New delivery systems and propellants

Detection of Asthma Inhaler Use via Terahertz Spectroscopy

Inhaled medications are commonplace for administering bronchodilators, anticholinergics, and corticosteroids. While they have a defined legitimate use, they are also used in sporting events as performance-enhancing drugs. These performance enhancers can be acquired via both legal (i.e., at a pharmacy through over-the-counter medications or through a prescription) and illicit (i.e., black market and foreign pharmacies) means, thus making monitoring procurement impossible. While urine tests can detect these pharmacological agents hours after they have been inhaled, there is a significant lag time before they are observed in urine. Direct detection of these inhaled agents is complicated and requires a multiplexed approach due to the sheer number of inhaled pharmacological agents. Therefore, detection of propellants, which carry the drug into the lungs, provides a simpler path forward toward detection of broad pharmacological agents. In this paper, we demonstrate the first use of terahertz spectroscopy (THz) to detect inhaled medications in human subjects. Notably, we were able to detect and quantitate the propellant, HFA-134a, in breath up to 30 min after using an asthma inhaler, enabling the use of a point-of-care device to monitor exhaled breath for the presence of propellants. We also demonstrate via simulations that the same approach can be leveraged to detect and identify next-generation propellants, specifically HFA-152a. As a result, we provide evidence that a single point-of-care THz sensor can detect when individuals have used pressure-mediated dose inhalers (pMDIs) without further modification of the hardware.

Treating the small airways

The final article in this series evaluates the approaches undertaken to treating the small-airway region of the lungs and the clinical implications of inhaled therapy targeting the periphery in patients with asthma and chronic obstructive pulmonary disease.

Lung function changes in asthmatic children treated with HFA-BDP

STUDY OBJECTIVES

Asthma guidelines suggest that normal or near normal lung function should be one of the goals for good asthma control. Therefore, children with chronic persistent asthma and reduced peripheral airway function were assessed after the replacement of conventional inhaled corticosteroids (ICS) with an extrafine aerosol formulation, hydrofluoroalkane-134a beclomethoasone diproprionate (HFA-BDP).

DESIGN AND SETTING

Lung function and clinical details were studied in children with moderate persistent asthma who regularly attended the pediatric pulmonary outpatient clinic at Kosair Children's Hospital, Louisville, Kentucky, USA.

SUBJECTS

A total of 20 children, 7 girls and 13 boys, with stable asthma but reduced forced expiratory flows between 25% and 75% of vital capacity (FEF(25-75) ) were included in the study.

INTERVENTION

After the initial assessment, each subject was switched from conventional ICS to HFA-BDP. All other medications remained the same. Reassessment of lung function and clinical status was performed at least 3 weeks after the intervention.

RESULTS

FEF(25-75) increased from a mean of 50.75% to 68.85% predicted (P < 0.001). Forced expiratory volume in 1 sec (FEV(1)) also increased significantly from 84.6% to 93.8% predicted (P = 0.001). No changes asthma symptoms were observed.

CONCLUSION

Compared to conventional ICS, the use of HFA-BDP in asthmatic children significantly improves airflow in both the large and the peripheral airways without loss of asthma control.

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.

Peripheral lung mechanics in asthma: exploring the outer limits

Asthma is a disease characterized by airways hyperresponsiveness (AHR), which is traditionally thought to involve the large, central airways. However, there is increasing evidence of the importance of peripheral airway involvement in asthma as well. Our group has developed particular expertise in measuring peripheral lung mechanics in both humans and mice. This presentation will review data on lung mechanics in subjects with asthma obtained by both classical means and uniquely through the wedged bronchoscope, as well as relevant experiments in mice. Our findings reveal that the lung periphery is hyperresponsive to stimuli in asthmatic subjects, with evidence of airway closure. We also show that the overall impedance of the lung is determined by a combination of peripheral airway narrowing and central airway shunting that occurs in both normal and asthmatic subjects. Experiments in mice have revealed the importance of airway closure in contributing to the phenomenon of AHR. Based on the effects of fibrin on lung mechanics, fibrin may contribute to airway closure via inactivation of surfactant. Another mechanism contributing to AHR is the heterogeneity of airway narrowing. We have explored this in humans by combining the forced oscillation technique with computerized tomography imaging of the lung, and demonstrated that heterogeneity is common to both normal and asthmatic subjects. Further experiments are ongoing and planned in both mice and humans to elucidate the role of fibrin, surfactant and heterogeneous airway narrowing and closure in contributing to AHR in asthma.

