Influence of Mouth Washing Procedures on the Removal of Drug Residues Following Inhalation of Corticosteroids

Respirable Clofazimine Particles Produced by Air Jet Milling Technique Are Efficacious in Treatment of BALB/c Mice with Chronic Mycobacterium tuberculosis Infection

Tuberculosis (TB) remains a major cause of morbidity and mortality, particularly in low- and middle-income countries where access to health care workers, cold-chain storage, and sterile water sources may be limited. Inhaled drug delivery is a promising alternative to systemic delivery of antimycobacterial drugs, as it enables rapid achievement of high infection-site drug concentrations. The off-patent drug clofazimine (CFZ) may be particularly suitable for this route, given its known systemic toxicities. In this study, micronized CFZ particles produced by air jet milling were assessed for shelf-stability, pharmacokinetics, and anti-TB efficacy by the oral and pulmonary routes in BALB/c mice. Intratracheal instillation of micronized CFZ particles produced several-fold higher lung concentrations after a single 30 mg/kg dose compared to delivery via oral gavage, and faster onset of bactericidal activity was observed in lungs of mice with chronic Mycobacterium tuberculosis infection compared to the oral route. Both infection status and administration route affected the multidose pharmacokinetics (PK) of micronized CFZ. Increased lung and spleen accumulation of the drug after pulmonary administration was noted in infected mice compared to naive mice, while the opposite trend was noted in the oral dosing groups. The infection-dependent PK of inhaled micronized CFZ may point to a role of macrophage trafficking in drug distribution, given the intracellular-targeting nature of the formulation. Lastly, air jet milled CFZ exhibited robustness to storage-induced chemical degradation and changes in aerosol performance, thereby indicating the suitability of the formulation for treatment of TB in regions with limited cold chain supply.

Bioequivalence assessment of pharmaceutical aerosol products through IVIVC

Many pharmaceutical developers of generic orally inhaled products (OIPs) are facing significant issues in passing the regulatory requirement to show pharmacokinetic (PK) bioequivalence (BE) to the originator product. The core of the issue is that no reliable in vitro-in vivo correlation (IVIVC) is available to guide their development. In this paper, several issues are identified and means to improve the data used for developing an IVIVC are discussed. The article also presents an "IVIVC-free" approach for developing a formulation matching the originator's PK performance.

Implementation of mouth rinsing after use of inhaled corticosteroids in Australia

BACKGROUND

Clinical guidelines recommend that patients using inhaled corticosteroids should rinse their mouth following inhalation. There is however, a paucity of research regarding patient implementation of this recommendation and the impact it has on the occurrence of adverse effects.

OBJECTIVE

The aim of this study was to determine how well patients implement mouth rinsing after using inhaled corticosteroids in practice and their understanding of the rationale, information sources and the impact of mouth rinsing on adverse effects.

SETTING

Australians aged 18 years and over with a diagnosis of asthma and/or chronic obstructive pulmonary disease who were currently using an inhaled corticosteroid.

METHOD

Participants were recruited via Facebook to complete an online survey.

MAIN OUTCOME MEASURE

Implementation of a mouth rinse which aligned to current guideline recommendations.

RESULTS

Of 380 eligible responses, 30.5% of patients reported suboptimal mouth rinsing after using inhaled corticosteroids. Receiving advice on mouth rinsing from a healthcare professional increased the likelihood of correct implementation (P < 0.001) and improved patient understanding of the rationale (P = 0.01). Whilst most (90.0%) patients were aware rinsing may reduce oropharyngeal adverse effects, few (5.5%) were aware of its potential to reduce systemic adverse effects. Patients were more likely to report their rinsing procedure had a positive impact if they had experienced oral candidiasis (P < 0.001) or sore mouth/throat (P = 0.01), compared to cough or hoarse voice.

CONCLUSION

Almost one-third of patients reported a suboptimal mouth rinsing procedure after using an inhaled corticosteroid. Interventions are required to improve awareness and correct implementation of mouth rinsing.

The use of inhaled corticosteroids in pediatric asthma: update

Despite the availability of several formulations of inhaled corticosteroids (ICS) and delivery devices for treatment of childhood asthma and despite the development of evidence-based guidelines, childhood asthma control remains suboptimal. Improving uptake of asthma management plans, both by families and practitioners, is needed. Adherence to daily ICS therapy is a key determinant of asthma control and this mandates that asthma education follow a repetitive pattern and involve literal explanation and physical demonstration of the optimal use of inhaler devices. The potential adverse effects of ICS need to be weighed against the benefit of these drugs to control persistent asthma especially that its safety profile is markedly better than oral glucocorticoids. This article reviews the key mechanisms of inhaled corticosteroid action; recommendations on dosage and therapeutic regimens; potential optimization of effectiveness by addressing inhaler technique and adherence to therapy; and updated knowledge on the real magnitude of adverse events.

Prevalence and associated factors of oropharyngeal side effects in users of inhaled corticosteroids in a real-life setting

BACKGROUND

Inhaled corticosteroids (ICS) are extensively used to treat asthma, and more recently, chronic obstructive pulmonary disease (COPD). Oropharyngeal disorders represent the most frequent side effect of these drugs, which may have a negative impact on adherence.

