olodaterol, 85.78% of patients were ‘satisfied’ or ‘very satisfied’ with inhaling from the device, and 84.33% of patients were ‘satisfied’ or ‘very satisfied’ with the handling of the inhaler. Treating physicians reported patient adherence as ‘high’ during the study, with 98.57% of patients regularly using the tiotropium/olodaterol SMI. Furthermore, 95.45% of patients expressed a willingness to continue using the tiotropium/olodaterol SMI at the end of the observation period. Conclusion In this study, over 9000 patients reported satisfaction with respect to inhalation and handling of the Respimat SMI, and patient adherence was high. Trial registration ClinicalTrials.gov: NCT02675517 (SPIRIT) and NCT02719639 (OTIVACTO). Inhalation devices are the main method of delivering treatments to patients with chronic obstructive pulmonary disease (COPD). However, there are many devices available, which can lead to confusion and poor inhaler technique. To help doctors decide which device to give to their patients, they consider whether the patient would be happy with the device and whether they can use it correctly. This study pooled data from two large real-life studies to assess patient satisfaction with the Respimat® Soft Mist™ inhaler. Patients assessed their satisfaction and willingness to continue using the device at the end of the study period. The pooled data included over 9000 patients on a range of baseline therapies. After 6 weeks of using the trial device, over 85% of patients were satisfied or very satisfied with inhaling from the device, and over 84% were satisfied with the handling of the device. Physicians reported that nearly 99% of patients regularly used their device. Also, over 95% of the patient population reported that they continued using the inhaler at the end of the study. Overall, these results support the view that many patients with COPD across a wide range of severities and baseline characteristics demonstrated satisfaction with the Respimat® Soft Mist™ inhaler to control their disease.
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13
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Lavorini F, Janson C, Braido F, Stratelis G, Løkke A. What to consider before prescribing inhaled medications: a pragmatic approach for evaluating the current inhaler landscape. Ther Adv Respir Dis 2020; 13:1753466619884532. [PMID: 31805823 PMCID: PMC6900625 DOI: 10.1177/1753466619884532] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Inhaled therapies are the cornerstone of treatment in asthma and chronic obstructive pulmonary disease, and there are a multitude of devices available. There is, however, a distinct lack of evidence-based guidance for healthcare providers on how to choose an appropriate inhaler. This review aims to summarise recent updates on topics related to inhaler choice, and to offer practical considerations for healthcare providers regarding currently marketed devices. The importance of choosing the right inhaler for the right patient is discussed, and the relative merits of dry powder inhalers, pressurised metered dose inhalers, breath-actuated pressurised metered dose inhalers, spacers and soft mist inhalers are considered. Compiling the latest studies in the devices therapy area, this review focuses on the most common types of handling errors, as well as the comparative rates of incorrect inhalation technique between devices. The impact of device-specific handling errors on inhaler performance is also discussed, and the characteristics that can impair optimal drug delivery, such as inhalation flow rate, inhalation volume and particle size, are compared between devices. The impact of patient perceptions, behaviours and problems with inhalation technique is analysed, and the need for appropriate patient education is also highlighted. The continued development of technology in inhaler design and the need to standardise study assessment, endpoints and patient populations are identified as future research needs. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Federico Lavorini
- Careggi University Hospital, Department of Experimental and Clinical Medicine, Largo Brambilla 3, 50134, Florence, Italy
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden
| | - Fulvio Braido
- Allergy and Respiratory Disease Clinic, DIMI-University of Genova, IRCCS AOU San Martino-IST, Genova, Italy
| | - Georgios Stratelis
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden.,AstraZeneca Nordic-Baltic, Astraallén, Sødertälje, Sweden
| | - Anders Løkke
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus C, Denmark
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14
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Lavorini F, Bianco A, Blasi F, Braido F, Corsico AG, Di Marco F, Gentile A, Paggiaro PL, Pegoraro V, Pelaia G, Rogliani P, Santus P, Scichilone N, Soldi A, Canonica GW. What drives inhaler prescription for asthma patients? Results from a real-life retrospective analysis. Respir Med 2020; 166:105937. [PMID: 32250870 DOI: 10.1016/j.rmed.2020.105937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/27/2020] [Accepted: 03/17/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The choice of inhaler device for asthma patients depends upon multiple attributes. We investigated factors that may drive general practitioners (GPs) and respiratory specialists in the prescription of inhaler devices for asthma patients who initiated inhalation therapy. METHODS We retrospectively analysed prescriptions by GPs and respiratory specialists to asthma patients commencing inhaled