Effect of hydrofluoroalkane-ethanol inhalers on estimated alcohol levels in asthmatic subjects

BACKGROUND AND OBJECTIVE

Inhaled medication administered via a metered dose inhaler (MDI) is often used to treat asthma. Hydrofluoroalkane (HFA) has replaced chlorofluorocarbons (CFC) as the propellant and these new MDI may contain alcohol. This raises concerns that their use may transiently increase breath ethanol concentration (BEC), thereby interfering with random breath testing. It was hypothesized that HFA-ethanol MDI may contribute to raising BEC above the legal limit.

METHODS

The effect of a HFA-ethanol MDI on BEC was compared with that of CFC and placebo MDI and the effect of ingesting a standard amount of alcohol was also investigated. Asthmatic (n = 16) and normal control subjects (n = 15) were recruited for the double-blind, placebo-controlled study. Each subject used the three MDI in random sequence. BEC was measured at baseline and at 2, 5 and 15 min after inhalation of each MDI, using the Lion Alcometer SD-400TM. Spirometry was performed at baseline and 20 min after the last inhalation. An identical procedure was followed after alcohol consumption.

RESULTS

Use of the HFA-ethanol MDI resulted in a significant increase in BEC from 0.002 to 0.0138 mg/100 mL (28 mg/100 mL of blood, P = 0.001) in asthmatics, and from 0.001 mg/100 mL to 0.016 mg/100 mL (33 mg/100 mL of blood, P = 0.002) in normal subjects. By 5 min, there were no significant differences in BEC of asthmatics (0.0031 mg/100 mL) and normal subjects (0.003 mg/100 mL), when compared with baseline (P > 0.2).

CONCLUSIONS

BEC are transiently elevated after inhalation of HFA-ethanol MDI; however, by 5 min, BEC had already returned to baseline levels. Thus the effect of HFA-ethanol MDI on BEC is transient and would be negligible after 5 min.

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.

Design optimization of a novel pMDI actuator for systemic drug delivery

Pressurized metered dose inhalers (pMDIs) are the most widely prescribed and economical respiratory drug delivery systems. Conventional pMDI actuators-those based on "two-orifice-and-sump" designs-produce an aerosol with a reasonable respirable fraction, but with high aerosol velocity. The latter is responsible for high oropharyngeal deposition, and consequently low drug delivery efficiency. Kos' pMDI technology is based on a proprietary vortex nozzle actuator (VNA), an innovative actuator configuration that seeks to reduce aerosol plume velocity, thereby promoting deep lung deposition. Using VNA development as a case study, this paper presents a systematic design optimization process to improve the actuator performance through use of advanced optical characterization tools. The optimization effort mainly relied on laser-based optical diagnostics to provide an improved understanding of the fundamentals of aerosol formation and interplay of various geometrical factors. The performance of the optimized VNA design thus evolved was characterized using phase Doppler anemometry and cascade impaction. The aerosol velocities for both standard and optimized VNA designs were found to be comparable, with both notably less than conventional actuators. The optimized VNA design also significantly reduces drug deposition in the actuator as well as USP throat adapter, which in turn, leads to a significantly higher fine particle fraction than the standard design (78 +/- 3% vs. 63 +/- 2% on an ex valve basis). This improved drug delivery efficiency makes VNA technology a practical proposition as a systemic drug delivery platform. Thus, this paper demonstrates how advanced optical diagnostic and characterization tools can be used in the development of high efficiency aerosol drug delivery devices.

