Withdrawal of albuterol inhalers containing chlorofluorocarbon propellants

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

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

Interprofessional peer-assisted learning for pharmacy and physical therapy students using inhalers and inhalation devices

BACKGROUND

Peer-assisted learning (PAL) is exchanging knowledge between learners often from similar professional levels. Limited evidence exists on the effectiveness of PAL between different healthcare professions. The purpose of this study is to evaluate the knowledge, confidence, and perception of students engaged in an interprofessional PAL activity with pharmacy students instructing physical therapy students on the proper technique, cleaning/storage and therapeutic knowledge on inhaler devices for treatment of pulmonary conditions.

METHODS

Pharmacy and physical therapy students completed a survey before and immediately after the PAL activity. As instructors, pharmacy students rated their experience with inhalers, their confidence if they were to assist clients on the use of inhaler devices and confidence in teaching peers. Physical therapy students completed surveys on inhaler knowledge with 10 scenario-based multiple-choice questions, and their confidence if they were to assist clients with inhaler devices. The knowledge questions were grouped into three categories: storage and cleaning of inhalers (3 questions), technique of using inhalers (4 questions), and therapeutic knowledge of drugs given by inhalation (3 questions).

RESULTS

102 physical therapy and 84 pharmacy students completed the activity and surveys. For the physical therapy students, the mean improvement of the total score for knowledge-based questions was 3.6 ± 1.8 (p < 0.001). The question with the fewest number of correct answers (13%) before the PAL activity had the highest number of correct answers post-activity (95%). Prior to the activity, no physical therapy students felt certain/very certain about their knowledge on inhalers, yet after PAL activity this proportion increased to 35%. The percent of pharmacy students reporting their confidence as "certain" and "very certain" in teaching peers increased from 46% before the activity to 90% afterwards. Pharmacy students rated the monitoring and follow-up of inhaler devices as the lowest expectation for physical therapists to play a role. Steps taken to prepare for this PAL activity were also discussed.

CONCLUSIONS

Interprofessional PAL can increase knowledge and confidence of healthcare students reciprocally learning and teaching in joint activities. Allowing such interactions facilitate students to build interprofessional relationships during their training, which can increase communication and collaboration to foster an appreciation for each other's roles in clinical practice.

The Effect of Adding a Training Device and Smartphone Application to Traditional Verbal Counseling in Asthmatic Children

INTRODUCTION

New training devices have been introduced to help in inhaler counseling by addressing the inspiratory flow through the metered-dose inhaler (MDI), which is the most important problem of the MDI inhalation technique. This study aims to compare the effects of MDI traditional verbal counseling and advanced counseling using training devices with a smartphone application in pediatric asthmatic patients.

METHODS

A total of 201 pediatric asthmatic subjects (8-18 years) were divided into two groups: a verbal counseling group, who received only MDI verbal counseling training (n = 101), and an advanced counseling group who received counseling using a training device (Flo-Tone with Trainhaler smartphone application) in addition to the traditional MDI verbal counseling (n = 100). Every patient in the two groups attended three counseling visits, 1 month apart. At each visit, pulmonary functions [peak expiratory flow (PEF), forced expiratory volume in 1 s (FEV₁) as % of predicted] were measured. Also, patients were asked to perform their normal inhalation technique using their MDI, and mistakes were detected and recorded by the investigator. Then, patients were trained on the correct steps of the MDI inhalation technique using either verbal counseling or advanced counseling depending on their study group. In the advanced group, the Flo-Tone was connected to the mouthpiece of the MDI to blow a whistle while the patient inhaled from the MDI. That whistle was detected by the Trainhaler smartphone application and the duration of inhalation determined by the application was recorded.

