Comparison of two budesonide powder inhalers, Easyhaler and Turbuhaler, in steroid-naïve asthmatic patients

Combined in Vitro-in Silico Approach to Predict Deposition and Pharmacokinetics of Budesonide Dry Powder Inhalers

PURPOSE

A combined in vitro - in silico methodology was designed to estimate pharmacokinetics of budesonide delivered via dry powder inhaler.

METHODS

Particle size distributions from three budesonide DPIs, measured with a Next Generation Impactor and Alberta Idealized Throat, were input into a lung deposition model to predict regional deposition. Subsequent systemic exposure was estimated using a pharmacokinetic model that incorporated Nernst-Brunner dissolution in the conducting airways to predict the net influence of dissolution, mucociliary clearance, and absorption.

RESULTS

DPIs demonstrated significant in vitro differences in deposition, resulting in large differences in simulated regional deposition in the central conducting airways and the alveolar region. Similar but low deposition in the small conducting airways was observed with each DPI. Pharmacokinetic predictions showed good agreement with in vivo data from the literature. Peak systemic concentration was tied primarily to the alveolar dose, while the area under the curve was more dependent on the total lung dose. Tracheobronchial deposition was poorly correlated with pharmacokinetic data.

CONCLUSIONS

Combination of realistic in vitro experiments, lung deposition modeling, and pharmacokinetic modeling was shown to provide reasonable estimation of in vivo systemic exposure from DPIs. Such combined approaches are useful in the development of orally inhaled drug products.

Today's improvement in asthma treatment: role of MART and Easyhaler

Asthma affects more than 330 million people worldwide, but many analyses have shown that there are still a lot of unmet needs for both patients and physicians in the treatment of asthma: poor adherence to treatment is one of the main causes of sub-optimal clinical results. Maintenance and Reliever Therapy (MART) with the combination of formoterol and inhaled corticosteroids (ICS) has an established scientific rationale and demonstrated to reduce asthma exacerbations. The aim of this review is to highlight how in asthmatic patients MART can be able to express its maximum therapeutic potential when administered through an 'ideal inhaler'. Since the treatment may be necessary several times a day, the use of a single combination inhaler simplifies the management, potentially improving adherence; moreover, easiness of use and comfort in administration of asthma treatment devices are not secondary aspects. Asthmatic patients are often young, with a normal relational and working life and they could request for a comfortable and not too noticeable device. Finally to the "ideal inhaler" is requested to guarantee accuracy, dose consistency, and resistance to stress conditions. Easyhaler® more closely demonstrates many expected characteristics: effective, consistent performance regardless of inspiration rate, stability, versatility, with several patient acceptability advantages. Asthma control is enhanced by a strong adherence obtained through the combination in a single inhaler of both maintenance and reliever therapy and the availability of a device as close as possible to the characteristics of the ideal inhaler.

A Multicenter, Observational, Prospective Study of the Effectiveness of Switching from Budesonide/Formoterol Turbuhaler® to Budesonide/Formoterol Easyhaler®

Introduction

In real-life practice, asthma remains poorly controlled, with a considerable burden on patients’ quality of life. Budesonide/formoterol (B/F) Easyhaler^® has demonstrated similar dose consistency, therapeutic equivalence, and equivalent bronchodilator efficacy to B/F Turbuhaler^®, but no real-life comparisons are yet available in patients switching from B/F Turbuhaler^® to B/F Easyhaler^®.

Methods

The primary objective of this real-life, non-interventional, observational study was to show non-inferiority of asthma control when adult patients in Swedish primary care with persistent asthma switched from B/F Turbuhaler^® to B/F Easyhaler^®. At visit 1, baseline demographic and endpoint data were recorded, and eligible patients switched to B/F Easyhaler^®. The study comprised a control visit (visit 2) and a concluding examination (visit 3) after 12 weeks. Asthma control was assessed using the Asthma Control Test (ACT). The mini-Asthma Quality of Life Questionnaire (AQLQ) and lung function test were performed, and participants and investigators answered questionnaires about ease-of-use and teaching.

