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Zhang C, D'Angelo D, Buttini F, Yang M. Long-acting inhaled medicines: Present and future. Adv Drug Deliv Rev 2024; 204:115146. [PMID: 38040120 DOI: 10.1016/j.addr.2023.115146] [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: 06/05/2023] [Revised: 11/15/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
Inhaled medicines continue to be an essential part of treatment for respiratory diseases such as asthma, chronic obstructive pulmonary disease, and cystic fibrosis. In addition, inhalation technology, which is an active area of research and innovation to deliver medications via the lung to the bloodstream, offers potential advantages such as rapid onset of action, enhanced bioavailability, and reduced side effects for local treatments. Certain inhaled macromolecules and particles can also end up in different organs via lymphatic transport from the respiratory epithelium. While the majority of research on inhaled medicines is focused on the delivery technology, particle engineering, combination therapies, innovations in inhaler devices, and digital health technologies, researchers are also exploring new pharmaceutical technologies and strategies to prolong the duration of action of inhaled drugs. This is because, in contrast to most inhaled medicines that exert a rapid onset and short duration of action, long-acting inhaled medicines (LAIM) improve not only the patient compliance by reducing the dosing frequency, but also the effectiveness and convenience of inhaled therapies to better manage patients' conditions. This paper reviews the advances in LAIM, the pharmaceutical technologies and strategies for developing LAIM, and emerging new inhaled modalities that possess a long-acting nature and potential in the treatment and prevention of various diseases. The challenges in the development of the future LAIM are also discussed where active research and innovations are taking place.
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Affiliation(s)
- Chengqian Zhang
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark
| | - Davide D'Angelo
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark; Food and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Francesca Buttini
- Food and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Mingshi Yang
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark; Wuya College of Innovation, Shenyang Pharmaceutical University, Wenhua Road No. 103, 110016, Shenyang, China.
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Mushkani EA, Hamidy F, Ahmad T, Adelyar MA. Misuse of Respiratory Inhalers Among Hospitalized Patients in a Tertiary Health Care Hospital in Kabul. Int J Chron Obstruct Pulmon Dis 2023; 18:365-371. [PMID: 36970445 PMCID: PMC10032212 DOI: 10.2147/copd.s396019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Objective Evaluation of the techniques of respiratory inhaler use among stable inpatients with COPD in Ali Abad Teaching Hospital. Methods This cross-sectional study was conducted between April 2020 and October 2022 at the cardiopulmonary department of Ali-Abad Teaching Hospital. Participants were requested to demonstrate how to use their prescribed inhalation devices. The inhaler's accuracy was evaluated using checklists that had been previously established and included key procedures. Results We studied 318 patients performing a total of 398 inhalation maneuvers with five different IDs. Across all studied inhalation maneuvers, the maximum number of misuses was observed in those using the Respimat (97.7%), and the minimum number of misuses was observed in those using the Accuhaler (58.8%). For the pMDI, the steps "take a deep breath after activating the inhaler" and "hold the breath a few seconds" were most frequently inaccurately performed. Regarding the pMDI with spacer, the steps "exhale fully" were most commonly carried out in mistake. For the Respimat, the steps "hold the breath a few seconds after inhalation activation" and "exhale fully" were most frequently inaccurately performed. According to gender, the misuse was less in females for all studied inhalers (p<0.05). Higher proportion of literate participant correctly used all types of inhalers as compared to the illiterate patients (p<0.05). According to the findings of this study, the majority of patients (77.6%) lacked knowledge of proper inhaler technique. Conclusion The misuse rates were high for all studied inhalers; however, among studied inhalers, the Accuhaler had the greatest proportion of correct inhalation techniques. In order to ensure proper inhaler technique, patients should be educated before receiving inhaler medicines. Therefore, it is crucial for doctors, nurses, and other healthcare professionals to comprehend the problems with the performance and proper usage of these inhaler devices.
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Affiliation(s)
- Ershad Ahmad Mushkani
- Department of Pharmacology, Kabul University of Medical Sciences, Kabul, Afghanistan
- Correspondence: Ershad Ahmad Mushkani, Department of Pharmacology, Kabul University of Medical Sciences, Kabul, Afghanistan, Tel +93-744600222, Email
| | - Fahima Hamidy
- Department of Nursing Skills, Aliabad Teaching Hospital, Kabul University of Medical Sciences, Kabul, Afghanistan
| | - Tawfiq Ahmad
- Department of Ophthalmology, Shahr Ara Hospital, Kabul University of Medical Sciences, Kabul, Afghanistan
| | - Mohammad Asef Adelyar
- Department of Abdominal Surgery, Aliabad Teaching Hospital, Kabul University of Medical Sciences, Kabul, Afghanistan
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Lugogo NL, DePietro M, Reich M, Merchant R, Chrystyn H, Pleasants R, Granovsky L, Li T, Hill T, Brown RW, Safioti G. A Predictive Machine Learning Tool for Asthma Exacerbations: Results from a 12-Week, Open-Label Study Using an Electronic Multi-Dose Dry Powder Inhaler with Integrated Sensors. J Asthma Allergy 2022; 15:1623-1637. [PMID: 36387836 PMCID: PMC9664923 DOI: 10.2147/jaa.s377631] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/02/2022] [Indexed: 10/12/2023] Open
Abstract
PURPOSE Machine learning models informed by sensor data inputs have the potential to provide individualized predictions of asthma deterioration. This study aimed to determine if data from an integrated digital inhaler could be used to develop a machine learning model capable of predicting impending exacerbations. PATIENTS AND METHODS Adult patients with poorly controlled asthma were enrolled in a 12-week, open-label study using ProAir® Digihaler®, an electronic multi-dose dry powder inhaler (eMDPI) with integrated sensors, as reliever medication (albuterol, 90 µg/dose; 1-2 inhalations every 4 hours, as needed). Throughout the study, the eMDPI recorded inhaler use, peak inspiratory flow (PIF), inhalation volume, inhalation duration, and time to PIF. A model predictive of impending exacerbations was generated by applying machine learning techniques to data downloaded from the inhalers, together with clinical and demographic information. The generated model was evaluated by receiver operating characteristic area under curve (ROC AUC) analysis. RESULTS Of 360 patients included in the predictive analysis, 64 experienced a total of 78 exacerbations. Increased albuterol use preceded exacerbations; the mean number of inhalations in the 24-hours preceding an exacerbation was 7.3 (standard deviation 17.3). The machine learning model, using gradient-boosting trees with data from the eMDPI and baseline patient characteristics, predicted an impending exacerbation over the following 5 days with an ROC AUC of 0.83 (95% confidence interval: 0.77-0.90). The feature of the model with the highest weight was the mean number of daily inhalations during the 4 days prior to the day the prediction was made. CONCLUSION A machine learning model to predict impending asthma exacerbations using data from the eMDPI was successfully developed. This approach may support a shift from reactive care to proactive, preventative, and personalized management of chronic respiratory diseases.
