Use of dry powder inhalers in acute exacerbations of asthma and COPD

The environmental impact of inhalers for asthma; a green challenge and a golden opportunity

The propellants in metered-dose inhalers (MDIs) are powerful greenhouse gases, which account for approximately 13% of the NHS's carbon footprint related to the delivery of care. Most MDI use is in salbutamol relievers in patients with poorly controlled disease. The UK lags behind Europe in this regard, with greater reliance on salbutamol MDI and correspondingly greater greenhouse gas emissions; roughly treble our European neighbours'. There has been a broad switch towards MDIs in asthma treatment UK over the last 20 years to reduce financial costs, such that the treatment for two-thirds of asthma patients in the UK is dominated by salbutamol MDI. Strategies that replace overuse of reliever MDIs with regimes emphasising inhaled corticosteroids have the potential to improve asthma control alongside significant reductions in greenhouse gas emissions. Real-world evidence shows that once-daily long-acting combination dry-powder inhalers can improve compliance, asthma control and reduce the carbon footprint of care. Similarly, maintenance and reliever therapy (MART) which uses combination reliever and inhaled steroids in one device (usually a dry-powder inhaler) can simplify therapy, improve asthma control, and reduce greenhouse gas emissions. Both treatment strategies are popular with patients, most of whom would be willing to change treatment to reduce their carbon footprint. By focussing on patients who are currently using high amounts of salbutamol MDI, and prioritising inhaled steroids via dry-powder inhalers, there are golden opportunities to make asthma care in the UK more effective, safer, and greener.

Sustainability in Inhaled Drug Delivery

Asthma and chronic obstructive pulmonary disease (COPD) are amongst the most common chronic diseases worldwide, and are largely preventable by improving the quality of the air we breathe. The most commonly deployed treatment, the metered dose inhaler (MDI), uses hydrofluorocarbon propellants, which are powerful greenhouse gases that contribute disproportionately to the climate crisis. Alternative treatment strategies are required if we are to avoid contributing to the worst effects of climate change. These strategies include promoting non-pharmacological therapies like smoking cessation and pulmonary rehabilitation; empowering patients to gain better disease control through written management plans and encouraging preventer, rather than reliever therapies. Pharmacological strategies include: improving inhaler technique and spacer use; minimising propellant release by using smaller volume MDIs and simpler dosing regimes; dose counters to prevent waste; switching to low global warming potential inhalers; and inhaler recycling. There are also opportunities to improve disease control alongside reduced greenhouse gas emissions, including better matching of patients' devices to inhaler technique rather than defaulting to MDIs, stopping unnecessary inhaled steroids in COPD and maintenance and reliever therapy in asthma. New, lower global warming potential propellants are on the horizon, and their introduction could offer a golden opportunity to enhance MDIs usability and sustainability by making them refillable, integrating whistles to optimise inhalation technique, adding integrated caps, optimising materials for recycling and adding dose counters to all MDIs.

Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus

The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.

Real-world evaluation of the clinical safety and efficacy of fluticasone/formoterol FDC via the Revolizer® in patients with persistent asthma in India

The combination of inhaled corticosteroids (ICS) and long-acting beta₂-agonists (LABAs) is widely used for the management of asthma. This prospective, open-label, non-comparative, observational, 24-week multicentre study is the first real-world study from India to compare the efficacy and safety of fixed-dose combination of fluticasone/formoterol (Maxiflo® 100/6 mcg or 250/6 mcg) capsules via the Revolizer® device in patients with persistent asthma. The primary efficacy analyses included mean change in Asthma Control Test (ACT™) at 4, 8, 16 and 24 weeks. Secondary efficacy analyses included mean change in morning and evening peak expiratory flow rate (PEFR) at the end of 4, 8, 16 and 24 weeks, number of patients having symptom-free days and nights at the end of 4, 8, 16 and 24 weeks, the number and severity of exacerbations over 24 weeks and response to the Usability Preference Satisfaction Confidence questionnaire after 1 week. Overall, 385 (of 401; 96.01%) enrolled patients completed the study. The mean change in ACT™ score was 6.7 ± 3.71 (95% CI: 6.32, 7.06; p < 0.0001) at week 24. The ACT™ score at weeks 4, 8 and 16 showed progressive and statistically significant increase from baseline. A statistically significant improvement in morning and evening PEFR at weeks 4, 8, 16 and 24 was reported. The proportion of patients experiencing symptom-free days and nights continuously increased from baseline to week 24. A good safety profile over the 24-week period was observed. The Revolizer® device was preferred by 94.26% patients over their current device. Fluticasone propionate/formoterol fumarate FDC capsules administered via a single-dose dry powder inhaler ([DPI], (Revolizer®) offers a novel, well-tolerated and effective treatment option for the long-term management of asthma.