corticosteroid/long-acting β2-agonist combination therapy available as both pressurised metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs). Patient characteristics were compared by device and multivariate analysis was used to model the likelihood of receiving a pMDI as opposed to a DPI in order to identify drivers for prescription. A sample of the respiratory specialists completed an ad-hoc survey of their perceived success in achieving asthma control in their patients and barriers to attaining full control. RESULTS Prescription of a particular inhaler device was unrelated to the characteristics of the patients. Multivariate analysis revealed that the main driver for the choice of inhaler device was the medication (Odds Ratio and 95% Confidence Interval, respectively for GPs and specialists: 0.19 [0.16-0.23]; 0.17 [0.08-0.37]). Specialists perceived asthma as being inadequately controlled in 41% of their patients, and considered patients' difficulties in using DPIs and pMDIs as instrumental in this, citing a need for a novel, more effective inhaler technology. CONCLUSION Physicians choose inhaler devices according to the prescribed drugs and not to the characteristics of the individual patient. This may reflect a lack of confidence in existing inhaler devices and underlines the need for technologies, which are more reliable and easier to use by patients.
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Affiliation(s)
- F Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - A Bianco
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - F Blasi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - F Braido
- Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genova, Azienda Policlinico IRCCs San Martino, Genoa, Italy
| | - A G Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation - Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - F Di Marco
- Department of Health Sciences, University of Milan, Italy - Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - A Gentile
- Mundipharma Pharmaceuticals, Milan, Italy
| | - P L Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Italy
| | | | - G Pelaia
- Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - P Rogliani
- Respiratory Medicine Department of Experimental Medicine, University of Rome "Tor Vergata" - Respiratory Unit, Policlinico Tor Vergata, Rome, Italy
| | - P Santus
- Department of Biomedical and Clinical Sciences (DIBIC) - University of Milan. Division of Respiratory Diseases - "L. Sacco" University Hospital - ASST Fatebenefratelli Sacco - Milan, Italy
| | - N Scichilone
- PROMISE Department, University of Palermo, Palermo, Italy
| | - A Soldi
- Mundipharma Pharmaceuticals, Milan, Italy
| | - G W Canonica
- Personalized Medicine, Asthma and Allergy Clinic, Humanitas Research Hospital - Department of Biomedical Sciences, Humanitas University, Milan, Italy
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15
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Cazzola M, Cavalli F, Usmani OS, Rogliani P. Advances in pulmonary drug delivery devices for the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Deliv 2020; 17:635-646. [DOI: 10.1080/17425247.2020.1739021] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Mario Cazzola
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Francesco Cavalli
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Omar S. Usmani
- Imperial College London and Royal Brompton Hospital, Airways Disease Section, National Heart and Lung Institute (NHLI), London, UK
| | - Paola Rogliani
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
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16
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The Respimat ® Soft Mist Inhaler: Implications of Drug Delivery Characteristics for Patients. Clin Drug Investig 2020; 39:1021-1030. [PMID: 31377981 PMCID: PMC6800401 DOI: 10.1007/s40261-019-00835-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Successful treatment for respiratory diseases relies on effective delivery of medication to the lungs using an inhalation device. Different inhalers have distinct characteristics affecting drug administration and patient adherence, which can impact clinical outcomes. We report on the development of the Respimat® soft mist inhaler (SMI) and compare key attributes with metered-dose inhalers (MDIs) and dry powder inhalers (DPIs). The Respimat SMI, a pocket-sized device generating a single-breath, inhalable aerosol, was designed to enhance drug delivery to the lungs, reduce the requirements for patient coordination and inspiratory effort, and improve the patients’ experience and ease of use. The drug deposition profile with Respimat SMI is favorable compared with MDIs and DPIs, with higher drug deposition to the lung and peripheral airways. The slow velocity and long spray duration of the Respimat SMI aerosol also aid patient coordination. Clinical equivalence has been demonstrated for maintenance treatment of chronic obstructive pulmonary disease using once-daily tiotropium between Respimat SMI (5 µg) and HandiHaler DPI (18 µg). In comparative studies, patients preferred Respimat SMI to MDIs and DPIs; they reported that Respimat SMI was easy to use and felt the inhaled dose was delivered. The Respimat SMI, designed to generate a slow-moving and fine mist, is easy to use and effectively delivers drug treatment to the lungs. The patient-centered design of Respimat SMI improved patient satisfaction, and may help to promote long-term adherence and improve clinical outcomes with asthma and chronic obstructive pulmonary disease.