RESULTS

Both groups showed a gradual significant decrease (p < 0.05) in the total mean number of MDI inhalation technique mistakes from the second visit of counseling, and the improvement continued in the third visit, with a lower number of mistakes in the advanced group especially in inhaling at a slow rate until the lungs are a full step. Also, the advanced counseling group showed a gradual significant increase (p < 0.05) in lung function (PEF and FEV1% of predicted) from the second visit of counseling, particularly (FEV1% predicted) results which showed a greater and more rapid overall improvement in the advanced group compared to the limited overall improvements that occurred in the control group, while significant improvement (p < 0.05) of lung function was obtained at the third visit in the verbal counseling group. In the advanced group, the number of seconds measured by the smartphone application, which represents the duration of inhalation, increased significantly (p < 0.05) in the second and third visits.

CONCLUSIONS

The addition of training devices and smartphone applications to traditional verbal counseling of MDI inhalation technique in asthmatic children resulted in significant improvements in lung function (especially in FEV1% of predicted results), and duration of inhalation, and progressive decreases in the average number of MDI inhalation techniques errors compared to the verbal counseling group.

Effects of health literacy and cognitive abilities on COPD self-management behaviors: A prospective cohort study

INTRODUCTION

Low rates of adherence to self-management behaviors are common among patients with COPD. Health literacy and cognitive abilities may influence engagement in self-management behaviors. We sought to assess the association between health literacy and cognitive abilities with self-management behaviors in patients with COPD.

METHODS

We conducted an observational cohort study among American adults with COPD in New York, New York, and Chicago, Illinois. Outcomes included adherence to COPD medication, metered dose inhaler (MDI) and dry powder inhaler (DPI) technique, receipt of vaccination, and routine healthcare appointments. Health literacy was measured with the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of global, fluid (working memory, processing speed, executive function) and crystallized (verbal) ability.

RESULTS

Adequate health literacy was associated with adequate adherence to COPD medications (OR 1.46; 95% CI, 1.02-2.08), correct MDI (OR 1.66; 95% CI, 1.13-2.44) and DPI (OR 2.17; 95% CI, 1.30-3.64) technique. Fluid abilities were also associated with medication behaviors and visiting a regular healthcare provider, while crystalized abilities were not. Global cognitive abilities were associated with correct inhaler technique. No other associations were found with non-medication self-management behaviors.

CONCLUSIONS

COPD patients with limited health literacy and deficits in fluid cognitive abilities have lower rates of adherence and poorer inhaler technique than individuals with adequate health literacy and greater fluid cognitive abilities. These findings highlight the importance of considering the health literacy level and cognitive ability when caring for and educating patients with COPD.

Effect of Study Design on Sample Size in Studies Intended to Evaluate Bioequivalence of Inhaled Short-Acting β-Agonist Formulations

Pharmacodynamic studies that use methacholine challenge to assess bioequivalence of generic and innovator albuterol formulations are generally designed per published Food and Drug Administration guidance, with 3 reference doses and 1 test dose (3‐by‐1 design). These studies are challenging and expensive to conduct, typically requiring large sample sizes. We proposed 14 modified study designs as alternatives to the Food and Drug Administration–recommended 3‐by‐1 design, hypothesizing that adding reference and/or test doses would reduce sample size and cost. We used Monte Carlo simulation to estimate sample size. Simulation inputs were selected based on published studies and our own experience with this type of trial. We also estimated effects of these modified study designs on study cost. Most of these altered designs reduced sample size and cost relative to the 3‐by‐1 design, some decreasing cost by more than 40%. The most effective single study dose to add was 180 μg of test formulation, which resulted in an estimated 30% relative cost reduction. Adding a single test dose of 90 μg was less effective, producing only a 13% cost reduction. Adding a lone reference dose of either 180, 270, or 360 μg yielded little benefit (less than 10% cost reduction), whereas adding 720 μg resulted in a 19% cost reduction. Of the 14 study design modifications we evaluated, the most effective was addition of both a 90‐μg test dose and a 720‐μg reference dose (42% cost reduction). Combining a 180‐μg test dose and a 720‐μg reference dose produced an estimated 36% cost reduction.