Access to inhaled corticosteroids is key to improving quality of care for asthma in developing countries

Asthma is a worldwide public health problem affecting about 300 million people. The majority of persons living with asthma are in the developing world where there is limited access to essential drugs. The financial burden for persons living with asthma and their families, as well as for healthcare systems and governments, is very high. Inadequate treatment and the high cost of medications leads to disability, absenteeism and poverty. Despite the existence of effective asthma medications and international guidelines, and progress made in the implementation of such guidelines over the last decade, the high cost of essential asthma medications remains a major obstacle for patient access to treatment in developing countries. The International Union Against Tuberculosis and Lung Disease has evaluated this problem and created an Asthma Drug Facility (ADF) so that countries can purchase affordable, good quality essential drugs for asthma. The ADF uses pooled procurement along with other purchasing and supply strategies to obtain the lowest possible prices. Accompanied by the implementation of standardized asthma management, the increased affordability of drugs provided by the ADF should bring rapid and significant health and cost benefits for patients, their communities and governments.

Heat decreases formoterol delivery

STUDY OBJECTIVES

Based on anecdotal reports of formoterol aggregating in mailboxes in the summer in Arizona, we examined the effect of heat on formoterol as well as on drug delivery.

DESIGN

Formoterol capsules in original blister packaging were heated to 40 to 70 degrees C (104 to 158 degrees F) for 3 h and at 70 degrees C (158 degrees F) for 15 to 180 min. Capsules were removed from packaging, and a vacuum setup was used to dispense the formoterol into a filter using the device provided by the manufacturer. The weights of the capsule predispensation and postdispensation were measured to calculate drug delivery. Measurements were compared to those of capsules not exposed to heat. For comparison, tiotropium and a combination of fluticasone propionate and salmeterol (Advair; GlaxoSmithKline; Research Triangle Park, NC) were similarly tested.

RESULTS

Visual inspection of the heated capsules revealed gross distortion as well as visible clumping of formoterol at the higher temperatures. The mean (+/- SEM) change in the weights of capsules that underwent heating were significantly less than those obtained from capsules that had not been heated (mean change after heating for 3 h at 70 degrees C, 2.3 +/- 0.7 vs 24.7 +/- 0.6 mg, respectively; p < 0.001), indicating decreased formoterol delivery. Heat produced a dose-responsive and time-responsive decrease in formoterol delivery. One of six capsules that were subjected to temperatures as low as 40 degrees C (104 degrees F) for 3 h had decreased delivery, and three of six capsules subjected to a temperature of 70 degrees C (158 degrees F) for times as short as 30 min decreased delivery. In contrast, neither tiotropium nor fluticasone propionate/salmeterol delivery was decreased by heating for up to 3 h at 70 degrees C (158 degrees F). Thermometers placed in mailboxes or in car windows in mid-summer in Arizona (approximate outside temperature, 110 degrees F [43 degrees C]) exceeded 70 degrees C (158 degrees F).

CONCLUSIONS

These data demonstrate that the exposure of formoterol to heat decreases drug delivery and that caution should be used when mailing, transporting or storing formoterol.

Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines

BACKGROUND

The proliferation of inhaler devices has resulted in a confusing number of choices for clinicians who are selecting a delivery device for aerosol therapy. There are advantages and disadvantages associated with each device category. Evidence-based guidelines for the selection of the appropriate aerosol delivery device in specific clinical settings are needed.

AIM

(1) To compare the efficacy and adverse effects of treatment using nebulizers vs pressurized metered-dose inhalers (MDIs) with or without a spacer/holding chamber vs dry powder inhalers (DPIs) as delivery systems for beta-agonists, anticholinergic agents, and corticosteroids for several commonly encountered clinical settings and patient populations, and (2) to provide recommendations to clinicians to aid them in selecting a particular aerosol delivery device for their patients.