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17
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Navaie M, Dembek C, Cho-Reyes S, Yeh K, Celli BR. Device use errors with soft mist inhalers: A global systematic literature review and meta-analysis. Chron Respir Dis 2020; 17:1479973119901234. [PMID: 31984767 PMCID: PMC6985977 DOI: 10.1177/1479973119901234] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/28/2019] [Indexed: 11/30/2022] Open
Abstract
Inhaled bronchodilators are the cornerstone of treatment for chronic obstructive pulmonary disease (COPD). Soft mist inhalers (SMIs) are devices that deliver bronchodilators. Although correct device use is paramount to successful medication delivery, patient errors are common. This global systematic literature review and meta-analysis examined device use errors with SMIs among patients with obstructive lung diseases. PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify studies published between 2010 and 2019 that met the following inclusion criteria: (a) English language; (b) a diagnosis of COPD, bronchitis, or emphysema; and (c) reported device use errors among adults receiving long-acting bronchodilator treatment with Respimat® SMI (i.e. Spiriva®, Stiolto®, Spiolto®, and Striverdi®). Descriptive statistics examined sociodemographics, clinical characteristics, and device use errors. Meta-analysis techniques were employed with random-effects models to generate pooled mean effect sizes and 95% confidence intervals (CIs) for overall and step-by-step errors. The I2 statistic measured heterogeneity. Twelve studies (n = 1288 patients) were included in this meta-analysis. Eighty-eight percent of patients had COPD, and most had moderate/very severe airflow limitation (Global Initiative for Chronic Obstructive Lung Disease spirometric stages II to IV). Aggregate results revealed that 58.9% (95% CI: 42.4-75.5; I2 = 92.8%) of patients made ≥1 device use errors. Among 11 studies with step-by-step data, the most common errors were failure to (1) exhale completely and away from the device (47.8% (95% CI: 33.6-62.0)); (2) hold breath for up to 10 seconds (30.6% (95% CI: 17.5-43.7)); (3) take a slow, deep breath while pressing the dose release button (27.9% (95% CI: 14.5-41.2)); (4) hold the inhaler upright (22.6% (95% CI: 6.2-39.0)); and (5) turn the base toward the arrows until it clicked (17.6% (95% CI: 3.0-32.2)). Device use errors occurred in about 6 of 10 patients who used SMIs. An individualized approach to inhalation device selection and ongoing training and monitoring of device use are important in optimizing bronchodilator treatment.