Ability of using different dry powder inhalers during COPD exacerbations

BACKGROUND

Guidelines suggest that patients hospitalized for acute COPD exacerbations (AECOPD) are treated with short acting bronchodilators. Long acting bronchodilators, offer longer symptom relief but since they are usually administered via Dry Powder Inhalers (DPIs) it is considered that during AECOPD patients would not be able to achieve appropriate inspiratory flow (IF) to receive appropriate drug doses. The aim of the present study was to evaluate whether patients admitted to the hospital for AECOPD, are able to achieve the necessary IF using different DPIs.

METHODS

IF was measured daily in patients admitted for AECOPD with a portable IF meter (In-Check Oral inhaler assessment kit), containing a series of adapters that simulate the resistance of 4 DPIs [Turbuhaler (T), Breezhaler/Aerolizer (B/F), Discus (A/A/D) and Handinhaler (HH)]. Dyspnea, spirometry and arterial blood gases were also recorded daily.

RESULTS

44 consecutive patients were included in the study. The majority of patients were able to achieve an IF over 30 L/min with all four device resistances. This minimum required IF was achieved in 90.9%, 100%, 95.5% and 81.8% of patients on admission and in 100%, 100%, 97.7%, and 95.5% of patients on discharge for T, B/F, A/A/D and HH respectively. No functional characteristic was able to predict the achievement of this minimum necessary IF.

CONCLUSION

Most patients hospitalized for AECOPD, are able to receive treatment with long acting bronchodilators administered via DPIs. The possible beneficial effects of such an intervention should be tested in further studies.

Fundamentals of aerosol therapy in critical care

Drug dosing in critically ill patients is challenging due to the altered drug pharmacokinetics–pharmacodynamics associated with systemic therapies. For many drug therapies, there is potential to use the respiratory system as an alternative route for drug delivery. Aerosol drug delivery can provide many advantages over conventional therapy. Given that respiratory diseases are the commonest causes of critical illness, use of aerosol therapy to provide high local drug concentrations with minimal systemic side effects makes this route an attractive option. To date, limited evidence has restricted its wider application. The efficacy of aerosol drug therapy depends on drug-related factors (particle size, molecular weight), device factors, patient-related factors (airway anatomy, inhalation patterns) and mechanical ventilation-related factors (humidification, airway). This review identifies the relevant factors which require attention for optimization of aerosol drug delivery that can achieve better drug concentrations at the target sites and potentially improve clinical outcomes.

A New Quantitative Method for Evaluating Dry Powder Inhalation Efficiency in Asthma Patients

PURPOSE

Many methods have been developed to evaluate dry powder inhalation techniques and their efficiency for disease control in asthma patients. However, it is difficult to apply these methods to clinical practice and research. In this study, we introduce a simple new method that can be applied to dry powder inhalation techniques to evaluate their efficiency in clinical practice.

METHODS

Twenty volunteers were recruited to evaluate the reliability of this new method. One hundred one asthma patients who met the inclusion criteria participated in this study. A dark cloth covered the outlet of the inhaler during dry powder inhalation. The image formed by the inhalation process was evaluated using analysis software and converted into integrated optical density (IOD). Inhalation techniques were scored before and after inhalation technique training, and asthma control was evaluated using the Asthma Control Questionnaire (ACQ) before inhalation technique training.

RESULTS

The relative standard deviation of IOD ranged from 3.8% to 7.8%. In patients with or without inhaler prior use, both the IOD and inhalation technique scores improved significantly after inhalation technique training (p < 0.05). Inhalation technique scores were positively correlated with IOD before (r = 0.80, p < 0.001) and after inhalation technique training (r = 0.52, p < 0.001). In patients with prior inhaler experience, ACQ results were negatively correlated with inhalation technique scores (r = -0.44; p < 0.05) and IOD (r = -0.52; p < 0.05).

CONCLUSION

The results from this study demonstrated that this quantitative method is equivalent to traditional methods for dry powder inhalation evaluation. This study also indicated that training significantly improved the inhalation technique and efficiency in asthma patients with or without prior inhaler use.

A method to assess adherence in inhaler use through analysis of acoustic recordings of inhaler events

RATIONALE

Poor adherence to inhaler use can be due to poor temporal and/or technique adherence. Up until now there has been no way of reliably tracking both these factors in everyday inhaler use.

OBJECTIVES

This paper introduces a device developed to create time stamped acoustic recordings of an individual's inhaler use, in which empirical evidence of temporal and technique adherence in inhaler use can be monitored over time. The correlation between clinical outcomes and adherence, as determined by this device, was compared for temporal adherence alone and combined temporal and technique adherence.