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Affiliation(s)
- Njira L Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael DePietro
- Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ, USA
| | - Michael Reich
- Teva Pharmaceutical Industries Ltd, Tel Aviv, Israel
| | - Rajan Merchant
- Woodland Clinic Medical Group, Allergy Department, Dignity Health, Woodland, CA, USA
| | | | - Roy Pleasants
- Population Health, University of Michigan, Ann Arbor, MI and Division of Pulmonary Disease and Critical Care Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | | | - Thomas Li
- Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ, USA
| | - Tanisha Hill
- Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ, USA
| | - Randall W Brown
- Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ, USA
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Ruggiero V, Aquino RP, Del Gaudio P, Campiglia P, Russo P. Post-COVID Syndrome: The Research Progress in the Treatment of Pulmonary sequelae after COVID-19 Infection. Pharmaceutics 2022; 14:pharmaceutics14061135. [PMID: 35745708 PMCID: PMC9229559 DOI: 10.3390/pharmaceutics14061135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 12/15/2022] Open
Abstract
Post-COVID syndrome or long COVID is defined as the persistence of symptoms after confirmed SARS-CoV-2 infection, the pathogen responsible for coronavirus disease. The content herein presented reviews the reported long-term consequences and aftereffects of COVID-19 infection and the potential strategies to adopt for their management. Recent studies have shown that severe forms of COVID-19 can progress into acute respiratory distress syndrome (ARDS), a predisposing factor of pulmonary fibrosis that can irreversibly compromise respiratory function. Considering that the most serious complications are observed in the airways, the inhalation delivery of drugs directly to the lungs should be preferred, since it allows to lower the dose and systemic side effects. Although further studies are needed to optimize these techniques, recent studies have also shown the importance of in vitro models to recreate the SARS-CoV-2 infection and study its sequelae. The information reported suggests the necessity to develop new inhalation therapies in order to improve the quality of life of patients who suffer from this condition.
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Affiliation(s)
- Valentina Ruggiero
- Department of Pharmacy, University of Salerno, 84084 Fisciano, Italy; (V.R.); (R.P.A.); (P.D.G.); (P.C.)
- PhD Program in Drug Discovery and Development, University of Salerno, 84084 Fisciano, Italy
| | - Rita P. Aquino
- Department of Pharmacy, University of Salerno, 84084 Fisciano, Italy; (V.R.); (R.P.A.); (P.D.G.); (P.C.)
| | - Pasquale Del Gaudio
- Department of Pharmacy, University of Salerno, 84084 Fisciano, Italy; (V.R.); (R.P.A.); (P.D.G.); (P.C.)
| | - Pietro Campiglia
- Department of Pharmacy, University of Salerno, 84084 Fisciano, Italy; (V.R.); (R.P.A.); (P.D.G.); (P.C.)
| | - Paola Russo
- Department of Pharmacy, University of Salerno, 84084 Fisciano, Italy; (V.R.); (R.P.A.); (P.D.G.); (P.C.)
- Correspondence:
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Pasqua E, Hamblin N, Edwards C, Baker-Glenn C, Hurley C. Developing inhaled drugs for respiratory diseases: A medicinal chemistry perspective. Drug Discov Today 2021; 27:134-150. [PMID: 34547449 DOI: 10.1016/j.drudis.2021.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 07/11/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022]
Abstract
Despite the devastating impact of many lung diseases on human health, there is still a significant unmet medical need in respiratory diseases, for which inhaled delivery represents a crucial strategy. More guidance on how to design and carry out multidisciplinary inhaled projects is needed. When designing inhaled drugs, the medicinal chemist must carefully balance the physicochemical properties of the molecule to achieve optimal target engagement in the lung. Although the medicinal chemistry strategy is unique for each project, and will change depending on multiple factors, such as the disease, target, systemic risk, delivery device, and formulation, general guidelines aiding inhaled drug design can be applied and are summarised in this review.
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Affiliation(s)
- Elisa Pasqua
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK.
| | - Nicole Hamblin
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK; Charles River Laboratories, Chesterford Research Park, Saffron Waldon CB10 1XL, UK
| | - Christine Edwards
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK
| | - Charles Baker-Glenn
- Charles River Laboratories, Chesterford Research Park, Saffron Waldon CB10 1XL, UK
| | - Chris Hurley
- Charles River Laboratories, 8-9 Spire Green Centre, Harlow CM19 5TR, UK
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Rajah R, Tang YW, Ho SC, Tan JL, Mat Said MS, Ooi LH. Critical Inhaler Administration Errors of Patients on Pressurized Meter Dose Inhaler (pMDI): A Hospital-Based Cross-Sectional Study in Malaysia. Hosp Pharm 2021; 57:217-222. [PMID: 35601709 PMCID: PMC9117768 DOI: 10.1177/00185787211010164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Inhaler technique errors can affect the disease outcome through reduced deposition of medication in the lungs with certain errors were more likely to deter the optimum drug from reaching the lung. The objective of this study was to evaluate the pressurized metered-dose inhaler (pMDI) critical technique errors among asthma and COPD patients, and to investigate the predictors of those errors. Methods: A cross-sectional, observational, and multi-centered study conducted in 3 major hospitals in the state of Penang, Malaysia. Asthma and COPD patients aged 18 years or older consented to the study were consecutively recruited if they were at least on 1 pMDI without mouthpiece spacer or facemask space. Direct observation of the patient’s technique was recorded using a standard checklist and certain steps in the checklist were pre-determined as critical steps. The number of patients missed or incorrectly performed the steps including the critical steps were documented. Using logistic regression, the factors associated with the critical errors were determined, and the correlation was evaluated between age and pMDI knowledge score with critical inhalation steps score. Results: Of 209 patients observed, only less than half (40.7%) could perform all the critical pMDI steps correctly. Low education level was the only factor associated with critical inhaler errors. The increased knowledge of their inhaled medication was found to positively correlate with the correct critical inhalation steps. The critical errors also increase with the increased age of patients. Conclusion: The majority of the study population make inhalation error particularly in critical steps. Training and education intervention programs may help patients with lower education level, as well as those of advanced age and lack of knowledge of their inhaled medication because those populations are at a greater risk of committing critical errors in their use of pMDI.