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Affiliation(s)
- Maryam Navaie
- Advance Health Solutions, LLC, New York, NY, USA
- School of Professional Studies, Columbia University, New York, NY, USA
| | - Carole Dembek
- Global Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | | | - Karen Yeh
- Advance Health Solutions, LLC, New York, NY, USA
| | - Bartolome R Celli
- Chronic Obstructive Pulmonary Disease Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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18
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Fernandes FLA, Tanni SE. The future is now. J Bras Pneumol 2019; 45:e20190354. [PMID: 31826105 PMCID: PMC7447550 DOI: 10.1590/1806-3713/e20190354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Frederico Leon Arrabal Fernandes
- . Ambulatório de DPOC, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
- . Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
- . Laboratório de Função Pulmonar, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, São Paulo (SP) Brasil
| | - Suzana Erico Tanni
- . Departamento de Medicina Interna, Área de Pneumologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
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19
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Lindh A, Theander K, Arne M, Lisspers K, Lundh L, Sandelowsky H, Ställberg B, Westerdahl E, Zakrisson A. Errors in inhaler use related to devices and to inhalation technique among patients with chronic obstructive pulmonary disease in primary health care. Nurs Open 2019; 6:1519-1527. [PMID: 31660180 PMCID: PMC6805258 DOI: 10.1002/nop2.357] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/25/2019] [Accepted: 07/10/2019] [Indexed: 11/27/2022] Open
Abstract
AIM The aim of this study was to describe inhaler use in primary health care patients with chronic obstructive pulmonary disease (COPD) and to categorize these patients into those making errors related to devices, those making errors related to inhalation technique and those making errors related to both. DESIGN Observational study. METHODS COPD nurses used a checklist to assess the use of inhalers by patients with spirometry-verified COPD (N = 183) from primary healthcare centres. The STROBE checklist has been used. RESULTS The mean age of the patients was 71 (SD 9) years. Almost half of them (45%) made at least one error; of these, 50% made errors related to devices, 31% made errors related to inhalation technique and 19% made errors related both to devices and to inhalation technique.
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Affiliation(s)
- Annika Lindh
- Faculty of Medicine and Health, School of Health SciencesÖrebro UniversityÖrebroSweden
- Centre for Clinical ResearchRegion VärmlandKarlstadSweden
| | | | - Mats Arne
- Centre for Clinical ResearchRegion VärmlandKarlstadSweden
- Department of Medical Sciences, Respiratory, Allergy & Sleep ResearchUppsala UniversityUppsalaSweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive MedicineUppsala UniversityUppsalaSweden
| | - Lena Lundh
- Academic Primary Health Care CentreStockholmSweden
- Division of Family Medicine and Primary CareKarolinska Institutet, NVSStockholmSweden
| | - Hanna Sandelowsky
- Academic Primary Health Care CentreStockholmSweden
- Division of Family Medicine and Primary CareKarolinska Institutet, NVSStockholmSweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive MedicineUppsala UniversityUppsalaSweden
| | - Elisabeth Westerdahl
- Faculty of Medicine and Health, School of Health SciencesÖrebro UniversityÖrebroSweden
- Faculty of Medicine and HealthUniversity Health Care Research Centre, Örebro UniversityÖrebroSweden
| | - Ann‐Britt Zakrisson
- Faculty of Medicine and HealthUniversity Health Care Research Centre, Örebro UniversityÖrebroSweden
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20
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Di Marco F, Balbo P, de Blasio F, Cardaci V, Crimi N, Girbino G, Pelaia G, Pirina P, Roversi P, Santus P, Scichilone N, Vatrella A, Pasqualetti P, Carone M. Early management of COPD: where are we now and where do we go from here? A Delphi consensus project. Int J Chron Obstruct Pulmon Dis 2019; 14:353-360. [PMID: 30787604 PMCID: PMC6366359 DOI: 10.2147/copd.s176662] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE There is a lack of consensus on the most appropriate early diagnostic strategy, criteria for early access to treatment and follow-up approach for patients with COPD. MATERIALS AND METHODS A Delphi consensus project investigated the early management of COPD. We formulated two questionnaires for completion by pneumologists in Italy. RESULTS A total of 207 specialists completed questionnaire 1 and 184 of them questionnaire 2, between November 2016 and October 2017. Early diagnosis of COPD was considered uncommon for 93.2% of the expert panel. Regardless of the definition of "early diagnosis" - a diagnosis made before the clinical manifestation of the disease for most responders (60.4%) - experts were confident of the positive effects of early disease management, which they consider is effective in modifying the natural history of the disease. Lack of awareness of the disease was considered the first limiting factor to early COPD management for 78% of respondents. The most effective steps to reduce functional decline were considered to be smoking cessation, followed by long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA), LAMA, LABA, and finally inhaled corticosteroid/LABA (P<0.01 for each paired comparison). Specialists considered it "inappropriate" for general practitioners to perform both the early diagnosis and therapy of COPD without the involvement of a specialist. CONCLUSION Early management of COPD is uncommon, and although data on the effects of early disease management on long-term outcomes are limited, Italian experts are confident of the clinical efficacy of this approach.