Results

A total of 117 patients were enrolled in the on-treatment population; 81 (64.8%) were female. At visit 3, B/F Easyhaler^® demonstrated non-inferiority to B/F Turbuhaler^®; the mean difference in change from baseline ACT was statistically significant (18.9 vs. 20.7, respectively; p < 0.0001) and met the non-inferiority criteria of B/F Easyhaler^® being greater than − 1.5 points versus the reference product. Asthma was well controlled in 62 (53.0%) patients at baseline, increasing to 83 patients (70.9%) at visit 3. Patients experienced statistically significant improvements in mini-AQLQ score after B/F Easyhaler^® treatment and lung function remained stable across the treatment period. B/F Easyhaler^® was easy to learn and prepare for use.

Conclusion

This real-life, non-interventional, non-inferiority study in adults with persist asthma demonstrates equivalent or better disease control when patients switch from B/F Turbuhaler^® to B/F Easyhaler^®. A further study with direct comparison between treatments could add to the understanding of inhaler switch.

Funding

Orion Corporation, Orion Pharma.

Electronic supplementary material

The online version of this article (10.1007/s12325-019-00940-7) contains supplementary material, which is available to authorized users.

Easyhaler®: an overview of an inhaler device for day-to-day use in patients with asthma and chronic obstructive pulmonary disease

Inhalation therapy is likely to continue to dominate asthma and chronic obstructive pulmonary disease (COPD) treatment. The pressurised metered-dose inhaler (pMDI) accounts for most of the global inhaler market, but this kind of device is difficult to use properly. Dry powder inhalers (DPIs) have several advantages over pMDIs: they are breath-activated, easy and convenient to use, and environmentally friendly. The Easyhaler^® (Orion; Finland) is a multidose reservoir-type DPI developed to efficiently deliver a wide range of medications, including fixed-dose combinations of bronchodilators and corticosteroids. Easyhaler shares a similar shape with the pMDI, and its performance is unaffected by moisture, dropping, vibration, and freezing/thawing. For these reasons, Easyhaler may be considered one of the most convenient inhalers for daily use in patients with asthma or COPD.

In Vitro Flow Rate Dependency of Delivered Dose and Fine Particle Dose of Salmeterol/Fluticasone Propionate Easyhaler and Seretide Diskus with Patient Flow Rates Collected in a Randomized Controlled Trial

Background: The Easyhaler^® device-metered dry powder inhaler containing Salmeterol and Fluticasone propionate (S/F) has been developed for the treatment of patients with asthma and chronic obstructive pulmonary disease (COPD). We report two studies which evaluated the in vitro flow rate dependence of delivered dose (DD) and fine particle dose (FPD) of S/F Easyhaler versus Seretide Diskus^®.

Methods: A randomized controlled trial (RCT) assessed inspiratory flow parameters of S/F Easyhaler and Seretide Diskus in subgroups of patients with asthma (children, adolescents and adults, and elderly) and in COPD patients. The 10th, 50th, and 90th percentile airflow rates were determined and utilized in vitro, to evaluate flow rate dependence of DD and FPD. Flow rate dependence was evaluated relative to the result obtained at the 50th percentile and any values deviating from 100% indicated flow rate dependence. The volumetric flow rate dependence (Q) index derived from FPD at 10th and 90th percentile airflows was also evaluated.

Results: Overall, 227 patients were enrolled and randomized; 216 completed the RCT. In total, 55.5% of patients were female, and the mean age was 46.3 years. Clinically relevant airflow rates (46, 68, and 85 L/min for S/F Easyhaler and 44, 71, and 96 L/min for Seretide Diskus) were carried forward into the in vitro study, which demonstrated similar flow rate dependence of DD and FPD for S/F Easyhaler compared with Seretide Diskus; all values were within ±15% limits across the 10th, 50th, and 90th percentile airflow rates. Q index results suggested that both S/F Easyhaler and Seretide Diskus are medium airflow-dependent products.

Conclusions: Similar in vitro flow rate dependence of DD and FPD was demonstrated for S/F Easyhaler compared with Seretide Diskus, across a range of clinically relevant airflow rates, collected from patients with asthma and COPD.