Optimizing drug delivery in COPD: The role of inhaler devices

BACKGROUND

Inhaled medication is the cornerstone of the pharmacological treatment for patients with asthma and chronic obstructive pulmonary disease (COPD). Several inhaler devices exist, and each device has specific characteristics to achieve the optimal inhalation of drugs. The correct use of inhaler devices is not granted and patients may incur in mistakes when using pressurized metered-dose inhalers (pMDIs) or dry-powder inhaler (DPIs). The incorrect use of inhaler devices can lead to a poorly controlled disease status. Unfortunately, guidelines provide limited guidance regarding the choice of devices. This article presents a review of the literature on different inhaler device requirements. Data from literature (PubMed and Google Scholar) on the commercially available inhaler devices have been evaluated and the history of inhaler medicine described. Furthermore, advantages and disadvantages of each type of device have been analyzed. The evaluation of literature indicated the availability of robust data on the devices characteristics and factors influencing selection of delivery devices. Each type of device has its own pro and cons. The age, cognitive status, visual acuity, manual dexterity, manual strength and ability to coordinate the inhaler actuation with inhalation may be as important as the disease severity in determining the correct approach to delivery of respiratory medication. The administration of effective therapies via a device that is simple to use and accepted by patients may help to improve treatment outcomes in patients with COPD.

All Health Is Global Health, All Medicine Is Social Medicine: Integrating the Social Sciences Into the Preclinical Curriculum

As physicians work to achieve optimal health outcomes for their patients, they often struggle to address the issues that arise outside the clinic. Social, economic, and political factors influence patients' burden of disease, access to treatment, and health outcomes. This challenge has motivated recent calls for increased attention to the social determinants of health. At the same time, advocates have called for increased attention to global health. Each year, more U.S. medical students participate in global health experiences. Yet, the global health training that is available varies widely. The discipline of social medicine, which attends to the social determinants of disease, social meanings of disease, and social responses to disease, offers a solution to both challenges. The analyses and techniques of social medicine provide an invaluable toolkit for providing health care in the United States and abroad.In 2007, Harvard Medical School implemented a new course, required for all first-year students, that teaches social medicine in a way that integrates global health. In this article, the authors argue for the importance of including social medicine and global health in the preclinical curriculum; describe Harvard Medical School's innovative, integrated approach to teaching these disciplines, which can be used at other medical schools; and explore the barriers that educators may face in implementing such a curriculum, including resistance from students. Such a course can equip medical students with the knowledge and tools that they will need to address complex health problems in the United States and abroad.

Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT)

Health professionals tasked with advising patients with asthma and chronic obstructive pulmonary disease (COPD) how to use inhaler devices properly and what to do about unwanted effects will be aware of a variety of commonly held precepts. The evidence for many of these is, however, lacking or old and therefore in need of re-examination. Few would disagree that facilitating and encouraging regular and proper use of inhaler devices for the treatment of asthma and COPD is critical for successful outcomes. It seems logical that the abandonment of unnecessary or ill-founded practices forms an integral part of this process: the use of inhalers is bewildering enough, particularly with regular introduction of new drugs, devices and ancillary equipment, without unnecessary and pointless adages. We review the evidence, or lack thereof, underlying ten items of inhaler ‘lore’ commonly passed on by health professionals to each other and thence to patients. The exercise is intended as a pragmatic, evidence-informed review by a group of clinicians with appropriate experience. It is not intended to be an exhaustive review of the literature; rather, we aim to stimulate debate, and to encourage researchers to challenge some of these ideas and to provide new, updated evidence on which to base relevant, meaningful advice in the future. The discussion on each item is followed by a formal, expert opinion by members of the ADMIT Working Group.

Is Patent "Evergreening" Restricting Access to Medicine/Device Combination Products?