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Affiliation(s)
- Fabiano Di Marco
- Department of Health Sciences, University of Milan, Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy,
| | - Piero Balbo
- SC Malattie dell'Apparato Respiratorio, AOU Maggiore della Carità, Novara, Italy
| | - Francesco de Blasio
- Respiratory Medicine and Pulmonary Rehabilitation Section, Clinic Center S.p.A. Private Hospital, Department of Medicine and Health Sciences "V Tiberio", University of Molise, Campobasso, Italy
| | - Vittorio Cardaci
- Unit of Pulmonary Rehabilitation, IRCCS "San Raffaele Pisana", Rome, Italy
| | - Nunzio Crimi
- Unità Operativa Complessa di Pneumologia e Allergologia, Policlinico Rodolico Vittorio Emanuele, Università di Catania, Catania, Italy
| | - Giuseppe Girbino
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali (BIOMORF), Università degli Studi di Messina, Messina, Italy
| | - Girolamo Pelaia
- Department of Medical and Surgical Sciences, Unit of Respiratory Diseases, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - Pietro Roversi
- Azienda Ospedaliera Universitaria, Policlinico di Modena, Modena, Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
- Division of Respiratory Diseases "L. Sacco" Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Nicola Scichilone
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), University of Palermo, Palermo, Italy
| | - Alessandro Vatrella
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Salerno, Italy
| | - Patrizio Pasqualetti
- Fondazione Fatebenefratelli per la Ricerca e la Formazione Sanitaria e Sociale, Rome, Italy
| | - Mauro Carone
- Istituti Clinici Scientifici Maugeri, IRCCS di Cassano delle Murge, Cassano delle Murge (BA), Italy
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Miravitlles M, Baek S, Vithlani V, Lad R. Optimal Bronchodilation for COPD Patients: Are All Long-Acting β₂-Agonist/Long-Acting Muscarinic Antagonists the Same? Tuberc Respir Dis (Seoul) 2018; 81:198-215. [PMID: 29926556 PMCID: PMC6030660 DOI: 10.4046/trd.2018.0040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 04/26/2018] [Accepted: 04/29/2018] [Indexed: 12/21/2022] Open
Abstract
Bronchodilators provide improvements in lung function and reductions in symptoms and exacerbations, and are the mainstay of pharmacological management of chronic obstructive pulmonary disease (COPD). The Global Initiative for Chronic Obstructive Lung Disease strategy recommends the use of a combination of long-acting β₂-agonist/long-acting muscarinic antagonists (LABA/LAMA) as the first-line treatment option in the majority of symptomatic patients with COPD. This review provides an indirect comparison of available LABA/LAMA fixed-dose combinations (FDCs) through discussion of important efficacy and safety data from the key literature, with the objective of providing physicians with a framework for informed decision-making. LABA/LAMA FDCs provided greater benefits compared with placebo and similar or greater benefits compared with tiotropium and salmeterol/fluticasone in improving lung function, dyspnea, health-related quality of life, reducing rescue medication use and preventing exacerbations, although with some variability in efficacy between individual FDCs; further, tolerability profiles were comparable among LABA/LAMA FDCs. However, there is a disparity in the amount of evidence generated for different LABA/LAMA FDCs. Thus, this review shows that all LABA/LAMA FDCs may not be the same and that care should be taken when extrapolating individual treatment outcomes to the entire drug class. It is important that physicians consider the efficacy gradient that exists among LABA/LAMA FDCs, and factors such as inhaler devices and potential biomarkers, when choosing the optimal bronchodilator treatment for long-term management of patients with COPD.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
| | | | | | - Rahul Lad
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
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22
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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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