OBJECTIVES

To evaluate the prevalence of oropharyngeal disorders in users of ICS in a real-life setting and investigate the factors associated with their occurrence.

METHODS

For this observational cross-sectional study, general practitioners and pulmonologists were contacted and asked to include patients suffering from asthma or COPD treated by ICS. Physicians collected data during a medical examination. A multivariate regression model for the occurrence of oropharyngeal disorders was constructed.

RESULTS

A total of 1778 physicians included 6740 patients. The mean (SD) age was 51.3 (18.5) years, 44.0% had no smoking history, and the ICS indication was asthma in 63.9% of subjects. Of the study subjects, 52.3% used beclometasone (43.4% without a long-acting ss(2)-agonist, LABA); 22.1% used budesonide (18.8% with a LABA), and 25.6% used fluticasone (19.3% with a LABA in a single inhaler). One-third (34.7%) of subjects suffered from at least one oropharyngeal disorder; the most frequently reported were hoarseness, tingling, mouth irritation, and reddening. Multivariate regression analysis found that the factors positively associated with oropharyngeal disorders were COPD indication [odds ratio (OR) 1.600; 95% confidence intervals (95% CI) 1.391, 1.839], nominal daily dose (OR = 1.388; 95% CI 1.227, 1.569), decreased adherence (OR = 1.318; 95% CI 1.104, 1.574) and the use of fluticasone (OR = 1.176; 95% CI 1.008, 1.372), whereas those negatively associated were the absence of smoking history (OR = 0.837; 95% CI 0.742, 0.945), increased adherence (OR = 0.663; 95% CI 0.581, 0.755), and beclometasone use (OR = 0.630; 95% CI 0.543, 0.732).

CONCLUSIONS

The high prevalence of oropharyngeal disorders and the association of adherence with these must be taken into account by prescribers, especially in patients suffering from COPD, a relatively new group of ICS users.

Kinetic analysis of effects of mouth washing on removal of drug residues following inhalation of fluticasone propionate dry powder

Fluticasone propionate dry powder inhaler (FP-DPI) is widely used for the treatment of asthma. However, local adverse effects such as oropharyngeal candidiasis are often seen and mouth washing after inhaling is recommended. In our previous study, we reported a nonlinear relationship between the amount of drug residue and number of times mouth washing was employed. Thus, we developed a compartment model, in which the inhaled drugs were distributed in both easy and difficult to remove areas. Using this model, we analyzed drug removal efficiency in each area with different mouth washing procedures. Three methods of mouth washing were studied; gargling and rinsing in combination, rinsing alone, and gargling alone, following administration of FP-DPI by sprinkling or inhaling. The amounts of drugs recovered from areas considered to be easy to remove (X(1)) and difficult to remove (X(2)) were determined using a nonlinear least-squares program, while the removal efficiency of each of the 3 methods was also calculated. The ratios of X(1) after sprinkling and inhalation were 63.9% and 21.8%, respectively, while those of X(2) were 6.0% and 12.4%, respectively. The numbers of mouth washings required to remove half doses from easy and difficult to remove areas were 0.2 and 1.4 times, respectively, with a combination of gargling and rinsing following inhalation of FP-DPI, while those were 0.3 and 3.6 times, respectively, with rinsing alone, and 0.4 and 5.8 times, respectively, with gargling only, thus demonstrating significant differences among the mouth washing methods for efficiency in the difficult to remove area. The present results show that the employed methods of mouth washing had a significant influence on the removal of drug residues following inhalation of FP-DPI, with gargling and rinsing in combination considered to be the most effective.

Effects of Mouth Washing Procedures on Removal of Budesonide Inhaled by Using Turbuhaler

Mouth washing after inhalation of corticosteroids is effective for prevention of local adverse effects. We determined the amounts of drug residues remaining on the oropharyngeal mucosa following inhalation of budesonide (BUD) via a Turbuhaler (BUD-TH) (100 microg). Further, we studied the effects of mouth washing on the removal of drug residues by quantification of BUD in expectorated wash solution using an HPLC method. The amount of BUD recovered after gargling and rinsing for 5 s each was 19.4+/-9.4 microg, as compared to 23.8+/-13.6 microg after rinsing alone for 10 s and 18.3+/-8.9 microg after gargling alone for 10 s, though the differences were not significant. Our results indicated that about 20% of the dose was remaining on the oropharyngeal mucosa after inhalation. In a comparison of washing times, the amounts of BUD recovered were 26.3+/-3.2 microg after gargling and rinsing for 3 s each, and 19.4+/-9.3 microg after those for 5 s each. As for the effect of lag time before beginning mouth washing, the ratio of BUD recovered following mouth washing with a lag time of 1 min was 73.2%, while it was reduced to 27.8% after 10 min, as compared to immediate mouth washing following administration. Our results suggest that the amount of BUD removed by mouth washing is associated with the lag time between inhalation and mouth washing, however, not with the duration of mouth washing. We concluded that immediate mouth washing after inhalation is most useful for the removal of drugs following BUD-TH administration.