METHODS

A systematic review of pertinent randomized, controlled clinical trials (RCTs) was undertaken using MEDLINE, EmBase, and the Cochrane Library databases. A broad search strategy was chosen, combining terms related to aerosol devices or drugs with the diseases of interest in various patient groups and clinical settings. Only RCTs in which the same drug was administered with different devices were included. RCTs (394 trials) assessing inhaled corticosteroid, beta2-agonist, and anticholinergic agents delivered by an MDI, an MDI with a spacer/holding chamber, a nebulizer, or a DPI were identified for the years 1982 to 2001. A total of 254 outcomes were tabulated. Of the 131 studies that met the eligibility criteria, only 59 (primarily those that tested beta2-agonists) proved to have useable data.

RESULTS

None of the pooled metaanalyses showed a significant difference between devices in any efficacy outcome in any patient group for each of the clinical settings that was investigated. The adverse effects that were reported were minimal and were related to the increased drug dose that was delivered. Each of the delivery devices provided similar outcomes in patients using the correct technique for inhalation.

CONCLUSIONS

Devices used for the delivery of bronchodilators and steroids can be equally efficacious. When selecting an aerosol delivery device for patients with asthma and COPD, the following should be considered: device/drug availability; clinical setting; patient age and the ability to use the selected device correctly; device use with multiple medications; cost and reimbursement; drug administration time; convenience in both outpatient and inpatient settings; and physician and patient preference.

Hydrofluoroalkane-beclomethasone versus chlorofluorocarbon-beclomethasone delivery in neonatal models

Dose delivery of hydrofluoroalkane-beclomethasone and chlorofluorocarbon-beclomethasone was compared during in vitro neonatal simulations: mechanical ventilation with 40% and 100% relative humidity + Neonatal Chamber-Ventilator System/endotracheal tube; manual ventilation + Neonatal Chamber/endotracheal tube; "spontaneous breathing" + Neonatal Chamber/face mask without/with manual assistance. The delivery of hydrofluoroalkane-beclomethasone was significantly greater in each simulation.

Pulmonary drug delivery. Part II: the role of inhalant delivery devices and drug formulations in therapeutic effectiveness of aerosolized medications

Research in the area of pulmonary drug delivery has gathered momentum in the last several years, with increased interest in using the lung as a means of delivering drugs systemically. Advances in device technology have led to the development of more efficient delivery systems capable of delivering larger doses and finer particles into the lung. As more efficient pulmonary delivery devices and sophisticated formulations become available, physicians and health professionals will have a choice of a wide variety of device and formulation combinations that will target specific cells or regions of the lung, avoid the lung's clearance mechanisms and be retained within the lung for longer periods. It is now recognized that it is not enough just to have inhalation therapy available for prescribing; physicians and other healthcare providers need a basic understanding of aerosol science, inhaled formulations, delivery devices, and bioequivalence of products to prescribe these therapies optimally.

One-Year Evaluation of the Safety and Efficacy of Ipratropium Bromide HFA and CFC Inhalation Aerosols in Patients with Chronic Obstructive Pulmonary Disease

INTRODUCTION

Ipratropium bromide (IB) is an established and effective first-line maintenance treatment for patients with chronic obstructive pulmonary disease (COPD). A new IB metered-dose inhaler (MDI) using hydrofluoroalkane 134a propellant (IB HFA) has been developed as an alternative to the MDI containing chlorofluorocarbon (IB CFC).

OBJECTIVE

To compare the long-term safety and efficacy of IB HFA and IB CFC in patients with COPD.

STUDY DESIGN

This was a randomised, open-label, parallel-group, 1-year, multi-centre trial. Primary endpoints included adverse events (AEs) and vital signs. Secondary endpoints included therapeutic response (>15% increase in forced expiratory volume in 1 second [FEV(1)] peak change from baseline), FEV(1) area under the response-time curve (AUC).