Dose uniformity of budesonide Easyhaler® under simulated real-life conditions and with low inspiration flow rates

Budesonide Easyhaler® multidose dry powder inhaler is approved for the treatment of asthma. Objectives were to determine the delivered dose (DD) uniformity of budesonide Easyhaler® in simulated real-world conditions and with different inspiration flow rates (IFRs). Three dose delivery studies were performed using 100, 200, and 400 µg/dose strengths of budesonide. Dose uniformity was assessed during in-use periods of 4-6 months after exposure to high temperature (30°C) and humidity (60% relative humidity) and after dropping and vibration testing. The influence of various IFRs (31, 43, and 54 L/min) on the DD was also investigated. Acceptable dose uniformity was declared when mean DD were within 80-120% of expected dose; all data reported descriptively. DD was constant (range: 93-109% of expected dose) at all in-use periods and after exposure to high temperature and humidity for a duration of up to 6 months. DD post-dropping and -vibration were unaffected (range 98-105% of expected dose). Similarly, DD was constant and within 10% of expected dose across all IFRs. Results indicate that budesonide Easyhaler® delivers consistently accurate doses in various real-life conditions. Budesonide Easyhaler® can be expected to consistently deliver a uniform dose and improve asthma control regardless of high temperature and humidity or varying IFR.

Treatment of asthma exacerbations with the human-powered nebuliser: a randomised parallel-group clinical trial

Background:

Nebulisers aid the treatment of respiratory diseases, including asthma, but they require electricity and are often cost-prohibitive for low- and middle-income countries.

Aims:

The aim of this study was to compare a low-cost, human-powered nebuliser compressor with an electric nebuliser compressor for the treatment of mild to moderate asthma exacerbations in adults and children.

Methods:

This was a non-blinded, parallel-group, equivalence study, with 110 subjects between 6 and 65 years of age, conducted in the emergency department of a district hospital in Ilopango, El Salvador. Participants were assigned by random allocation to receive a 2.5-mg dose of salbutamol from the experimental human-powered nebuliser or the electric nebuliser control. All assigned participants completed treatment and were included in analysis. The study was not blinded as this was clinically unfeasible; however, data analysis was blinded.

Results:

The mean improvement in peak flow of the experimental and control groups was 37.5 (95% confidence interval (CI) 26.7–48.2) l/min and 38.7 (95% CI, 26.1–51.3) l/min, respectively, with a mean difference of 1.3 (95% CI, −15.1 to 17.7) l/min. The mean improvement in percent-expected peak flow for the experimental and control groups was 12.3% (95% CI, 9.1–15.5%) and 13.8% (95% CI, 9.8–17.9%), respectively, with a mean difference of 1.5% (95% CI, −3.6 to 6.6%).

Conclusions:

The human-powered nebuliser compressor is equivalent to a standard nebuliser compressor for the treatment of mild-to-moderate asthma. (Funded by the Opus Dean’s Fund, Marquette University College of Engineering; ClinicalTrials.gov NCT01795742.)

Inhaler competence and patient satisfaction with Easyhaler®: results of two real-life multicentre studies in asthma and COPD

Objective

The aim of this study was to investigate patients’ inhaler competence and satisfaction with the Easyhaler^® dry powder inhaler.

Design

Two open, uncontrolled, non-randomised studies.

Setting

Real life based on patients attending 56 respiratory clinics in Hungary.

Participants

Patients with asthma or chronic obstructive pulmonary disease (COPD) (n = 1016).

Intervention

In a 3-month study, adult patients (age range 18–88 years; n = 797) received twice-daily inhalations of formoterol via Easyhaler^®, and in a consequential study (from one visit to another, with 3–12 months in-between) children and adolescents (age range 4–17 years; n = 219) received salbutamol via Easyhaler^® as needed.

Main Outcome Measures

Control of six Easyhaler^® handling steps and patients’ satisfaction with Easyhaler^® based on questionnaires.

Results

Correct performances (minimum and maximum of the six steps) were noticed after one demonstration in 92–98 % of the adults, 87–99 % of the elderly, 81–96 % of the children and 83–99 % of the adolescents. These figures had markedly increased at the last visit. Repeat instructions were necessary in 26 % of the cases. Investigators found Easyhaler^® easy to teach in 87 % of the patients and difficult in only 0.5 %. Patients found Easyhaler^® easy to learn and use, and the patients’ (and parents’) satisfaction with the inhaler was very high. Lung function values [forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), peak expiratory flow (PEF)] improved statistically significantly during the studies, indicating good inhaler competence and treatment adherence.