BACKGROUND

Not all new drug products are truly new. Some are the result of marginal innovation and incremental patenting of existing products, but in such a way that confers no major therapeutic improvement. This phenomenon, pejoratively known as "evergreening", can allow manufacturers to preserve market exclusivity, but without significantly bettering the standard of care. Other studies speculate that evergreening is especially problematic for medicine/device combination products, because patents on the device component may outlast expired patents on the medicine component, and thereby keep competing, possibly less-expensive generic products off the market.

MATERIALS AND METHODS

We focused on four common conditions that are often treated by medicine/device product combinations: asthma and chronic obstructive pulmonary disease (COPD), diabetes, and severe allergic reactions. The patent data for a sample of such products (n = 49) for treating these conditions was extracted from the United States Food and Drug Administration's Orange Book. Additional patent-related data (abstracts, claims, etc) were retrieved using LexisNexis TotalPatent. Comparisons were then made between each product's device patents and medicine patents.

RESULTS

Unexpired device patents exist for 90 percent of the 49 medicine/device product combinations studied, and were the only sort of unexpired patent for 14 products. Overall, 55 percent of the 235 patents found by our study were device patents. Comparing the last-to-expire device patent to that of the last-to-expire active ingredient patent, the median additional years of patent protection afforded by device patents was 4.7 years (range: 1.3-15.2 years).

CONCLUSION

Incremental, patentable innovation in devices to extend the overall patent protection of medicine/device product combinations is very common. Whether this constitutes "evergreening" depends on whether these incremental innovations and the years of extra patent protection they confer are proportionately matched by therapeutic improvements in the standard of care, which is highly debatable.

[Inhaled therapy in asthma]

Because of its advantages, inhaled administration of aerosolized drugs is the administration route of choice for the treatment of asthma and COPD. Numerous technological advances in the devices used in inhaled therapy in recent decades have boosted the appearance of multiple inhalers and aerosolized drugs. However, this variety also requires that the prescribing physician is aware of their characteristics. The main objective of the present review is to summarize the current state of knowledge on inhalers and inhaled drugs commonly used in the treatment of asthma. The review ranges from theoretical aspects (fundamentals and available devices and drugs) to practical and relevant aspects for asthma care in the clinical setting (therapeutic strategies, education, and adherence to inhalers).

The Impact of the US Food and Drug Administration Chlorofluorocarbon Ban on Out-of-pocket Costs and Use of Albuterol Inhalers Among Individuals With Asthma

IMPORTANCE

The US Clean Air Act prohibits use of nonessential ozone-depleting substances. In 2005, the US Food and Drug Administration announced the ban of chlorofluorocarbon (CFC) albuterol inhalers by December 31, 2008. The policy resulted in the controversial replacement of generic CFC inhalers by more expensive, branded hydrofluoroalkane inhalers. The policy's impact on out-of-pocket costs and utilization of albuterol is unknown.

OBJECTIVE

To study the impact of the US Food and Drug Administration's CFC ban on out-of-pocket costs and utilization of albuterol inhalers.

DESIGN, SETTING, AND PARTICIPANTS

Using private insurance data from January 1, 2004, to December 31, 2010, we investigated the effect of the CFC ban on out-of-pocket costs and utilization of albuterol inhalers among individuals with asthma (109,428 adults; 37,281 children), as well as asthma-related hospitalizations, emergency department visits, and outpatient visits. We estimated multivariable models adjusted for age, sex, comorbidities, and mean out-of-pocket costs of albuterol inhalers in an individual's drug plan. We analyzed whether effects varied between adults vs children and those with persistent vs nonpersistent asthma.

MAIN OUTCOMES AND MEASURES

Pharmacy claims for albuterol inhalers, as well as asthma-related hospitalizations, emergency department visits, and outpatient visits.