FINDINGS

The technology was validated by showing that the doses taken matched the number of audio recordings (r2 = 0.94, p<0.01). To demonstrate that audio analysis of inhaler use gives objective information, in vitro studies were performed. These showed that acoustic profiles of inhalations correlated with the peak inspiratory flow rate (r2 = 0.97, p<0.01), and that the acoustic energy of exhalations into the inhaler was related to the amount of drug removed. Despite training, 16% of participants exhaled into the mouthpiece after priming, in >20% of their inhaler events. Repeated training reduced this to 7% of participants (p = 0.03). When time of use was considered, there was no evidence of a relationship between adherence and changes in AQLQ (r2 = 0.2) or PEFR (r2 = 0.2). Combining time and technique the rate of adherence was related to changes in AQLQ (r2 = 0.53, p = 0.01) and PEFR (r2 = 0.29, p = 0.01).

CONCLUSIONS

This study presents a novel method to objectively assess how errors in both time and technique of inhaler use impact on clinical outcomes.

TRIAL REGISTRATION

EudraCT 2011-004149-42.

Dry-powder inhalers in acute asthma

An updated literature search was performed to evaluate the efficacy of rapid-acting β2-agonists delivered via dry powder inhalers in the treatment of moderate-to-severe acute asthma. Databases were searched from 1985 up to December 2012. A total of 23 randomized, double-blind or open clinical studies in acute asthma comparing the efficacy of a dry powder inhaler with a pressurized metered-dose inhaler or a nebulizer, and performed under controlled hospital conditions, were identified. This review found that administration of β2-agonist bronchodilators via dry powder inhalers (formoterol, salbutamol, terbutaline and budesonide/formoterol) was effective during severe asthma worsening and acute asthma attacks, and was as effective as established therapies with a pressurized metered-dose inhaler with or without a spacer, or nebulization. These results ensure that patients can rely upon dry powder inhalers equally well as other inhaler devices during episodes of asthma worsening.

Beclometasone for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic obstructive lung condition, diagnosed in patients with dyspnoea, chronic cough or sputum production and/or a history of risk factor exposure, if their postbronchodilator forced expiratory lung volume in 1 second (FEV1)/forced vital lung capacity (FVC) ratio is less than 0.70, according to the international GOLD (Global Initiative for Obstructive Lung Disease) criteria.Inhaled corticosteroid (ICS) medications are now recommended for COPD only in combination treatment with long-acting beta2-agonists (LABAs), and only for patients of GOLD stage 3 and stage 4 severity, for both GOLD groups C and D.ICS are expensive and how effective they are is a topic of controversy, particularly in relation to their adverse effects (pneumonia), which may be linked to more potent ICS. It is unclear whether beclometasone dipropionate (BDP), an unlicensed but widely used inhaled steroid, is a safe and effective alternative to other ICS.

OBJECTIVES

To determine the effectiveness and safety in COPD of inhaled beclometasone alone compared with placebo, and of inhaled beclometasone in combination with LABAs compared with LABAs alone.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) (includes Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearching of respiratory journals and meeting abstracts) (February 2013), conference abstracts, ongoing studies and reference lists of articles. We contacted pharmaceutical companies and drug marketing authorisation bodies/ethics committees in 49 countries and obtained licensing information.

SELECTION CRITERIA

Randomised controlled trials of BDP compared with placebo, or BDP/LABA compared with LABA, in stable COPD. Minimum trial duration is 12 weeks.

DATA COLLECTION AND ANALYSIS

Inclusion, bias assessment and data extraction were conducted by two review authors independently. The analysis was performed by one review author. Study authors were contacted to obtain missing information.

MAIN RESULTS

For BDP versus placebo, two studies were included, of which one trial (participants n = 194) was included in the quantitative analysis. This study was a very high-dose trial with stable stage 2 and 3 COPD participants. No statistically significant results in change in lung function, mortality, exacerbations, dyspnoea scores or withdrawal were obtained. The quality of the evidence of all these outcomes was graded low to very low. Data on risk of pneumonia were lacking.The main focus of the review was the more clinically relevant BDP/LABA versus LABA arm. Therefore the findings are reported more fully.For BDP/LABA versus LABA, one study (n = 474) was included, with a further ongoing study identified for future inclusion. The included trial was a high-dose study of stable stage 3 COPD participants. Compared with LABA, people receiving BDP/LABA showed a statistically significant improvement in FEV1 lung function measurements of 0.051 L (95% confidence Interval (CI) 0.001 to 0.102, P = 0.046) (high quality of evidence) and in (self-reported) days without rescue bronchodilators (mean difference 7.05, 95% CI 0.84 to 13.26, P = 0.03) (low quality), both of which are unlikely to be clinically significant. Participants receiving BDP/LABA also had a statistically significant increased rate of exacerbations leading to hospitalisation (risk ratio (RR) 1.84, 95% CI 1.17 to 2.90, P = 0.008) (moderate quality), although this finding is debatable as this study's post hoc analysis showed no statistically significant difference when accounting for country-specific differences in hospitalisation policies. We did not find statistically significant differences for mortality (very low quality), pneumonia (low quality), exacerbations, exercise capacity, quality of life and dyspnoea scores, adverse events and withdrawal (all moderate quality).