Conclusion

Investigators found Easyhaler^® easy to teach and patients found it easy to use, and their satisfaction with the device was high.

Switching patients from other inhaled corticosteroid devices to the Easyhaler(®): historical, matched-cohort study of real-life asthma patients

Purpose

To investigate the clinical and cost effectiveness of switching real-life asthma patients from other types of inhalers to the Easyhaler^® (EH) for the administration of inhaled corticosteroids (ICS).

Patients and methods

Historical, matched-cohort study of 1,958 asthma patients (children and adults) treated in UK primary-care practices, using data obtained from the Optimum Patient Care Research Database and Clinical Practice Research Datalink. Other inhalers (OH) included pressurized metered-dose inhalers, breath-actuated inhalers, and dry-powder inhalers, delivering beclomethasone, budesonide, fluticasone, or ciclesonide. Patients remaining on OH unchanged (same drug, dosage, and device; n=979) were matched 1:1 with those switched to the EH (beclomethasone or budesonide) at the same or lower ICS dosage (n=979), based on age, sex, year of index patient review/switch, most recent ICS drug, dosage, and device, and the number of severe exacerbations and average daily short-acting β₂ agonist (SABA) dosage in the preceding year. Clinical outcomes and health care costs were compared between groups for 12 months before and after the switch. Co-primary clinical outcomes were: 1) risk domain asthma control (RDAC) – no asthma-related hospitalization, acute oral steroid use, or lower respiratory tract infection (LRTI); 2) exacerbation rate (American Thoracic Society [ATS] definition) – where exacerbation is asthma-related hospitalization or acute oral steroid use; 3) exacerbation rate (clinical definition) – where exacerbation is ATS exacerbation or LRTI; and 4) overall asthma control (OAC) – RDAC plus average salbutamol-equivalent SABA dosage ≤200 μg/day. Non-inferiority (at least equivalence) of EH was tested against OH for the four co-primary outcomes in order (hierarchical approach) by comparing the difference in proportions of patients [EH-OH] achieving asthma control or having no exacerbations in the outcome year, using a limit of 10% difference.

Results

Non-inferiority was shown for the EH for all four co-primary outcomes. There were no significant differences between groups for RDAC or exacerbation rates, but EH patients were significantly more likely to achieve OAC (adjusted odds ratio [95% confidence interval]: 1.26 [1.05, 1.52]), as significantly more EH than OH patients had an average SABA dosage of ≤200 μg/day (52% versus 47%, respectively; P<0.001). Mean asthma-related health care costs increased from baseline to outcome years in both groups, but SABA costs increased significantly more in OH than EH patients (mean difference £5.5/patient/year) and consultation costs decreased significantly more in EH than OH patients (mean difference £13.5/patient/year).

Conclusion

Typical asthma patients may be switched from other ICS devices to the Easyhaler^® with no reduction in clinical effectiveness or increase in cost.

Closer to an ???Ideal Inhaler??? with the Easyhaler??

The characteristics of an ideal inhaler are based around the design and formulation of the device, patient use and the clinical effect, together with concordance and patient preference. To ensure consistent drug delivery to the lungs, with regular adherence to the prescribed dosage regimen, it is essential that all these characteristics simultaneously interact to provide smooth and sustained therapeutic control affected only by the clinical status of the patient. The literature highlights that dose emission from an Easyhaler is fairly consistent irrespective of the inhalation technique used by patients of all age groups. Clinical studies have shown equivalence of this device to those frequently prescribed and that it is preferred by many patients. Although further research is required into the development of inhalation devices, the literature describing the Easyhaler dry powder inhaler indicates how an inhaler can closely meet the criteria for an ideal inhaler.