RESULTS

The mean out-of-pocket albuterol cost rose from $13.60 (95% CI, $13.40-$13.70) per prescription in 2004 to $25.00 (95% CI, $24.80-$25.20) immediately after the 2008 ban. By the end of 2010, costs had lowered to $21.00 (95% CI, $20.80-$21.20) per prescription. Overall albuterol inhaler use steadily declined from 2004 to 2010. Steep declines in use of generic CFC inhalers occurred after the fourth quarter of 2006 and were almost fully offset by increases in use of hydrofluoroalkane inhalers. In multivariable analyses, a $10 increase in out-of-pocket albuterol prescription costs was estimated to lower utilization by 0.92 percentage points (95% CI, -1.39 to -0.44; P < .001) for adults and 0.54 percentage points (95% CI, -0.84 to -0.24; P = .001) for children, with no difference between adults vs children and patients with persistent vs nonpersistent asthma and with no impact on asthma-related hospitalizations, emergency department visits, and outpatient visits.

CONCLUSIONS AND RELEVANCE

The Federal ban of CFC inhalers led to large relative increases in out-of-pocket albuterol costs among privately insured individuals with asthma and modest declines in utilization. The policy's impact on individuals without insurance, who faced greater cost increases, is unknown.

New inhaler devices - the good, the bad and the ugly

Drug delivery to the lungs is an effective way of targeting inhaled therapeutic aerosols and treating obstructive airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD). In the past 10 years, several new drugs for the management of asthma and COPD have been marketed and more are under development. These new therapeutic respiratory drugs have been furthered by innovations in all categories of pulmonary drug delivery systems to ensure optimal aerosolisation performance, consistency in efficacy and satisfactory patient adherence. In this review, we discuss the technological advances and innovations in recent inhaler devices and the evolving roles of pressurised metered-dose inhalers, dry powder inhalers and nebulisers, as well as their impact on patient adherence to treatment.

The challenge of delivering therapeutic aerosols to asthma patients

The number of people with asthma continues to grow around the world, and asthma remains a poorly controlled disease despite the availability of management guidelines and highly effective medication. Patient noncompliance with therapy is a major reason for poor asthma control. Patients fail to comply with their asthma regimen for a wide variety of reasons, but incorrect use of inhaler devices is amongst the most common. The pressurised metered-dose inhaler (pMDI) is still the most frequently used device worldwide, but many patients fail to use it correctly, even after repeated tuition. Breath-actuated inhalers are easier to use than pMDIs. The rationale behind inhaler choice should be evidence based rather than empirical. When choosing an inhaler device, it is essential that it is easy to use correctly, dosing is consistent, adequate drug is deposited in both central and peripheral airways, and that drug deposition is independent of airflow. Regular checking of inhalation technique is crucial, as correct inhalation is one of the cornerstones of successful asthma management.

Inhaler devices for patients with COPD

Chronic obstructive pulmonary disease (COPD) continues to be associated with increased morbidity and mortality risk in spite of updated guidelines and a better understanding of this condition. Progressive airflow limitation and resultant hyperinflation-the respiratory hallmarks of this complex and often under-diagnosed disease-can be treated with pharmacotherapies emitted via nebulizers, pressurized metered-dose inhalers, dry powder inhalers, or a Soft Mist inhaler. Pharmaceutical company proprietary issues, technological innovations, and societal pressure have expanded the list of available inhalers, with a limited range of medications available for any one device. Each device has different operating and maintenance instructions, and successful use of a given drug/device combination requires that patients understand, maintain, and use each of their devices properly in order to ensure consistent and optimal pulmonary drug delivery. Clinicians are faced with a range of physical and psychosocial issues unique to each patient with COPD that must be overcome in order to match a suitable inhaler to the individual. Improved drug delivery afforded by next-generation inhalers, coupled with an awareness of device-specific and patient-specific variables affecting inhaler use, may improve clinical outcomes in the treatment of COPD.

Inhaler devices - from theory to practice

This brief overview of the factors determining lung deposition of aerosols provides background information required by health care providers when instructing patients to use their prescribed inhalers. We discuss differences in the optimal inhalation manoeuvres for each type of aerosol generator and the difficulties patients face. Provision of short, clear instructions with demonstration of critical steps and checking technique during later clinical visits are necessary if these aerosolised medications are to be fully beneficial.