AUTHORS' CONCLUSIONS

We found little evidence to suggest that beclometasone is a safer or more effective treatment option for people with COPD when compared with placebo or when used in combination with LABA; when statistically significant differences were found, they mostly were not clinically meaningful or were based on data from only one study. The review was limited by an inability to obtain data from one study and likely publication bias for BDP versus placebo, and by the inclusion of one study only for BDP/LABA versus LABA. An ongoing study of BDP/LABA versus LABA may have a further impact on these conclusions.

Inhaler devices for patients with COPD

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

Engineered PLGA nano- and micro-carriers for pulmonary delivery: challenges and promises

Objectives

The aim of this review is to summarize the current state-of-the-art in poly(lactic-co-glycolic acid) (PLGA) carriers for inhalation. It presents the rational of use, the potential and the recent advances in developing PLGA microparticles and nanoparticles for pulmonary delivery. The most promising particle engineering strategies are discussed, highlighting the advantages along with the major challenges for researchers working in this field.

Key findings

Biodegradable polymer carriers, such as PLGA particles, may permit effective protection and long-term delivery of the inhaled drug and, when adequately engineered, its efficient transport to the target. The carrier can be designed for inhalation on the basis of several strategies through the adequate combination of available particle technologies and excipients. In so doing, the properties of PLGA particles can be finely tuned at micro-size and nano-size level to fulfill specific therapeutic needs. This means not only to realize optimal in vitro/in vivo lung deposition of the formulation, which is still crucial, but also to control the fate of the drug in the lung after particle landing.

Summary

Although many challenges still exist, PLGA carriers may be highly beneficial and present a new scenario for patients suffering from chronic lung diseases and for pharmaceutical companies working to develop novel inhaled products.

[Asthma: treatment of exacerbations]

INTRODUCTION

Exacerbations remain, in both adults and children, a common reason for emergency consultation. The management of the asthmatic patient with an acute exacerbation is well defined.

BACKGROUND

The initial evaluation, based on the background risk factors and the clinical examination, will determine the choice of treatment and management. Treatment is based on bronchodilators and corticosteroids in the majority of cases.

VIEWPOINTS

An episode of exacerbation may be the opportunity to establish contact with the patient (an educational approach) to improve the adherence to long-term treatment with inhaled corticosteroids, which remain the best way of preventing future exacerbations.

CONCLUSION

Early and appropriate management of exacerbations of asthma should reduce asthma morbidity and mortality. It could also reduce the socioeconomic costs of these episodes and the number and duration of hospital admissions.

Applications of capsule dosing techniques for use in dry powder inhalers

Dry powder inhaler (DPI) devices that utilize two-piece capsules as the dose-holding system can require specialized dosing equipment to fill the capsules. Such products are known as ‘premetered’ because they contain previously measured doses in a dose carrier (the capsule). The capsule is either inserted into the device during manufacture or by the patient prior to use. The dose is inhaled directly from the device/premetered unit by the patient. Regardless of DPI design, the most crucial attributes are the reproducibility of the discharged dose and the particle size distribution of the drug within that dose. Filling inhalation powders into capsules often requires specialized equipment in order to handle the very low weights that are often contained in each dose. The equipment typically needs to incorporate in-process checks to confirm the filling process has been correctly performed, with the ability to reject any under- or over-filled capsules, in line with established quality criteria. In the majority of cases, such processing equipment is maintained in a temperature and humidity controlled environment to avoid moisture uptake and potential powder aggregation and, in particular, to ensure the powder is free flowing on introduction into the capsule. This ensures that the emitted dose is maximized and controlled according to industry guidelines and that the fine particle fraction provides an optimum clinical benefit. Several methods of dosing precise doses of powder into capsules are available and include dosator technology and tamp processes, as well as equipment that utilize the ‘pepper-shaker’ or ‘pepper-pot’ principle for the accurate dispensing of powders. This article reviews the suitability of each method with respect to dosing inhalation powder into capsules for use in DPI devices, and discusses why the pepper-pot principle could offer a number of clear benefits.