Safety of formoterol after cumulative dosing via Easyhaler and Aerolizer

This randomised, double-blind, double-dummy, cumulative dose, multicentre crossover study aimed to demonstrate non-inferiority in safety of formoterol delivered via Easyhaler versus Aerolizer. The secondary objective was to compare the efficacy of the devices. Thirty-three adult asthmatic subjects entered the study and 32 completed it. The study comprised screening and two study days, with each subject inhaling 96 microg (12, 12, 24 and 48 microg) cumulative dose of formoterol via the study inhalers. Serum potassium (S-K+), vital signs and spirometry were performed at baseline, 1h after each dose and additionally 4h after the last dose. The primary safety variable was S-K+. Secondary safety variables were heart rate, corrected QT interval, blood pressure, serum glucose and adverse events. Spirometry was assessed to evaluate efficacy. The results showed non-inferiority in safety of formoterol inhaled via Easyhaler compared to Aerolizer. The adjusted treatment difference in the S-K+ values after 96 microg cumulative dose of formoterol was 0.14 mmol/L being clearly above the pre-determined lower limit of the non-inferiority criterion of -0.2 mmol/L. There were dose-related changes in secondary efficacy variables after both treatments. The changes were comparable in most of the parameters but heart rate was statistically significantly higher and decrease in diastolic blood pressure greater after formoterol via Aerolizer than that via Easyhaler. The occurrence of adverse events was dose-related, the most common events being tremor, hypokalaemia, headache and palpitation. The spirometry results showed no statistically significant difference in efficacy between the treatments. In conclusion, formoterol delivered via Easyhaler was as safe as via Aerolizer.

Clinically equivalent bronchodilatation achieved with formoterol delivered via Easyhaler and Aerolizer

BACKGROUND

User-friendly devices for the delivery of asthma drugs are needed to enhance treatment compliance. Formoterol inhalation powder has been developed to Easyhaler multidose powder inhaler to enable the treatment of all asthma severities with the same device.

OBJECTIVES

This double-blind, double-dummy, single- dose, placebo-controlled, cross-over study aimed to demonstrate the non-inferiority of the bronchodilating effect of formoterol 12 microg delivered via Easyhaler versus via Aerolizer. In addition, dose responses following placebo, 12-microg and 48-microg doses of formoterol via Easyhaler were compared. Furthermore, onset and duration of action, and safety of formoterol inhaled using the two inhalers were compared.

METHODS

Sixty-seven adult asthmatic subjects showing >or=15% increase in forced expiratory volume in 1 s (FEV(1)) after short-acting sympathomimetic inhalation were enrolled and completed the study. The study comprised screening and 4 treatment days, with each subject inhaling a single 12-mug dose of formoterol via Easyhaler, a 12-microg dose via Aerolizer, a 48-microg dose via Easyhaler or placebo. Repeat spirometry and vital sign measurements were performed for 12 h during treatment days. The primary efficacy variable was the area under the flow volume curve (AUC(0-12)) of FEV(1). Secondary efficacy variables comprised maximum FEV(1 )(FEV(1max)), forced vital capacity (FVC), and the need of rescue medication during the treatment days. Safety was evaluated by determining blood pressure, heart rate and the number of adverse events (AEs).

RESULTS

Results showed the non-inferiority of the bronchodilating effect of 12 microg formoterol via Easyhaler compared to Aerolizer. The Easyhaler-Aerolizer ratio for AUC(0-12) of FEV(1 )was 0.991 (95% confidence interval from 0.969 to 1.013). No statistically significant differences emerged for secondary efficacy variables. A statistically significant dose response was seen following placebo, 12- and 48-microg doses in FEV(1). No safety differences emerged for the 12-microg dose inhaled via Easyhaler or Aerolizer, but the incidence of AEs was higher following formoterol 48 microg and placebo treatments.

CONCLUSIONS

Formoterol delivered via Easyhaler was therapeutically equivalent to Aerolizerat the 12-microg dose. The 48-microg dose via Easyhaler demonstrated statistically significantly greater bronchodilation but showed an increased occurrence of AEs.

Equivalent lung deposition of budesonide in vivo: a comparison of dry powder inhalers using a pharmacokinetic method

AIMS

The aim of this study was to compare lung deposition of budesonide administered from two dry powder inhalers, Giona Easyhaler 200 microg/dose and Pulmicort Turbuhaler 200 microg/dose by utilizing a pharmacokinetic method.