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Affiliation(s)
- Retha Rajah
- Hospital Seberang Jaya, Seberang Jaya, Malaysia
| | - Yi Woei Tang
- Hospital Pulau Pinang, Georgetown, Pulau Pinang, Malaysia
| | - Shien Chee Ho
- Hospital Besar Pulau Pinang, Georgetown, Pulau Pinang, Malaysia
| | - Jo Lyn Tan
- Hospital Besar Pulau Pinang, Georgetown, Pulau Pinang, Malaysia
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Chen YC, Gad SF, Chobisa D, Li Y, Yeo Y. Local drug delivery systems for inflammatory diseases: Status quo, challenges, and opportunities. J Control Release 2021; 330:438-460. [PMID: 33352244 DOI: 10.1016/j.jconrel.2020.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022]
Abstract
Inflammation that is not resolved in due course becomes a chronic disease. The treatment of chronic inflammatory diseases involves a long-term use of anti-inflammatory drugs such as corticosteroids and nonsteroidal anti-inflammatory drugs, often accompanied by dose-dependent side effects. Local drug delivery systems have been widely explored to reduce their off-target side effects and the medication frequency, with several products making to the market or in development over the years. However, numerous challenges remain, and drug delivery technology is underutilized in some applications. This review showcases local drug delivery systems in different inflammatory diseases, including the targets well-known to drug delivery scientists (e.g., joints, eyes, and teeth) and other applications with untapped opportunities (e.g., sinus, bladder, and colon). In each section, we start with a brief description of the disease and commonly used therapy, introduce local drug delivery systems currently on the market or in the development stage, focusing on polymeric systems, and discuss the remaining challenges and opportunities in future product development.
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Affiliation(s)
- Yun-Chu Chen
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
| | - Sheryhan F Gad
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut 71526, Egypt
| | - Dhawal Chobisa
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; Integrated product development organization, Innovation plaza, Dr. Reddy's Laboratories, Hyderabad 500090, India
| | - Yongzhe Li
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; School of Pharmacy, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, Liaoning 110016, PR China
| | - Yoon Yeo
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA.
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Richards LB, Li M, Folkerts G, Henricks PA, Garssen J, van Esch BC. Butyrate and Propionate Restore the Cytokine and House Dust Mite Compromised Barrier Function of Human Bronchial Airway Epithelial Cells. Int J Mol Sci 2020; 22:ijms22010065. [PMID: 33374733 PMCID: PMC7793466 DOI: 10.3390/ijms22010065] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 02/06/2023] Open
Abstract
Barrier dysfunction of airway epithelium contributes to the development of allergies, airway hyper-responsiveness and immunological respiratory diseases. Short-chain fatty acids (SCFA) enhance and restore the barrier function of the intestinal epithelium. This study investigated whether acetate, propionate and butyrate enhance the integrity of bronchial epithelial cells. Differentiating human bronchial epithelial cells (16HBE) grown on transwells were exposed to butyrate, propionate and acetate while trans-epithelial electrical resistance was monitored over time. Restorative effects of SCFA were investigated by subsequent incubation of cells with IL-4, IL-13 or house dust mite extract and SCFA. SCFA effects on IL-4-induced cytokine production and the expression of zonula occludens-1 (ZO-1) and Mitogen-activated protein kinases (MAPK) signalling pathways were investigated by ELISA and Western blot assays. Propionate and butyrate enhanced the barrier function of differentiating 16HBE cells and induced complete recovery of the barrier function after exposure to the above-mentioned stimuli. Butyrate decreased IL-4-induced IL-6 production. IL-4 decreased ZO-1 protein expression and induced phosphorylation of extracellular signal-regulated protein kinases 1/2 (ERK1/2) and c-Jun N-terminal kinases (JNK) in 16HBE cells, both of which could be restored by SCFA. SCFA showed prophylactic and restorative effects on airway epithelial barrier function, which might be induced by increased ZO-1 expression.
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Affiliation(s)
- Levi B. Richards
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (L.B.R.); (M.L.); (G.F.); (P.A.J.H.); (J.G.)
- Department of Respiratory Medicine, Amsterdam University Medical Centres (AUMC), University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Meng Li
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (L.B.R.); (M.L.); (G.F.); (P.A.J.H.); (J.G.)
| | - Gert Folkerts
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (L.B.R.); (M.L.); (G.F.); (P.A.J.H.); (J.G.)
| | - Paul A.J. Henricks
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (L.B.R.); (M.L.); (G.F.); (P.A.J.H.); (J.G.)
| | - Johan Garssen
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (L.B.R.); (M.L.); (G.F.); (P.A.J.H.); (J.G.)
- Nutricia Research, 3584 CT Utrecht, The Netherlands
| | - Betty C.A.M. van Esch
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (L.B.R.); (M.L.); (G.F.); (P.A.J.H.); (J.G.)
- Nutricia Research, 3584 CT Utrecht, The Netherlands
- Correspondence: ; Tel.: +31-62-573-2735
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9
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Ming SWY, Haughney J, Ryan D, Small I, Lavorini F, Papi A, Singh D, Halpin DMG, Hurst JR, Patel S, Ochel M, Kocks J, Carter V, Hardjojo A, Price DB. A Comparison of the Real-Life Clinical Effectiveness of the Leading Licensed ICS/LABA Combination Inhalers in the Treatment for COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:3093-3103. [PMID: 33273812 PMCID: PMC7705280 DOI: 10.2147/copd.s263745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/26/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The Fostair® 100/6 (BDP/FF) pressurized metered-dose inhaler, delivering an extrafine formulation, is licensed for asthma and COPD in the UK. However, its real-life effectiveness for COPD has not been evaluated. This study compared the clinical effectiveness of BDP/FF against other licensed ICS/LABA combination inhalers: the Seretide® Accuhaler® (FP/SAL) and the Symbicort® Turbohaler® (BUD/FF). Methods A matched historical cohort study was conducted using records of patients with diagnostic codes for COPD from the Optimum Patient Care Research Database (OPCRD). Patients who had received BDP/FF as their first ICS/LABA were matched 1:1 with patients who had received FP/SAL or BUD/FF, resulting in two matched comparisons. Additional analysis was conducted on patients who had never had diagnostic codes for asthma. Noninferiority in terms of the proportion of patients with moderate/severe COPD exacerbations on the different inhalers in the following year was assessed. Noninferiority was achieved if the upper CI limit were ≤1.2. Results This study included 537 and 540 patient pairs in the BDP/FF vs FP/SAL cohort and the BDP/FF vs BUD/FF cohort, respectively. The proportion of patients with COPD exacerbations in the BDP/FF group was not significantly different from either the FP/SAL (68.7% vs 70.2%, AOR 0.89, 95% CI 0.67–1.19) or BUD/FF group (68.5% vs 69.4%, AOR 0.79, 95% CI 0.58–1.08). Noninferiority of BDP/FF in preventing COPD exacerbations was fulfilled in both comparisons. In patients without asthma, BDP/FF was also noninferior to BUD/FF (proportion with COPD exacerbations, 67.8% vs 64.7%, AOR 0.79, 95% CI 0.51–1.1997). Additionally, a significantly lower proportion of patients prescribed BDP/FF had COPD exacerbations than FP/SAL (64.8% vs 73.7%, AOR 0.64 95% CI 0.43–0.96). Conclusion Initiating ICS/LABA treatment of COPD with extrafine-formulation BDP/FF was noninferior in preventing moderate/severe exacerbations compared to FP/SAL and BUD/FF.