PATIENTS AND INTERVENTIONS

Patients (n = 456) with moderate-to-severe COPD, who received either IB HFA (n = 305) or IB CFC (n = 151 ), both 42µg four times daily.

RESULTS

There were no significant differences in the incidences of individual AEs between groups over the short and long term; respiratory disorders were the most common. The incidence of anticholinergic AEs possibly related to treatment was low (1.3% IB HFA, 0.7% IB CFC). Serious AEs occurred in 19.0% and 20.5%, and discontinuations due to AEs in 7.2% and 7.3%, of patients receiving IB HFA and IB CFC, respectively. Therapeutic bronchodilatory responses were achieved in 76-81% and 72-84% of patients, and AUC ranged from 0.117-0.148L and 0.117-0.174L, in patients receiving IB HFA and IB CFC, respectively.

CONCLUSIONS

IB HFA had similar efficacy and tolerability to IB CFC over 1 year, supporting a seamless transition from the CFC MDI to the HFA MDI in both short- and long-term treatment.

Clinically important improvements in asthma-specific quality of life, but no difference in conventional clinical indexes in patients changed from conventional beclomethasone dipropionate to approximately half the dose of extrafine beclomethasone dipropionate

STUDY OBJECTIVE

Clinical trials of asthma treatments usually use measures of asthma control to assess efficacy. However, it is also important to determine whether patients themselves benefit from interventions. The aim of this study was to evaluate health-related quality of life in patients with asthma switched from conventional chlorofluorocarbon (CFC) beclomethasone dipropionate (BDP) to hydrofluroalkane-134a (HFA) BDP extrafine aerosol at half the daily dose.

DESIGN

Open-label, 12-month, parallel-group, randomized trial.

SETTING

Fifty-seven centers in four countries (United States, Belgium, the Netherlands, and United Kingdom).

PATIENTS

Four hundred seventy-three patients with a > or = 6-month history of asthma, stable symptoms, and maintained on CFC-BDP, 400 to 1,600 microg/d.

INTERVENTIONS

HFA-BDP, 200 to 800 microg/d (n = 354), or CFC-BDP, 400 to 1,600 microg/d (n = 119).

MEASUREMENTS AND RESULTS

The Asthma Quality of Life Questionnaire (AQLQ) and pulmonary function tests were completed at months 0, 2, 4, 8, and 12. For 1 month before each visit, patients made daily recordings of symptoms, peak expiratory flow, and beta(2)-agonist use. Two hundred ninety-six patients completed the study (HFA-BDP, 83.6%; CFC-BDP, 83.2%). At month 12, improvements in overall AQLQ scores were greater in the HFA-BDP group than in the CFC-BDP group (p = 0.0024). The number of patients who need to be treated with HFA-BDP for one to have a clinically important improvement in overall asthma-specific quality of life compared with CFC-BDP was 7.3. There was no evidence of differences (p > 0.05) between treatment groups for airway caliber, symptoms, or beta(2)-agonist use.

CONCLUSION

Clinically important improvements in the AQLQ score were observed at month 12 for HFA-BDP vs CFC-BDP, while conventional clinical indexes of pulmonary function and asthma control were similar in the two groups.

A comparison of the efficacy and tolerability of single doses of HFA 134a albuterol and CFC albuterol in mild-to-moderate asthmatic patients

BACKGROUND

After the signing of the Montreal Protocol in 1987, new propellants for use in pressurized metered-dose inhalers that are non-ozone-depleting have been developed.

OBJECTIVE

This study was designed to compare the efficacy and tolerability of single doses of albuterol/HFA 134a with albuterol/CFC and to demonstrate a dose-response among the different doses of both formulations.