[Inhalation devices: characteristics, modeling, regulation and use in routine practice. GAT Aerosolstorming, Paris 2011]

Aerosoltherapy is a first-line treatment for chronic obstructive respiratory diseases such as asthma and COPD. Treatment modalities and devices are varied and the choice of the device must be adapted to and optimized for every patient. Spacers can be used for some categories of patients for whom the use of other devices turns out to be complicated. The improvement of these treatments requires the optimization of the lung deposition of inhaled particles; lung modeling plays an essential role in the understanding of the mechanisms of flow in the airways. Regulations must frame prescription of inhaled treatments to optimize its quality and, thus, the care for these chronic diseases. Many generally-accepted ideas concerning these treatments turn out to be false. Inhaled treatments are constantly evolving, both pharmacologically and technologically.

Aerosol drug delivery: developments in device design and clinical use

Aerosolised drugs are prescribed for use in a range of inhaler devices and systems. Delivering drugs by inhalation requires a formulation that can be successfully aerosolised and a delivery system that produces a useful aerosol of the drug; the particles or droplets need to be of sufficient size and mass to be carried to the distal lung or deposited on proximal airways to give rise to a therapeutic effect. Patients and caregivers must use and maintain these aerosol drug delivery devices correctly. In recent years, several technical innovations have led to aerosol drug delivery devices with efficient drug delivery and with novel features that take into account factors such as dose tracking, portability, materials of manufacture, breath actuation, the interface with the patient, combination therapies, and systemic delivery. These changes have improved performance in all four categories of devices: metered dose inhalers, spacers and holding chambers, dry powder inhalers, and nebulisers. Additionally, several therapies usually given by injection are now prescribed as aerosols for use in a range of drug delivery devices. In this Review, we discuss recent developments in the design and clinical use of aerosol devices over the past 10-15 years with an emphasis on the treatment of respiratory disorders.

Uniform definition of asthma severity, control, and exacerbations: document presented for the World Health Organization Consultation on Severe Asthma

Asthma is a global health problem affecting around 300 million individuals of all ages, ethnic groups and countries. It is estimated that around 250,000 people die prematurely each year as a result of asthma. Concepts of asthma severity and control are important in evaluating patients and their response to treatment, as well as for public health, registries, and research (clinical trials, epidemiologic, genetic, and mechanistic studies), but the terminology applied is not standardized, and terms are often used interchangeably. A common international approach is favored to define severe asthma, uncontrolled asthma, and when the 2 coincide, although adaptation may be required in accordance with local conditions. A World Health Organization meeting was convened April 5-6, 2009, to propose a uniform definition of severe asthma. An article was written by a group of experts and reviewed by the Global Alliance against Chronic Respiratory Diseases review group. Severe asthma is defined by the level of current clinical control and risks as "Uncontrolled asthma which can result in risk of frequent severe exacerbations (or death) and/or adverse reactions to medications and/or chronic morbidity (including impaired lung function or reduced lung growth in children)." Severe asthma includes 3 groups, each carrying different public health messages and challenges: (1) untreated severe asthma, (2) difficult-to-treat severe asthma, and (3) treatment-resistant severe asthma. The last group includes asthma for which control is not achieved despite the highest level of recommended treatment and asthma for which control can be maintained only with the highest level of recommended treatment.