METHODS

This was an open, randomized, crossover study in 33 healthy subjects. The study consisted of four treatment periods separated by at least 4 wash-out days. Equivalence in lung deposition was assessed after a single inhaled 1000 microg (5 x 200 microg) dose of budesonide from Giona Easyhaler and from Pulmicort Turbuhaler. Concomitant oral charcoal administration (40 g) was used to prevent gastrointestinal (GI) absorption of budesonide. The efficacy of the charcoal was studied after oral administration of a budesonide 2 mg capsule. The subjects were trained to inhale the study drugs with controlled flow rates, which resulted in an equal pressure drop (4 kPa) across both inhalers. Venous blood samples for the determination of budesonide concentrations in plasma were drawn before and at predetermined time points up to 8 h after drug administration. Budesonide concentrations in plasma were determined using liquid chromatography-tandem mass spectrometry. Several pharmacokinetic parameters were estimated, the area under the budesonide concentration in plasma vs time curve from dosing to infinity (AUC(0, infinity)) being the primary response variable. Equivalence in lung deposition was concluded if the 90% confidence interval (CI) for the Easyhaler : Turbuhaler ratio of AUC(0, infinity) fell within the limits of 0.8-1.25.

RESULTS

The mean AUC(0,infinity) value after Easyhaler treatment was 3.48 (standard deviation (SD) 0.93) ng ml(-1) h and after Turbuhaler treatment 3.46 (1.13) ng ml(-1) h. The Easyhaler : Turbuhaler AUC(0, infinity) ratio was 1.02 and the 90% CI was from 0.96 to 1.09. The mean C(max) values (SD) for budesonide in plasma after Easyhaler and Turbuhaler treatments were 1.22 (0.41) ng ml(-1) and 1.29 (0.44) ng ml(-1), respectively. There was no statistically significant difference (P = 0.39) between the median t(max) for Easyhaler (30 min) and Turbuhaler treatment (23 min). Charcoal impaired the GI absorption of budesonide by 96%. The occurrence of adverse events was similar during both treatments.

CONCLUSIONS

The results show that the lung deposition of budesonide from Giona Easyhaler 200 microg/dose and Pulmicort Turbuhaler 200 microg/dose dry powder inhalers is equivalent. The charcoal block used to prevent GI absorption of swallowed budesonide was found to be effective.

[Patient preference in the choice of dry powder inhalers]

OBJECTIVE

To investigate a group of patients' preferences among 3 dry powder inhalers--Accuhaler, Easyhaler, and Turbuhaler--and to analyze the features that were most important for motivating choices.

MATERIAL AND METHOD

The study enrolled 30 patients with stable asthma with a mean (SD) age of 40 (13) and who habitually used inhaled corticosteroids. The patients were shown in detail how to use each of the devices and were randomized to begin using them in different orders. After using each inhaler for a week, the patients assessed 9 different features on a scale of 0 to 10 with an independent observer. The patients were asked to put the inhalers in order of preference, and finally to demonstrate they could use them correctly.

RESULTS

All patients correctly performed the inhalation maneuver at the beginning and the end of the study. The mean final scores out of 90 of the 9 features evaluated were 75 (13) for the Easyhaler, 67 (12) for the Accuhaler, and 65 (14) for the Turbuhaler. Differences were statistically significant between the first and the second device (P=0.02) and the first and the third (P=.001) but not between the Accuhaler and the Turbuhaler (P=.376). Mean rating scores were 8.6 (1.4) for the Easyhaler, 7.3 (1.9) for the Turbuhaler, and 7.1 (1.6) for the Accuhaler. The Easyhaler was the first choice for 53% of patients, the Turbuhaler for 27%, and the Accuhaler for 20%.

CONCLUSIONS

The Easyhaler was rated the highest by the patients in the study. The scores were a long way from the maximum score, so research into developing an ideal inhaler must continue.

The influence of inhaler selection on efficacy of asthma therapies

Many different devices are available to aid inhalational drug delivery. Although each device is claimed to have advantages over its rivals, the evidence to support greater efficacy of a particular device is scanty. Most comparative studies are underpowered or flawed in their design. They may use inappropriate end-points, or involve healthy subjects, whose response may be very different from the patient with acute severe asthma. The dosage of drug used in a trial may be at the shallow part of the dose-response curve, masking differences in devices. Only in a few cases have clinical trials detected a significant difference between devices, and trials have rarely taken patient preference into account. The most efficacious device in practice is likely to be the one that the patient will use regularly and in accordance with a health care workers' recommendations.