METHODS

A single-center, randomized, double-blind, placebo-controlled, cross-over study. Sixty-three adolescent and adult asthmatic patients were randomized to receive at separate treatment visits single doses via a pressurized metered-dose inhaler of either placebo/hydrofluoroalkane (HFA) 134a; 100 microg, 200 microg, or 400 microg albuterol/HFA 134a; 100 microg or 200 microg albuterol/chlorofluorocarbon (CFC). Triplicate measurements of forced expiratory volume in 1 second (FEV1) were made immediately before dosing and 15 minutes, 30 minutes, 1, 2, 3, 4, 5, and 6 hours postdose. The primary efficacy variables were area under the entire 6-hour FEV1 curve, relative to baseline subtracted from the area above baseline (AUC(0-6)) and peak effect (derived from serial FEV1 measurements).

RESULTS

Analysis of AUC(0-6) and peak effect showed that all doses of albuterol had a significantly greater effect than placebo (HFA 134a propellant). Comparisons of the two formulations at 100 microg and 200 microg showed no difference in AUC(0-6) (100 microg, -0.23 Lhr, P = 0.114 and 200 microg -0.08 Lhr, P = 0.590) or in peak effect, percentage of baseline (100 microg, -1.3%, P = 0.354 and 200 microg, 0.17%, P = 0.902). There were no differences seen among formulations in the incidence of adverse events or with any of the other safety parameters, including electrocardiograms, vital signs, clinical laboratory assessments, and asthma exacerbations.

CONCLUSIONS

The study demonstrated comparability in terms of efficacy and safety between albuterol/HFA 134a and albuterol/CFC.

Ipratropium bromide hydrofluoroalkane inhalation aerosol is safe and effective in patients with COPD

STUDY OBJECTIVE

To compare the efficacy and safety of ipratropium bromide reformulated with the chlorofluorocarbon (CFC)-free propellant hydrofluoroalkane (HFA)-134a (ipratropium bromide HFA) to that of the marketed ipratropium bromide inhalation aerosol (containing CFC) in patients with COPD.

DESIGN

This was a randomized, double-blind, parallel-group, placebo-controlled, multicenter trial. The primary efficacy parameter was acute bronchodilator response. The primary end points were peak change in FEV(1) from baseline and area under the response-time curve.

SETTING

Thirty-one clinical centers in the United States participated in this project.

PATIENTS

A total of 507 patients with moderate-to-severe COPD were randomized, and 444 patients completed the trial.

INTERVENTIONS

Twelve weeks of treatment four times daily with one of the following: ipratropium bromide HFA, 42 microg; ipratropium bromide HFA, 84 microg; HFA placebo; ipratropium bromide inhalation aerosol, 42 microg; or CFC placebo.

MEASUREMENTS AND RESULTS

Patients in all active treatment groups had significant bronchodilator responses as shown by increases in mean FEV(1) from baseline of at least 15%. Bronchodilator response in all active treatment groups was also significantly more than their respective placebo treatments based on FEV(1), area under the time-response curve from 0 to 6 h, and peak response. FVC results were similar to those seen with FEV(1). There were no significant differences in adverse events, laboratory findings, or ECG findings among the treatment groups.

CONCLUSIONS

Ipratropium bromide HFA, 42 and mgr;g, provided bronchodilation comparable to the marketed ipratropium bromide CFC, 42 and mgr;g, over 12 weeks of regular use.

The effect of cold air cooling on 585 nm pulsed dye laser treatment of port-wine stains

BACKGROUND

The use of cryogen spray cooling in the course of dye laser treatment of port-wine stains has established itself in recent years because of its good analgesic and epidermally protective effects. The disadvantages of this kind of evaporative cooling are the cost and, in the case of dichlorodifluoromethane, the effects on the ozone layer. Cold air is an innovative cooling method that costs nearly nothing to use, is environmentally friendly, and can be easily adapted to existing laser systems.

OBJECTIVE

To examine and evaluate cold air cooling as an alternative method of cooling in laser treatment.

METHODS

In a prospective study, 13 patients (9 female, 4 male) with port-wine stains were treated with a pulsed dye laser (lambda = 585 nm, tau(p) = 450 microsec). In every case, either the entire area or a sample area of the port-wine stain was treated with cold air cooling on 50% of the surface and without on the other 50%. Clearance, analgesia, and adverse and concomitant effects were assessed.