Special article: general anesthetic gases and the global environment

General anesthetics are administered to approximately 50 million patients each year in the United States. Anesthetic vapors and gases are also widely used in dentists' offices, veterinary clinics, and laboratories for animal research. All the volatile anesthetics that are currently used are halogenated compounds destructive to the ozone layer. These halogenated anesthetics could have potential significant impact on global warming. The widely used anesthetic gas nitrous oxide is a known greenhouse gas as well as an important ozone-depleting gas. These anesthetic gases and vapors are primarily eliminated through exhalation without being metabolized in the body, and most anesthesia systems transfer these gases as waste directly and unchanged into the atmosphere. Little consideration has been given to the ecotoxicological properties of gaseous general anesthetics. Our estimation using the most recent consumption data indicates that the anesthetic use of nitrous oxide contributes 3.0% of the total emissions in the United States. Studies suggest that the influence of halogenated anesthetics on global warming will be of increasing relative importance given the decreasing level of chlorofluorocarbons globally. Despite these nonnegligible pollutant effects of the anesthetics, no data on the production or emission of these gases and vapors are publicly available. The primary goal of this article is to critically review the current data on the potential effects of general anesthetics on the global environment and to describe possible alternatives and new technologies that may prevent these gases from being discharged into the atmosphere.

The Chicago Breathe Project: a regional approach to improving education on asthma inhalers for resident physicians and minority patients

BACKGROUND

Asthma affects minority citizens in Chicago disproportionately. Policy changes introducing hydrofluroalkane (HFA) inhalers may worsen already-existing health disparities related to asthma.

AIMS

To teach internal medicine residents about the transition to HFAs so they can better counsel their patients on asthma self-management. To provide minority community members with interactive educational sessions.

SETTING

Internal medicine residents at 5 Chicago programs. Community workshops in primarily Spanish-speaking (Cicero) Latino population and a primarily African American population from the south side of Chicago.

PROGRAM DESCRIPTION

The Chicago Breathe Project provides residents with education and tools necessary to counsel patients with asthma on inhaler use and provides minority community members with interactive educational sessions on asthma and inhaler use.

PROGRAM EVALUATION

Eleven workshops were held across 5 academic institutions, with a total of 161 residents. Resident knowledge regarding HFA inhalers improved dramatically (5% pre vs. 91% post, p < .001). Six months post education, residents were more likely to assess inhaler technique (44% vs. 11%, p = .046) and discuss new HFA inhalers (69% vs. 24%, p = .011) with their asthma patients. Community members provided feedback after the workshops that they would come again, found the session helpful ,and enjoyed the session.

DISCUSSION

The Chicago Breathe Project resulted in improved resident knowledge and skill on inhaler use during HFA transition. Regional educational approaches targeting internal medicine residencies in urban areas may be helpful to address future changes in chronic disease management. This training can be taken into minority communities to provide high-quality interactive educational workshops directly to patients and their families.

Albuterol HFA for the management of obstructive airway disease

Albuterol (salbutamol outside the USA) is used to acutely relieve symptoms related to airway obstruction and prevent exercise-induced bronchospasm. Albuterol is most commonly administered by metered-dose inhaler (MDI). MDIs had used chlorofluorocarbon (CFC) propellants, but CFCs accumulate in the stratosphere and contribute to ozone catabolism. Loss of the 'ozone layer', which filters UVB rays, has public health concerns. Albuterol has been reformulated in MDIs using hydrofluoroalkane (HFA) propellants, which do not affect the ozone layer. Albuterol HFA MDIs deliver the same amount of drug per puff with similar particle size distributions as albuterol CFC MDIs, resulting in comparable bronchodilator efficacy of the two products. The highly favorable safety profile of albuterol has not been altered with reformulation. The propellant HFA-134a appears to be devoid of safety concerns.

Beta-Adrenergic Agonists

Inhaled β₂-adrenoceptor (β₂-AR) agonists are considered essential bronchodilator drugs in the treatment of bronchial asthma, both as symptoms-relievers and, in combination with inhaled corticosteroids, as disease-controllers. In this article, we first review the basic mechanisms by which the β₂-adrenergic system contributes to the control of airway smooth muscle tone. Then, we go on describing the structural characteristics of β₂-AR and the molecular basis of G-protein-coupled receptor signaling and mechanisms of its desensitization/ dysfunction. In particular, phosphorylation mediated by protein kinase A and β-adrenergic receptor kinase are examined in detail. Finally, we discuss the pivotal role of inhaled β₂-AR agonists in the treatment of asthma and the concerns about their safety that have been recently raised.