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Affiliation(s)
| | - John Haughney
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | | | - Dave Singh
- University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | | | - Janwillem Kocks
- Observational and Pragmatic Research Institute, Singapore, Singapore.,General Practitioners Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Antony Hardjojo
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Saffaran S, Wang W, Das A, Schmitt W, Becker‐Pelster E, Hardman JG, Weimann G, Bates DG. Inhaled sGC Modulator Can Lower PH in Patients With COPD Without Deteriorating Oxygenation. CPT Pharmacometrics Syst Pharmacol 2018; 7:491-498. [PMID: 29962065 PMCID: PMC6118299 DOI: 10.1002/psp4.12308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/25/2018] [Indexed: 01/12/2023] Open
Abstract
This study uses a highly fidelity computational simulator of pulmonary physiology to evaluate the impact of a soluble guanylate cyclase (sGC) modulator on gas exchange in patients with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension (PH) as a complication. Three virtual patients with COPD were configured in the simulator based on clinical data. In agreement with previous clinical studies, modeling systemic application of an sGC modulator results in reduced partial pressure of oxygen (PaO2 ) and increased partial pressure of carbon dioxide (PaCO2 ) in arterial blood, if a drug-induced reduction of pulmonary vascular resistance (PVR) equal to that observed experimentally is assumed. In contrast, for administration via dry powder inhalation (DPI), our simulations suggest that the treatment results in no deterioration in oxygenation. For patients under exercise, DPI administration lowers PH, whereas oxygenation is improved with respect to baseline values.
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Affiliation(s)
- Sina Saffaran
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
| | - Wenfei Wang
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
| | - Anup Das
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
| | | | | | | | | | - Declan G. Bates
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
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11
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Borghardt JM, Kloft C, Sharma A. Inhaled Therapy in Respiratory Disease: The Complex Interplay of Pulmonary Kinetic Processes. Can Respir J 2018; 2018:2732017. [PMID: 30018677 PMCID: PMC6029458 DOI: 10.1155/2018/2732017] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/26/2018] [Accepted: 05/10/2018] [Indexed: 11/18/2022] Open
Abstract
The inhalation route is frequently used to administer drugs for the management of respiratory diseases such as asthma or chronic obstructive pulmonary disease. Compared with other routes of administration, inhalation offers a number of advantages in the treatment of these diseases. For example, via inhalation, a drug is directly delivered to the target organ, conferring high pulmonary drug concentrations and low systemic drug concentrations. Therefore, drug inhalation is typically associated with high pulmonary efficacy and minimal systemic side effects. The lung, as a target, represents an organ with a complex structure and multiple pulmonary-specific pharmacokinetic processes, including (1) drug particle/droplet deposition; (2) pulmonary drug dissolution; (3) mucociliary and macrophage clearance; (4) absorption to lung tissue; (5) pulmonary tissue retention and tissue metabolism; and (6) absorptive drug clearance to the systemic perfusion. In this review, we describe these pharmacokinetic processes and explain how they may be influenced by drug-, formulation- and device-, and patient-related factors. Furthermore, we highlight the complex interplay between these processes and describe, using the examples of inhaled albuterol, fluticasone propionate, budesonide, and olodaterol, how various sequential or parallel pulmonary processes should be considered in order to comprehend the pulmonary fate of inhaled drugs.
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Affiliation(s)
- Jens Markus Borghardt
- Drug Discovery Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Ashish Sharma
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
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12
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Usmani OS, Lavorini F, Marshall J, Dunlop WCN, Heron L, Farrington E, Dekhuijzen R. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res 2018; 19:10. [PMID: 29338792 PMCID: PMC5771074 DOI: 10.1186/s12931-017-0710-y] [Citation(s) in RCA: 202] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Inhaled drug delivery is the cornerstone treatment for asthma and chronic obstructive pulmonary disease (COPD). However, use of inhaler devices can be challenging, potentially leading to critical errors in handling that can significantly reduce drug delivery to the lungs and effectiveness of treatment. METHODS A systematic review was conducted to define 'critical' errors and their impact on health outcomes and resource use between 2004 and 2016, using key search terms for inhaler errors in asthma and COPD (Search-1) and associated health-economic and patient burden (Search-2). RESULTS Search-1 identified 62 manuscripts, 47 abstracts, and 5 conference proceedings (n = 114 total). Search-2 identified 9 studies. We observed 299 descriptions of critical error. Age, education status, previous inhaler instruction, comorbidities and socioeconomic status were associated with worse handling error frequency. A significant association was found between inhaler errors and poor disease outcomes (exacerbations), and greater health-economic burden. CONCLUSIONS We have shown wide variations in how critical errors are defined, and the evidence shows an important association between inhaler errors and worsened health outcomes. Given the negative impact diminished disease outcomes impose on resource use, our findings highlight the importance of achieving optimal inhaler technique, and a need for a consensus on defining critical and non-critical errors.
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Affiliation(s)
- Omar Sharif Usmani
- Airway Disease, NHLI, Imperial College London & Royal Brompton Hospital, Dovehouse Street, London, SW3 6LY UK
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Jonathan Marshall
- Mundipharma International Limited, Cambridge Science Park, Cambridge, CB4 0AB UK
| | | | - Louise Heron
- Adelphi Values, Adelphi Mill, Macclesfield, Cheshire, SK10 5JB UK
| | - Emily Farrington
- Adelphi Values, Adelphi Mill, Macclesfield, Cheshire, SK10 5JB UK
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13
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Wu M, Woodrick NM, Arora VM, Farnan JM, Press VG. Developing a Virtual Teach-To-Goal ™ Inhaler Technique Learning Module: A Mixed Methods Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:1728-1736. [PMID: 28600133 PMCID: PMC5681390 DOI: 10.1016/j.jaip.2017.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/03/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Most hospitalized patients with asthma or chronic obstructive pulmonary disease misuse respiratory inhalers. An in-person educational strategy, teach-to-goal (TTG), improves inpatients' inhaler technique. OBJECTIVE To develop an effective, portable education intervention that remains accessible to hospitalized patients postdischarge for reinforcement of proper inhaler technique. METHODS A mixed methods approach at an urban academic hospital was used to iteratively develop, modify, and test a virtual teach-to-goal™ (V-TTG™) educational intervention using patient end-user feedback. A survey examined access and willingness to use technology for self-management education. Focus groups evaluated patients' feedback on access, functionality, and quality of V-TTG™. RESULTS Forty-eight participants completed the survey, with most reporting having Internet access; 77% used the Internet at home and 82% used the Internet at least once every few weeks. More than 80% reported that they were somewhat or very likely to use V-TTG™ to gain skills to improve their health. Most participants reported smartphone access (73%); half owned laptop computers (52%). Participants with asthma versus chronic obstructive pulmonary disease were more likely to own a smartphone, have a data plan, and have daily Internet use (P < .05). Nine focus groups (n = 25) identified themes for each domain: access-platform and delivery, Internet access, and technological literacy; functionality-usefulness, content, and teaching strategy; and quality-clarity, ease of use, length, and likability. CONCLUSIONS V-TTG™ is a promising educational tool for improving patients' inhaler technique, iteratively developed and refined with patient input. Patients in our urban, academic hospital overwhelmingly reported access to platforms and willingness to use V-TTG™ for health education.
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Affiliation(s)
- Meng Wu
- Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | | | - Vineet M Arora
- Department of Medicine, University of Chicago, Chicago, Ill
| | | | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, Ill.
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14
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Algorta J, Andrade L, Medina M, Kirkov V, Arsova S, Li F, Chi J. Pharmacokinetic Bioequivalence of Two Inhaled Tiotropium Bromide Formulations in Healthy Volunteers. Clin Drug Investig 2017; 36:753-762. [PMID: 27470430 PMCID: PMC4987402 DOI: 10.1007/s40261-016-0441-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background and Objective A novel tiotropium bromide monodose capsule dry powder inhaler (DPI) formulation and device have been developed. The formulation was based on a spray-dried matrix that enhances the aerosolizaton properties, allowing a less active tiotropium metered dose (13 µg/capsule) while maintaining the same delivered dose (10 µg/actuation). This study describes the pharmacokinetic bioequivalence to the reference product. Methods This randomized, two-stage, crossover, semi-replicate (three-way) study was performed in healthy volunteers. In each study period, subjects received a single dose of two capsules (20 μg delivered dose) of the study medication, separated by a 14-day washout period: tiotropium 10 μg delivered dose (Laboratorios Liconsa, Spain) and Spiriva HandiHaler® (Boehringer Ingelheim Pharma GmbH & Co KG, Germany). Blood samples were obtained up to 48 h post-dose to evaluate the comparative bioavailability. Tiotropium was measured in plasma by means of dual stage liquid–liquid extraction followed by the two-dimensional ultra-high performance liquid chromatography sensitive sub-pg/mL bioanalytical method. The main pharmacokinetic parameters were maximum plasma concentration (Cmax), area under the concentration–time curve (AUC) from time zero hours to the last observed concentration at time t (AUCt), and AUC from time zero hours to 30 min (AUC0.5). Bioequivalence was accepted if the 90.20 % confidence interval (CI) for the ratio test/reference of the primary pharmacokinetic parameters lay within the acceptance range of 80–125 %. Safety assessment was a secondary endpoint. Results A total of 30 subjects were randomized and bioequivalence was demonstrated for all primary pharmacokinetic parameters: Cmax (CI 87.26–106.60 %), AUCt (CI 101.33–111.64 %), and AUC0.5 (CI 97.95–113.49 %). Both study treatments were well tolerated (four non-serious adverse events [AEs] were reported in four subjects: one AE before any product administration, two AEs after test product administration; and one AE after reference product administration). Conclusions Both products containing tiotropium 10 µg delivered-dose DPI were bioequivalent and showed good tolerability and a similar safety profile.
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Affiliation(s)
- Jaime Algorta
- Laboratorios Liconsa, Avda. Miralcampo 7, 19200, Azuqueca de Henares, Spain.
| | - Laura Andrade
- Laboratorios Liconsa, Avda. Miralcampo 7, 19200, Azuqueca de Henares, Spain
| | - Marta Medina
- Laboratorios Liconsa, Avda. Miralcampo 7, 19200, Azuqueca de Henares, Spain
| | - Valentin Kirkov
- Clinic for Internal Diseases, MHAT Tokuda Hospital Sofia EAD, Sofia, Bulgaria
| | - Sacha Arsova
- Cooperative Clinical Drug Research and Development, Hoppegarten, Germany
| | - Fumin Li
- PPD Laboratories, Middleton, WI, USA
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15
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Westerik JAM, Carter V, Chrystyn H, Burden A, Thompson SL, Ryan D, Gruffydd-Jones K, Haughney J, Roche N, Lavorini F, Papi A, Infantino A, Roman-Rodriguez M, Bosnic-Anticevich S, Lisspers K, Ställberg B, Henrichsen SH, van der Molen T, Hutton C, Price DB. Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting. J Asthma 2016; 53:321-9. [PMID: 26810934 PMCID: PMC4819842 DOI: 10.3109/02770903.2015.1099160] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 09/07/2015] [Accepted: 09/18/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Correct inhaler technique is central to effective delivery of asthma therapy. The study aim was to identify factors associated with serious inhaler technique errors and their prevalence among primary care patients with asthma using the Diskus dry powder inhaler (DPI). METHODS This was a historical, multinational, cross-sectional study (2011-2013) using the iHARP database, an international initiative that includes patient- and healthcare provider-reported questionnaires from eight countries. Patients with asthma were observed for serious inhaler errors by trained healthcare providers as predefined by the iHARP steering committee. Multivariable logistic regression, stepwise reduced, was used to identify clinical characteristics and asthma-related outcomes associated with ≥1 serious errors. RESULTS Of 3681 patients with asthma, 623 (17%) were using a Diskus (mean [SD] age, 51 [14]; 61% women). A total of 341 (55%) patients made ≥1 serious errors. The most common errors were the failure to exhale before inhalation, insufficient breath-hold at the end of inhalation, and inhalation that was not forceful from the start. Factors significantly associated with ≥1 serious errors included asthma-related hospitalization the previous year (odds ratio [OR] 2.07; 95% confidence interval [CI], 1.26-3.40); obesity (OR 1.75; 1.17-2.63); poor asthma control the previous 4 weeks (OR 1.57; 1.04-2.36); female sex (OR 1.51; 1.08-2.10); and no inhaler technique review during the previous year (OR 1.45; 1.04-2.02). CONCLUSIONS Patients with evidence of poor asthma control should be targeted for a review of their inhaler technique even when using a device thought to have a low error rate.
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Affiliation(s)
| | | | - Henry Chrystyn
- Research in Real-Life, Ltd,
Cambridge,
United Kingdom
- Inhalation Consultancy, Ltd,
Yeadon,
Leeds,
United Kingdom
| | - Anne Burden
- Research in Real-Life, Ltd,
Cambridge,
United Kingdom
| | | | - Dermot Ryan
- Woodbrook Medical Centre, Loughborough, United Kingdom, Centre for Population Health Sciences, University of Edinburgh,
United Kingdom
| | | | - John Haughney
- Academic Primary Care, University of Aberdeen,
Aberdeen,
United Kingdom
| | - Nicolas Roche
- University Paris Descartes (EA2511), Cochin Hospital Group (AP-HP),
Paris,
France
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital,
Florence,
Italy
| | - Alberto Papi
- Department of Medical Sciences, University of Ferrara,
Ferrara,
Italy
| | - Antonio Infantino
- Special Interest Respiratory Area, Società Italiana Interdisciplinare per le Cure Primarie,
Bari,
Italy
| | - Miguel Roman-Rodriguez
- Primary Care Respiratory Research Unit, Instituto de Investigación Sanitaria de Palma IdisPa, Palma de Mallorca,
Spain
| | - Sinthia Bosnic-Anticevich
- Sydney Medical School and the Woolcock Institute of Medical Research, University of Sydney,
Sydney,
Australia
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Preventive Medicine and Family Medicine, Uppsala University,
Uppsala,
Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Preventive Medicine and Family Medicine, Uppsala University,
Uppsala,
Sweden
| | | | - Thys van der Molen
- Department of Primary Care, University of Groningen, University Medical Centre Groningen,
Groningen,
The Netherlands
| | | | - David B. Price
- Research in Real-Life, Ltd,
Cambridge,
United Kingdom
- Academic Primary Care, University of Aberdeen,
Aberdeen,
United Kingdom
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16
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Pothirat C, Chaiwong W, Phetsuk N, Pisalthanapuna S, Chetsadaphan N, Choomuang W. Evaluating inhaler use technique in COPD patients. Int J Chron Obstruct Pulmon Dis 2015; 10:1291-8. [PMID: 26185435 PMCID: PMC4501446 DOI: 10.2147/copd.s85681] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Poor inhalation techniques are associated with decreased medication delivery and poor disease control in chronic obstructive pulmonary disease (COPD). The purpose of this study was to evaluate techniques for using inhaler devices in COPD patients. Methods A prospective cross-sectional study was conducted to assess patient compliance with correct techniques for using inhaler devices across four regimens, ie, the pressurized metered-dose inhaler (pMDI), the pMDI with a spacer, the Accuhaler®, and the Handihaler®. The percentage of compliance with essential steps of correct device usage for each regimen was recorded without prior notification when COPD patients presented for a routine visit, and 1 month after receiving face-to-face training. We compared the percentage of compliance between the devices and risk factors related to incorrect techniques using logistic regression analysis. Percentage of patient compliance with correct techniques was compared between the two visits using the chi-square test. Statistical significance was set at P<0.05. Results A total of 103 COPD patients (mean age 71.2±9.2 years, males 64.1%, low education level 82.5%, and percent predicted forced expiratory volume in 1 second 51.9±22.5) were evaluated. Seventy-seven patients (74.8%) performed at least one step incorrectly. Patients using the Handihaler had the lowest compliance failure (42.5%), and the odds ratio for failure with the other devices compared with the Handihaler were 4.6 (95% confidence interval [CI] 1.8–11.8) for the pMDI, 3.1 (95% CI 1.2–8.2) for the pMDI with a spacer, and 2.4 (95% CI 1.1–5.2) for the Accuhaler. Low education level was the single most important factor related to incorrect technique (adjusted odds ratio 4.1, 95% CI 1.2–13.4, P=0.022). Formal training resulted in a statistically significant decrease in percentage of incorrect techniques for all devices and for the pMDI (59.4% vs 48.6%, P<0.001; 72.4% vs 48.3%, P=0.039, respectively). Conclusion Inhalation technique in COPD patients without face-to-face training was mostly unsatisfactory, especially in patients with low education levels. The Handihaler was the inhaler device associated with the lowest technique failure. Face-to-face inhalation technique training significantly increased technique compliance for the pMDI.
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Affiliation(s)
- Chaicharn Pothirat
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Warawut Chaiwong
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nittaya Phetsuk
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sangnual Pisalthanapuna
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nonglak Chetsadaphan
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Woranoot Choomuang
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Capanoglu M, Dibek Misirlioglu E, Toyran M, Civelek E, Kocabas CN. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. J Asthma 2015; 52:838-45. [PMID: 26037396 DOI: 10.3109/02770903.2015.1028075] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To address the problems about correct use of inhaler devices, adherence to inhaler corticosteroid treatment and the effects of these problems on the control of asthma. METHODS Children with asthma were evaluated for the correct use of inhaler devices and adherence to therapy using a questionnaire. Effect of these on control of asthma was defined. RESULTS A hundred and seventy-one patients and/or their families were interviewed. The mean age was 8.29 ± 4.65 years (1-19) and 62.6% were male. Metered dose inhaler (MDI) with spacer was used by 119 (69.5%) patients and 52 (30.5%) used dry powder inhalers (DPIs). The devices were used correctly by 68.1% of patients using MDI and 34.6% of patients using DPI (p < 0.001). The most common improper step was "breathe in from the spacer 5-6 times or 10 s" for MDI (24.4%) and "exhale to residual volume" for DPI (51.9%). Frequency of correct use was higher in patients trained 3 times (p < 0.001). Asthma was controlled more frequently among correct users (p < 0.001). Partial or poor adherence was showed 22.8% of patients. Patients with mothers who had lower educational status had higher frequency of incorrect use of inhaler device (p = 0.007). CONCLUSION It was found that asthma control was better among correct users. Repetitive training about using devices may contribute improving inhaler technique. Especially children whose mothers had low education level and patients using DPI should be evaluated more carefully.
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Affiliation(s)
- Murat Capanoglu
- a Department of Pediatric Allergy and Immünology , Ankara Pediatrics & Pediatrics Hematology Oncology Training and Research Hospital , Ankara , Turkey
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18
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Grekas N, Athanassiou K, Papataxiarchou K, Rizea Savu S, Silvestro L. Pharmacokinetic study for the establishment of bioequivalence of two inhalation treatments containing budesonide plus formoterol. ACTA ACUST UNITED AC 2014; 66:1677-85. [PMID: 25109416 DOI: 10.1111/jphp.12303] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 06/04/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this study was to compare lung deposition and assess the bioequivalence of two formulations containing budesonide and formoterol and being delivered via Elpenhaler and Turbuhaler, respectively. A pharmacokinetic (PK) study was conducted. METHODS An open, randomized, two-sequence, two-period, crossover, single-dose study in 100 asthmatic patients under fasting conditions was performed. Wash out period was 6 days. Equivalence in lung deposition was assessed after a single inhalation of each treatment with concomitant oral administration of activated charcoal (40 g) to prevent gastrointestinal absorption of the drugs. Several PK parameters were estimated, the area under the drug concentration in plasma versus time curve (AUC0-t ) and the maximum drug concentration in plasma (Cmax ) being the primary response variables. Equivalent lung deposition was concluded if the 90% confidence interval (CI) for the Elpenhaler/Turbuhaler geometric mean ratio of AUC0-t and Cmax , for both drug substances fell within the regulatory limits (0.80-1.25). KEY FINDINGS Acceptance criteria were met. Equivalent lung deposition can be concluded. No statistically significant differences between treatments in the incidence of adverse events were found. CONCLUSIONS The formulations are bioequivalent regarding both rate and extent of absorption. The treatments were also well tolerated by the participating subjects.
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Vargas O, Martinez J, Ibanez M, Pena C, Santamaria M. The use of metered-dose inhalers in hospital environments. J Aerosol Med Pulm Drug Deliv 2013; 26:287-96. [PMID: 23458577 DOI: 10.1089/jamp.2011.0940] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Metered-dose inhalers (MDIs) have become a firsthand therapeutic strategy for the management of respiratory diseases, mainly for chronic obstructive pulmonary disease (COPD) and asthma. It has been determined, however, that patients do not always use these devices correctly. Our primary goal was to establish the level of technical knowledge of patients with COPD and/or asthma on the use of MDIs, as well as other associated factors related to the effective use of this delivery method. METHODOLOGY This study was performed with 191 patients (49.2% male, 50.8% female) diagnosed with COPD and/or asthma at Hospital Universitario Mayor (Bogotá, Colombia). The agreement between different observers on nine aspects of the use of the inhaler was assessed by testing the unweighted kappa correlation coefficient and its significance. The correlations between demographic variables, risk factors, and proper knowledge of the adequate use of inhalers were established by means of the Pearson chi-square test (also called Fisher exact test) (expected values less than 5). Statistical tests were evaluated at a significance level equivalent to 5% (p<0.05). RESULTS AND CONCLUSIONS The study detected deficiencies in educational factors, specifically regarding the initial contact with the patient and regular follow-up by the team of health professionals. It also showed insufficient strategies for the training of patients in the use of the inhalers. There were no significant differences by gender (p>0.05) in the implementation of the various aspects of the proper use sequence for MDIs. However, there were significant differences related to education levels, socioeconomic status, age, and current occupation. A worse inhaler technique was associated with lower education level (0.034), higher age (p=0.003), and absence of job (p=0.005). Changes in the education of patients on the issue, together with the use of the spacer/valved holding chamber proved to be valid strategies that, with the support of the patients' health-care team, were able to improve the MDI technique of the studied group.
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Affiliation(s)
- O Vargas
- 1 Rosario University , Program of Physiotherapy, Bogotá, Colombia
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20
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Göriş S, Taşci S, Elmali F. The effects of training on inhaler technique and quality of life in patients with COPD. J Aerosol Med Pulm Drug Deliv 2013; 26:336-44. [PMID: 23421900 DOI: 10.1089/jamp.2012.1017] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This experimental study was conducted to determine the effects of training on inhaler technique and quality of life in patients with chronic obstructive pulmonary disease (COPD). METHODS Among the patients who applied at the outpatient clinic of chest diseases between March 2009 and May 2010, a total of 69 with COPD who complied with the criteria of the study were recruited; of these, 34 subjects were put in the intervention group and 35 in the control group. The intervention group was educated on using an inhaler by verbal training, demonstration movie, and leaflet. A follow-up after 3 months was carried out in both groups. RESULTS Of the intervention group, 82.4% used the inhaler correctly; however, in the follow-up, all of the controls used it incorrectly (p<0.05). The number of attacks (p<0.001), emergency applications, and hospitalizations (p>0.05) of the intervention group was lower at the follow-up than in the control. Promotion in all areas of quality of life was determined in the intervention group (p<0.001). CONCLUSION Consequently, a planned inhaler training given to the patients with COPD was found to decrease attack frequency and dyspnea, and improve quality of life.
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Affiliation(s)
- Songül Göriş
- 1 Department of Medical Nursing, Erciyes University , Faculty of Health Sciences, 38039, Kayseri, Türkiye
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21
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Ram FSF, Carvallho CR, White J. Clinical effectiveness of the Respimat inhaler device in managing chronic obstructive pulmonary disease: evidence when compared with other handheld inhaler devices. Int J Chron Obstruct Pulmon Dis 2011; 6:129-39. [PMID: 21468167 PMCID: PMC3064421 DOI: 10.2147/copd.s8092] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Indexed: 11/23/2022] Open
Abstract
Objectives: Medication for the management of chronic obstructive pulmonary disease (COPD) may be delivered by a number of different inhaler devices. This study was undertaken to determine the clinical effectiveness of the Respimat® handheld inhaler device compared with other handheld inhaler devices for the delivery of medication in stable COPD. Methodology: A systematic review of high-quality randomized controlled clinical trials comparing Respimat with other inhaler devices using the same medication was performed. Studies were searched for in the Cochrane Central Register of Controlled Trials as well as other relevant electronic databases. Manufacturers of inhaled COPD medication were also contacted for potential trials. Results: Seven studies of high methodological quality with 3813 participants were included in the review. Three trials used Handihaler® as the comparator inhaler, three used a chlorofluorocarbon metered-dose inhaler (CFC-MDI), and one trial used a hydroflouroalkane (HFA)-MDI. When Respimat was compared with Handihaler, the following reported outcomes were not significantly different: trough forced expiratory volume in 1 second (FEV1) (weighted mean difference [WMD] 0.01 L; P = 0.14), trough forced vital capacity (FVC) (WMD 0.001 L: P = 0.88), peak FEV1 (WMD 0.01 L: P = 0.08), peak FVC (WMD 0.01 L: P = 0.55), morning peak expiratory flow rate (PEFR) (WMD 5.06 L/min: P = 0.08), and evening PEFR (WMD 4.39 L/min: P = 0.15). Furthermore, there were no differences when Respimat was compared with Handihaler for risk of exacerbations (relative risk [RR] 0.94: P = 0.81), dry mouth (RR 1.57: P = 0.34), or nasopharyngitis (RR 1.42: P = 0.22). For Respimat compared with CFC-MDI, the only outcome for which data were available for meta-analysis was exacerbations, which were not significantly different (RR 1.20: P = 0.12). In addition, five trials with 2136 patients showed that there was no difference in risk of exacerbations or nasopharyngitis when Respimat was compared with all other handheld inhaler devices (RR 1.18: P = 0.13 and RR 1.33: P = 0.19, respectively). None of the clinical outcome measures reported was significantly different when the same, higher, or lower doses of medication were used in the inhaler devices being compared. Unfortunately, none of the included trials reported mortality as an outcome measure. Conclusions: Evidence from high-quality trials published to date suggests that the Respimat inhaler does not provide any additional clinical benefit to that provided by other inhaler devices in the management of COPD. Although in vitro studies have reported differences between the Respimat inhaler device and other handheld devices, we found no difference in any clinical outcome measures, including lung function and adverse events. Although recent reports have highlighted concerns of increased mortality with the Respimat inhaler device, none of the included trials reported mortality as an outcome. Only a small number of trials reported data that could be used in this systematic review, and a limited number of studies have been published that compare Respimat with other inhaler devices using the same drug and strength. Therefore, further trials comparing Respimat with other handheld inhaler devices using the same drug and dose are required before firm conclusions can be drawn. The concern with increased mortality with Respimat use should be investigated urgently.
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Affiliation(s)
- Felix S F Ram
- School of Health and Social Services, Massey University, Auckland, New Zealand.
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22
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Souza MLDM, Meneghini AC, Ferraz E, Vianna EO, Borges MC. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol 2010; 35:824-31. [PMID: 19820807 DOI: 10.1590/s1806-37132009000900002] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 05/19/2009] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate knowledge of and techniques for using prescribed inhalation devices among patients with asthma or COPD treated at a tertiary teaching hospital. METHODS Patients were assessed after medical visits, and their physicians were blinded to this fact. Patients were asked to demonstrate their inhaler technique and were then interviewed regarding their knowledge of inhalation devices, control of the disease and instructions received during medical visits. RESULTS We included 120 volunteers: 60 with asthma and 60 with COPD. All of the asthma patients and 98.3% of the COPD patients claimed to know how to use inhaled medications. In the sample as a whole, 113 patients (94.2%) committed at least one error when using the inhalation device. Patients committed more errors when using metered-dose inhalers than when using the dry-powder inhalers Aerolizer (p < 0.001) or Pulvinal (p < 0.001), as well as committing more errors when using the Aerolizer inhaler than when using the Pulvinal inhaler (p < 0.05). Using the metered-dose, Pulvinal and Aerolizer inhalers, the COPD group patients committed more errors than did the asthma group patients (p = 0.0023, p = 0.0065 and p = 0.012, respectively). CONCLUSIONS Although the majority of the patients claimed to know how to use inhalation devices, the fact that 94.2% committed at least one error shows that their technique was inappropriate and reveals a discrepancy between understanding and practice. Therefore, it is not sufficient to ask patients whether they know how to use inhalation devices. Practical measures should be taken in order to minimize errors and optimize treatment.
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Quinet P, Young CA, Héritier F. The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmonary disease. Ann Phys Rehabil Med 2009; 53:69-76. [PMID: 20018583 DOI: 10.1016/j.rehab.2009.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Accepted: 10/23/2009] [Indexed: 11/17/2022]
Abstract
UNLABELLED Twenty-five COPD patients, aged 65years or above, were recruited to test their ability to use dry powder inhaler Handihaler (Boeringher-Ingelheim) and Aerolizer (Novartis). The results of a score created to evaluate the inhalation technique were compared with age, MMSE, Barthel Index, FEV(1), maximum inspiratory and expiratory pressures, and peak inspiratory flow (PIF). RESULTS Dry powder inhalers were correctly used by 60% of the patients (15 out of 25). Among the capable ones, 13 out of 15 were aged less than 80 years (p< or =0.02), 13 out of 15 had a maximum inspiratory pressure greater or equal to 53cm H(2)O (p< or =0.001) and a PIF greater or equal to 120l/min (p< or =0.05). All skilled patients had a minimum MMSE of 25 (p< or =0.001). CONCLUSION In a geriatric population, age, the decrease of maximum inspiratory pressure and PIF as well as cognitive functions, limit the use of dry powder inhalers.
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Affiliation(s)
- P Quinet
- Hôpital Riviera, CTR Riviera, Blonay, Switzerland.
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Pleasants RA, Haden D. An update on chronic obstructive pulmonary disease. ACTA ACUST UNITED AC 2006; 20:965-75. [PMID: 16548673 DOI: 10.4140/tcp.n.2005.965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Provide an update on the diagnosis and management of chronic obstructive pulmonary disease (COPD) based on new international and national guidelines. COPD affects approximately 5% to 7% of adults in the United States, with a higher prevalence in elderly persons (10% in elderly males). DATA SOURCE A Medline search of relevant articles and the Global Initiative for Obstructive Lung Disease and the American Thoracic Society/European Respiratory Society COPD Guidelines. STUDY SELECTION Articles and current guidelines relevant to pharmacists working with COPD patients in extended-care facilities. DATA SYNTHESIS COPD is a chronically progressive disease that ultimately leads to major health impairment. New international and national guidelines recently have become available; these guidelines provide extensive insight into many aspects of the disease. Key interventions include early diagnosis, use of pulmonary-function testing, smoking cessation, supplemental oxygen, pulmonary rehabilitation, optimization of pharmacological therapies, and preventing--as well as minimizing--the impact of acute exacerbations of COPD. Optimizing the use of bronchodilators and, in selected patients, the use of corticosteroids are especially important pharmacological interventions in the management of COPD. Patients are started on short-acting bronchodilators; long-acting agents can be added and, in some patients, inhaled corticosteroids can be added as well. Other pharmacological interventions include smoking cessation therapies and the use of anti-infective and mucolytics/expectorants. CONCLUSION Pharmacists can assist in proper drug selection and administration in COPD patients in long-term care facilities. In addition, they can assist in preventing complications of drug therapy such as steroid-induced osteoporosis.
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Affiliation(s)
- Roy A Pleasants
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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Krishna G, Sankaranarayanan V, Chitkara RK. New therapies for chronic obstructive pulmonary disease. Expert Opin Investig Drugs 2004; 13:255-67. [PMID: 15013944 DOI: 10.1517/13543784.13.3.255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the most common lung disease, carrying a significant mortality and morbidity. None of the therapeutic interventions currently available alter the progression of the disease. As our understanding of the basic mechanisms of alveolar destruction and airflow limitation improves, new targets are identified that may eventually result in treatment options which will affect the progression of this disease. In this review, we discuss some of the novel therapeutic options recently developed that may have an impact on the management of COPD. Future directions in research and development of pharmacological agents based on improved understanding of COPD are also discussed.
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Affiliation(s)
- Ganesh Krishna
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Ziedalski TM, Sankaranarayanan V, Chitkara RK. Advances in the management of chronic obstructive pulmonary disease. Expert Opin Pharmacother 2003; 4:1063-82. [PMID: 12831334 DOI: 10.1517/14656566.4.7.1063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible airflow limitation with extreme economic and social burden. It is estimated that over the next two decades, it will become the 5(th) most prevalent disease and the 3(rd) most common cause of death in the world. A better understanding of the pathogenesis of airway inflammation and alveolar destruction allows for the development of new therapeutic targets. Tobacco smoking is the most important risk factor in the development of COPD, thus making smoking cessation of the outermost importance. This article provides a critical review of present therapy for COPD. In addition to conventional treatment (bronchodilators, corticosteroids and antibiotics) and smoking cessation therapies, novel approaches with potential benefit are discussed.
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Affiliation(s)
- Tomasz M Ziedalski
- Medical Service, Pulmonary Section, Veterans Affairs Palo Alto Healthcare System, USA.
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