RESULTS

In nine patients (69%) there were similar results in terms of clearance. In four cases, better lightening results (in two patients) and worse lightening results (in two other patients) were achieved in the area treated with cold air. Nine of the patients (69%) felt that the laser impulses accompanied by cold air were significantly less painful. Adverse effects (purpura, erythema, edema) and concomitant effects (hypopigmentation, hyperpigmentation, scars) were much less marked in the cooled areas.

CONCLUSION

Cold air is a safe and effective alternative to cryogen spray cooling. It is easy to use, economical, and environmentally friendly. Continuing studies are necessary to determine if there are interactions which affect the tissue.

Long-term safety and efficacy of a chlorofluorocarbon-free beclomethasone dipropionate extrafine aerosol

BACKGROUND

Beclomethasone dipropionate (BDP) extrafine aerosol, a newly developed pressurized metered dose inhaler (pMDI) with a hydrofluoroalkane-134a (HFA) propellant (HFA-BDP; Qvar, 3M Pharmaceuticals, St. Paul, MN), has been shown to be effective in controlling asthma symptoms at approximately half the daily dose of chlorofluorocarbon (CFC)-BDP.

OBJECTIVE

This study evaluated the long-term efficacy and safety of switching patients with asthma maintained on a stable dose of CFC-BDP pMDI to therapy with HFA-BDP pMDI at approximately half their previous daily dose of CFC-BDP.

METHODS

This was an open-label, randomized, parallel-group multicenter trial. Patients with at least a 6-month history of asthma whose symptoms were controlled on CFC-BDP, 400 to 1600 microg daily, during a 2-week run-in period were randomized in a 1:3 ratio to CFC-BDP at the same daily dose or HFA-BDP at approximately half the daily dose of CFC-BDP for 12 months.

RESULTS

A total of 473 patients were randomized: 354 to HFA-BDP, 119 to CFC-BDP. There were no statistically significant differences between groups in mean change from baseline in morning (AM) peak expiratory flow rate or forced expiratory volume in one second throughout the study. There were no consistent differences between treatment groups in individual asthma symptoms or daily beta2-agonist use during the study. There was an increase in the percentage of symptom-free days between baseline and month 12 in the HFA-BDP group (11.5%) and the CFC-BDP group (4.6%). No statistically significant differences in serum osteocalcin levels or adverse events were seen during the study or in AM plasma cortisol levels at month 12.

CONCLUSIONS

Asthma control was maintained in patients switched from a stable dose of CFC-BDP (400 to 1600 microg daily) to HFA-BDP at approximately half the CFC-BDP dose (200 to 800 microg daily), and was maintained over the next 12 months. HFA-BDP demonstrated a similar safety profile to CFC-BDP; there were no differences between the agents with regard to systemic effects.

New propellant-free technologies under investigation

Interest in the use of solution inhalers and dry powder inhalers (DPIs) has increased in recent years, broadening from systems for the delivery of traditional respiratory medications to the delivery of inhaled proteins, peptides, and analgesics. This has led to numerous developments and a range of inhaler designs and technology, each with advantages and distinctive features. Novel devices for aerosolization of solutions can be broadly divided into three main classes: adaptive aerosol delivery devices, metered dose liquid inhalers (MDLIs), and breath-actuated nebulizers. Similarly, the wide range of DPIs in development can be classified generally according to their means of storing and providing the drug, that is, as single capsules, a bulk reservoir, or multiunit-dose devices. Choice of a system for delivering a liquid solution is based on a number of factors (e.g., ease of use, convenience, aerosol properties, dose delivery, and drug deposition), the combination of which will have an impact on the single most important factor: clinical benefit. Ultimately, the patient must be able to use the device easily, maintain it, and derive clinical benefit from the drug delivered by the system. Physicians and patients must recognize that if one system does not work, an alternative must be tried.