Hydrofluoroalkane mandate in effect January 1, 2009: Switch from chlorofluorocarbon- to hydrofluoroalkane-propelled inhalers requires active transition

The manufacture, sale, and distribution of chlorofluorocarbon-propelled albuterol metered-dose inhalers ceased as of December 31, 2008. Clinicians should actively transition patients to currently available hydrofluoroalkane-propelled devices, providing concise education and instruction for using the newer devices.

Inhalant abuse: a case of hemoptysis associated with halogenated hydrocarbons abuse

An 18-year-old man presented to a community emergency department with increasing shortness of breath and fever. His condition was diagnosed, and he was treated as an inpatient for bilateral pneumonia associated with hypoxemia. When his condition became worse, he acknowledged to deliberate inhalation of keyboard cleaner and to having hemoptysis. Before his death on hospital day 11, known causes of alveolar hemorrhage were excluded. We postulated a cause-and-effect relationship, adding alveolar hemorrhage to the known complications of inhalant abuse.

Advances in adult asthma diagnosis and treatment and health outcomes, education, delivery, and quality in 2008

In 2008 the Journal reported new findings in management of asthma. Dosing schedules of inhaled steroids have been modified and individualized. New, more costly propellants are replacing ozone-depleting chlorofluorocarbons. An association of asthma with pneumococcal disease has been observed. Smoking bans in public places are eliminating second-hand smoke and reducing asthma-related emergency department visits among adults. In contrast with these advances, however, disparity in asthma morbidity persists: black persons compared with white persons have a 4-fold greater risk of an asthma-related emergency department visit.

Advancements in dry powder delivery to the lung

The dry powder inhaler (DPI) has become widely known as a very attractive platform for drug delivery. Many patients have traditionally used DPIs to treat asthma and chronic obstructive pulmonary disease. Recently, the development of new DPIs for delivering therapeutic proteins such as insulin has been accelerated by patient demands, and innovative research. The current market for DPIs has over 20 devices presently in use, and many devices under development for delivering a variety of therapeutic agents. DPIs are recognized as suitable alternatives to pressurized metered dose inhalers for some patients, but the performance of DPI devices may vary according to a given patient's physiological condition. This variation can be associated with the necessary powder dispersion mechanism of each device. As such, much interest has focused on the development of efficient powder dispersion mechanisms, as this effectively minimizes the influence of interpatient variability. This article reviews DPI devices currently available, advantages of newly developed devices, outlines some requirements for future device design.

How best to deliver aerosol medications to mechanically ventilated patients

Pressurized metered-dose inhalers (pMDIs) and nebulizers are employed routinely for aerosol delivery to ventilator-supported patients, but the ventilator circuit and artificial airway previously were thought to be major barriers to effective delivery of aerosols to patients receiving mechanical ventilation. In the past two decades, several investigators have shown that careful attention to many factors, such as the position of the patient, the type of aerosol generator and its configuration in the ventilator circuit, aerosol particle size, artificial airway, conditions in the ventilator circuit, and ventilatory parameters, is necessary to optimize aerosol delivery during mechanical ventilation. The best techniques for aerosol delivery during noninvasive positive-pressure ventilation are not well established as yet, and the efficiency of aerosol delivery in this setting is lower than that during invasive mechanical ventilation. The most efficient methods of using the newer hydrofluoroalkane-pMDIs and vibrating mesh nebulizers in ventilator-supported patients also require further evaluation. When optimal techniques of administration are employed, the efficiency of aerosolized drug delivery in mechanically ventilated patients is comparable to that achieved in ambulatory patients.

Hospital Pharmacy Pulse - Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics. Suggestions or comments may be addressed to: Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave., Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .