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Ojanperä L, Lehtimäki L, Huhtala H, Csonka P. Inhaled corticosteroid delivery is markedly affected by breathing pattern and valved holding chamber model. Pediatr Pulmonol 2024. [PMID: 39347594 DOI: 10.1002/ppul.27300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 08/15/2024] [Accepted: 09/21/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND There is a scarcity of high-quality research on the efficient delivery of inhaled corticosteroids using valved holding chambers (VHCs) in children. METHODS The delivered dose (DD) of fluticasone from a metered dose inhaler (pMDI) was tested using four VHCs: AeroChamber plus Flow-Vu (AC), Babyhaler (BH), EasyChamber (EC), and Optichamber Diamond (OD). The in vitro setup included an anatomical child throat model, Next Generation Impactor, and a breathing simulator to generate tidal breathing of a four and a 6-year-old child, and adult type single inhalation. RESULTS OD showed the lowest proportion of fluticasone trapped in the throat with all breathing patterns. AC showed similar fine particle dose (FPD) in the respirable range (1-5 µm) irrespective of the breathing pattern. For BH, the median FPD 1-5 µm was highest during adult breathing. OD and EC showed higher overall DD and higher doses in the 1-5 µm range with paediatric breathing profiles compared to adult inhalation. The median DD and FPD 1-5 µm were significantly lower with BH compared to any other VHCs during tidal breathing. Compared to EC, the FPD of the other VHCs were skewed towards <2 µm particles. CONCLUSION Fluticasone delivery is markedly affected by breathing pattern and VHC model. The observed differences in throat deposition and FPD delivered may have significant clinical implications for side effects and controlling airway inflammation. All VHCs intended for paediatric use should undergo testing using internationally recognised standardised methods incorporating clinically relevant paediatric breathing patterns.
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Affiliation(s)
- Laura Ojanperä
- Centre for Child Health Research, Tampere University, Arvo Ylpön katu 34, Tampere, 33520, Finland
- Tampere University Hospital, Kalevantie 4, Tampere, 33014, Finland
| | - Lauri Lehtimäki
- Tampere University Hospital, Kalevantie 4, Tampere, 33014, Finland
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, Tampere, 33520, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Arvo Ylpön katu 34, Tampere, 33520, Finland
| | - Péter Csonka
- Centre for Child Health Research, Tampere University, Arvo Ylpön katu 34, Tampere, 33520, Finland
- Terveystalo Healthcare, Rautatienkatu 27, Tampere, 33100, Finland
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Karjalainen J, Vartiainen V, Tikkakoski A, Malmberg LP, Vuotari L, Lähelmä S, Sairanen U, Vahteristo M, Lehtimäki L. Salbutamol Easyhaler provides non-inferior relief of methacholine induced bronchoconstriction in comparison to Ventoline Evohaler with spacer: A randomized trial. Respir Med 2024; 230:107693. [PMID: 38851404 DOI: 10.1016/j.rmed.2024.107693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/17/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Salbutamol is a cornerstone for relieving acute asthma symptoms, typically administered through a pressurized metered-dose inhaler (pMDI). Dry powder inhalers (DPIs) offer an alternative, but concerns exist whether DPIs provide an effective relief during an obstructive event. OBJECTIVE We aimed to show non-inferiority of Salbutamol Easyhaler DPI compared to pMDI with spacer in treating methacholine-induced bronchoconstriction. Applicability of Budesonide-formoterol Easyhaler DPI as a reliever was also assessed. METHODS This was a randomized, parallel-group trial in subjects sent to methacholine challenge (MC) test for asthma diagnostics. Participants with at least 20 % decrease in forced expiratory volume in 1 s (FEV1) were randomized to receive Salbutamol Easyhaler (2 × 200 μg), Ventoline Evohaler with spacer (4 × 100 μg) or Budesonide-formoterol Easyhaler (2 × 160/4.5 μg) as a reliever. The treatment was repeated if FEV1 did not recover to at least -10 % of baseline. RESULTS 180 participants (69 % females, mean age 46 yrs [range 18-80], FEV1%pred 89.5 [62-142] %) completed the trial. Salbutamol Easyhaler was non-inferior to pMDI with spacer in acute relief of bronchoconstriction showing a -0.083 (95 % LCL -0.146) L FEV1 difference after the first dose and -0.032 (-0.071) L after the last dose. The differences in FEV1 between Budesonide-formoterol Easyhaler and Salbutamol pMDI with spacer were -0.163 (-0.225) L after the first and -0.092 (-0.131) L after the last dose. CONCLUSION The study confirms non-inferiority of Salbutamol Easyhaler to Ventoline Evohaler with spacer in relieving acute bronchoconstriction, making Easyhaler a sustainable and safe reliever for MC test and supports its use during asthma attacks.
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Affiliation(s)
- Jussi Karjalainen
- Allergy Centre, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ville Vartiainen
- Heart and Lung Center, Helsinki University Hospital, Finland and Faculty of Medicine, University of Helsinki, Finland
| | - Antti Tikkakoski
- Clinical Physiology and Nuclear Medicine, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - L Pekka Malmberg
- Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Vuotari
- Clinical Physiology and Nuclear Medicine, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Finland
| | | | | | | | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Cazzola M, Ora J, Maniscalco M, Rogliani P. A clinician's guide to single vs multiple inhaler therapy for COPD. Expert Rev Respir Med 2024; 18:457-468. [PMID: 39044348 DOI: 10.1080/17476348.2024.2384702] [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: 05/14/2024] [Accepted: 07/22/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION In the management of chronic obstructive pulmonary disease (COPD), inhalation therapy plays a pivotal role. However, clinicians often face the dilemma of choosing between single and multiple inhaler therapies for their patients. This choice is critical because it can affect treatment efficacy, patient adherence, and overall disease management. AREAS COVERED This article examines the advantages and factors to be taken into consideration when selecting between single and multiple inhaler therapies for COPD. EXPERT OPINION Both single and multiple inhaler therapies must be considered in COPD management. While single inhaler therapy offers simplicity and convenience, multiple inhaler therapy provides greater flexibility and customization. Clinicians must carefully evaluate individual patient needs and preferences to determine the most appropriate inhaler therapy regimen. Through personalized treatment approaches and shared decision-making, clinicians can optimize COPD management and improve patient well-being. Nevertheless, further research is required to compare the effectiveness of single versus multiple inhaler strategies through rigorous clinical trials, free from industry bias, to determine the optimal inhaler strategy. Smart inhaler technology appears to have the potential to enhance adherence and personalized management, but the relative merits of smart inhalers in single inhaler regimens versus multiple inhaler regimens remain to be determined.
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Affiliation(s)
- Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital "Fondazione Policlinico Tor Vergata", Rome, Italy
| | - Mauro Maniscalco
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, Telese Terme, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Respiratory Medicine, University Hospital "Fondazione Policlinico Tor Vergata", Rome, Italy
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4
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A S, Haward R, Chakraborty A. Evaluation of the Metered Dose Inhaler Technique: Initial Assessment and Post-counseling Improvements Among the Indian Population. Cureus 2024; 16:e57397. [PMID: 38694667 PMCID: PMC11062477 DOI: 10.7759/cureus.57397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2024] [Indexed: 05/04/2024] Open
Abstract
Objective The objective of this study was to evaluate errors in the use of metered-dose inhalers (MDIs) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD). Additionally, we aimed to assess improvements following corrective interventions. Settings and design This cross-sectional study was done by simple random sampling. Methods and materials This study was done at a tertiary care center in South India in an outpatient department and ward for tuberculosis and chest disease to find out the right way to use an MDI and investigate the reasons why people with asthma and COPD don't use it correctly. There were a total of 12 steps. The patient was given an empty canister to try the inhalation technique and was scored one point for every correct step and zero for every incorrect step, for a total of 12 steps. Following the demonstration, an educator used a variety of tools, including verbal communication, pictorial demonstrations, and practical demonstrations, to correct the mistakes. After education was provided, post-interventional data was collected. Results During pre-intervention of the 12 steps out of the 183 participants, step one had 183 correct participants (100%), step two had 104 correct participants (56.83%), step three had 129 correct participants (70.49%), step four had 71 correct participants (38.79%), step five had 167 correct participants (91.25%), step six had 123 correct participants (67.21%), step seven had 132 correct participants (72.13%), step eight had 81 correct participants (43.71%), step nine had 123 correct participants (67.21%), step 10 had 108 correct participants (59.01%), step 11 had 128 correct participants (69.94%), and step 12 had 175 correct participants (95.62%). During the post-intervention of the 12 steps, out of the 183 participants, step one remained at 183 correct participants (100%), step two increased to 149 correct participants (81.42%), step three to step seven increased to 183 correct participants (100%), step eight increased to 142 correct participants (77.59%), step nine increased to 174 correct participants (95.08%), step 10 increased to 177 correct participants (96.72%), step 11 increased to 143 correct participants (78.14%) and step 12 increased to 177 correct participants (96.72%). Conclusion This study highlights the prevalent errors in the use of metered-dose inhalers (MDIs) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD). The results demonstrate significant improvements in the MDI technique. Following educational interventions such as verbal communication, pictorial demonstrations, and practical exercises, patients were able to correct their inhaler technique effectively and emphasized the importance of patient education and counseling to ensure the maintenance of correct usage over time.
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Affiliation(s)
- Siddharth A
- Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - Raymond Haward
- Internal Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - Ananya Chakraborty
- Department of Pharmacology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
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Fernández-Parra R, Pey P, Reinero C, Malvè M. Salbutamol transport and deposition in healthy cat airways under different breathing conditions and particle sizes. Front Vet Sci 2023; 10:1176757. [PMID: 37533457 PMCID: PMC10391164 DOI: 10.3389/fvets.2023.1176757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
Salbutamol is a bronchodilatator commonly used for the treatment of feline inflammatory lower airway disease, including asthma or acute bronchospasm. As in humans, a pressurized metered dose inhaler (pMDI) is used in conjunction with a spacer and a spherical mask to facilitate salbutamol administration. However, efficacy of inhalation therapy is influenced by different factors including the non-cooperative character of cats. In this study, the goal was to use computational fluid dynamics (CFD) to analyze the impact of breathing patterns and salbutamol particle size on overall drug transport and deposition using a specific spherical mask and spacer designed for cats. A model incorporating three-dimensional cat airway geometry, a commercially available spherical mask, and a 10 cm spacer, was used for CFD analysis. Two peak inspiratory flows were tested: 30 mL/s and 126 mL/s. Simulations were performed with 30s breathing different inspiratory and expiratory times, respiratory frequencies and peaks. Droplet spray transport and deposition were simulated with different particle sizes typical of the drug delivery therapies (1, 5, 10, and 15 μm). The percentage of particle deposition into the device and upper airways decreased with increasing particle diameter during both flows imposed in this cat model. During increased mean ventilatory rate (MVR) conditions, most of the salbutamol was lost in the upper airways. And during decreased MVR conditions, most of the particles remained in suspension (still in hold-up) between the mask and the carina, indicating the need for more than 30 s to be transported. In both flows the percentage of particles traveling to the lung was low at 1.5%-2.3%. In conclusion, in contrast to what has been described in the human literature, the results from this feline model suggest that the percentage of particles deposited on the upper airway decreases with increasing particle diameter.
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Affiliation(s)
- Rocio Fernández-Parra
- Department of Small Animal Medicine and Surgery, Faculty of Veterinary Medicine, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | | | - Carol Reinero
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, MO, United States
| | - Mauro Malvè
- Department of Engineering, Public University of Navarre (UPNA), Pamplona, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
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Fei Q, Bentley I, Ghadiali SN, Englert JA. Pulmonary drug delivery for acute respiratory distress syndrome. Pulm Pharmacol Ther 2023; 79:102196. [PMID: 36682407 PMCID: PMC9851918 DOI: 10.1016/j.pupt.2023.102196] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
The acute respiratory distress syndrome (ARDS) is a life-threatening condition that causes respiratory failure. Despite numerous clinical trials, there are no molecularly targeted pharmacologic therapies to prevent or treat ARDS. Drug delivery during ARDS is challenging due to the heterogenous nature of lung injury and occlusion of lung units by edema fluid and inflammation. Pulmonary drug delivery during ARDS offers several potential advantages including limiting the off-target and off-organ effects and directly targeting the damaged and inflamed lung regions. In this review we summarize recent ARDS clinical trials using both systemic and pulmonary drug delivery. We then discuss the advantages of pulmonary drug delivery and potential challenges to its implementation. Finally, we discuss the use of nanoparticle drug delivery and surfactant-based drug carriers as potential strategies for delivering therapeutics to the injured lung in ARDS.
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Affiliation(s)
- Qinqin Fei
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, 500 West 12th Avenue, Columbus, OH, 43210, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Columbus, OH, 43210, USA; Department of Biomedical Engineering, The Ohio State University, 140West 19th Avenue, Columbus, OH, 43210, USA; The Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Columbus, OH, 43210, USA
| | - Ian Bentley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Columbus, OH, 43210, USA; The Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Columbus, OH, 43210, USA
| | - Samir N Ghadiali
- Department of Biomedical Engineering, The Ohio State University, 140West 19th Avenue, Columbus, OH, 43210, USA; The Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Columbus, OH, 43210, USA
| | - Joshua A Englert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Columbus, OH, 43210, USA; The Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Columbus, OH, 43210, USA.
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Dissanayake S, Mundin G, Woodward J, Lomax M, Dalvi P. Pharmacokinetic and Pharmacodynamic Comparison of Fluticasone Propionate/Formoterol Fumarate Administered via a Pressurized Metered-Dose Inhaler and a Novel Breath-Actuated Inhaler in Healthy Volunteers. J Aerosol Med Pulm Drug Deliv 2023; 36:65-75. [PMID: 36796001 DOI: 10.1089/jamp.2022.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Introduction: Fluticasone propionate/formoterol fumarate (fluticasone/formoterol) exposures, following administration of Flutiform® K-haler®, a breath-actuated inhaler (BAI), were compared with the Flutiform pressurized metered-dose inhaler (pMDI) with/without spacer in two healthy volunteer studies. In addition, formoterol-induced systemic pharmacodynamic (PD) effects were examined in the second study. Methods: Study 1: single-dose, three-period, crossover pharmacokinetic (PK) study with oral charcoal administration. Fluticasone/formoterol 250/10 μg was administered via BAI, pMDI, or pMDI with spacer (pMDI+S). Pulmonary exposure for BAI was deemed no less than for pMDI (primary comparator) if the lower limit of 94.12% confidence intervals (CIs) for BAI:pMDI maximum plasma concentration (Cmax) and area under the plasma concentration-time curve (AUCt) ratios was ≥80%. Study 2: two-stage adaptive design, both stages being single-dose, crossover without charcoal administration. The PK stage compared fluticasone/formoterol 250/10 μg via BAI, pMDI, or pMDI+S. The primary comparisons were as follows: BAI versus pMDI+S for fluticasone and BAI versus pMDI for formoterol. Systemic safety with BAI was deemed no worse than primary comparator if the upper limit of 94.12% CIs for Cmax and AUCt ratios was ≤125%. PD assessment was to be conducted if BAI safety was not confirmed in the PK stage. Based on PK results, only formoterol PD effects were evaluated. The PD stage compared fluticasone/formoterol 1500/60 μg via BAI, pMDI, or pMDI+S; fluticasone/formoterol 500/20 μg pMDI; and formoterol 60 μg pMDI. The primary endpoint was maximum reduction in serum potassium within 4 hours postdose. Equivalence was defined as 95% CIs for BAI versus pMDI+S and pMDI ratios within 0.5-2.0. Results: Study 1: lower limit of 94.12% CIs for BAI:pMDI ratios >80%. Study 2, PK stage: upper limit of 94.12% CIs for fluticasone (BAI:pMDI+S) ratios <125%; upper limit of 94.12% CIs for formoterol (BAI:pMDI) ratios >125% (for Cmax, not AUCt). Study 2, PD stage: 95% CIs for serum potassium ratios 0.7-1.3 (BAI:pMDI+S) and 0.4-1.5 (BAI:pMDI). Conclusions: Fluticasone/formoterol BAI performance was within the range observed for the pMDI with/without a spacer. Sponsor: Mundipharma Research Ltd. EudraCT 2012-003728-19 (Study 1) and 2013-000045-39 (Study 2).
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Affiliation(s)
| | - Gill Mundin
- Mundipharma Research Limited, Cambridge, United Kingdom
| | - Jo Woodward
- Mundipharma Research Limited, Cambridge, United Kingdom
| | - Mark Lomax
- Mundipharma Research Limited, Cambridge, United Kingdom
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Bacterial Contamination of Inhalation Chambers Used for Cats and Dogs with Chronic Airway Diseases. Pathogens 2023; 12:pathogens12020275. [PMID: 36839547 PMCID: PMC9961833 DOI: 10.3390/pathogens12020275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
Inhalation chambers (ICs) are regularly used in veterinary medicine for the inhalative treatment of chronic respiratory diseases in dogs and cats. Since therapy is usually required lifelong and daily, devices are frequently in use. The aim of this study was to identify bacterial contamination of ICs used for cats and dogs in relation to the applied cleaning measures. Swabs from ICs of 66 cats and 19 dogs with chronic airway diseases were obtained using a standardized protocol and subsequently cultured. A questionnaire was completed by the pet owners regarding the history of their pet's illness and applied device cleaning measures. Overall, 64% (54/86) of the ICs were found to be contaminated; the mask was significantly (p < 0.001) more often contaminated than other device parts. Most cultured bacteria were environmental contaminants; however, some harbored pathogenic potential. Cleaning frequency and method did not significantly influence the presence of contamination. Bacterial contamination of ICs, used for cats and dogs, is common but is not significantly influenced by the type or frequency of cleaning. To avoid potential infection by opportunistic bacteria, the instruction of pet owners regarding the maintenance of the ICs is recommended.
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Tony SM, Abdelrahman MA, Abd Elsalam M, Sameer Shafik M, Abdelrahim MEA. Effect of using acoustic flo-tone training device and its smartphone application on enhancing inhalation technique from metered-dose inhaler with spacer in asthmatic children. Exp Lung Res 2022; 48:224-238. [PMID: 35997099 DOI: 10.1080/01902148.2022.2113573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aim of study: This research study aims to compare between two different counseling approaches; traditional verbal counseling vs. advanced counseling (in which we used the acoustic Flo-tone training device and its smartphone application combined with traditional verbal counseling) to determine the most beneficial counseling approach for asthmatic children who use metered-dose inhaler (MDI) with spacers concerning inhalation duration and inhalation technique mistakes. Methods: A total of 100 asthmatic children (8-18) years old were randomized into two groups (a control group, and an advanced group). Each group included 50 subjects. Every subject received 3 counseling meetings, one each month. Asthmatic children in the control group were trained on inhalation technique from MDI + spacer verbally (traditional counseling), while asthmatic children in advanced group were trained on inhalation technique from MDI + spacer verbally and by advanced counseling (whistling Flo-tone + smartphone application). At each visit mistakes in inhalation technique steps were; detected, corrected, and recorded and the inhalation duration was measured for every child in each group. Results: In both study groups, the total mean number of inhalation technique mistakes decreased significantly (p < 0.05) from visit 2, also the total mean inhalation durations in seconds showed a significant increase (p < 0.05) from visit 2. A significant (p < 0.05) reduction in the total mean number of mistakes and a significant (p < 0.05) increase in total mean inhalation durations were observed from visit 2 in advanced group compared to control group. Conclusion: Combination between traditional verbal and advanced counseling methods resulted in significant (P < 0.05) improvements in the number of inhalation technique mistakes and inhalation durations from MDI with spacer in children compared to using traditional verbal counseling alone.
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Affiliation(s)
- Sara M Tony
- Beni-Suef Specialized Hospital, Beni-Suef, Egypt
| | - Mona A Abdelrahman
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | | | | | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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10
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Klenk FK, Schulz B. [Inhalation therapy in dogs and cats with chronic lower airway disease - a literature review]. TIERARZTLICHE PRAXIS. AUSGABE K, KLEINTIERE/HEIMTIERE 2022; 50:279-292. [PMID: 36067770 DOI: 10.1055/a-1910-3327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Chronic respiratory diseases are prevalent medical conditions in dogs and cats requiring lifelong treatment. Mainstay of therapy for chronic inflammatory respiratory diseases are glucocorticoids. Concurrent treatment with bronchodilators may be necessary to control clinical signs sufficiently. Due to the successful use in people as well as subsequent reduction of adverse effects of long-term glucocorticoid therapy, inhalative therapy has become increasingly important in veterinary medicine as well. Primarily spacers or valved holding chambers, in combination with metered dose inhalers, are used in dogs and cats. The technical properties of these devices, as well as their use and maintenance will be described in the following article. Furthermore, the existing literature regarding efficacy of inhalative medications for therapy of chronic inflammatory airway diseases in dogs and cats will be summarized.
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Tony SM, Abdelrahman MA, Osama H, Abdelrahim MEA. Advanced counselling using training device and smartphone application on inhalation technique from metered-dose inhaler with spacer equipped with different interfaces in asthmatic children. Int J Clin Pract 2021; 75:e14413. [PMID: 34047001 DOI: 10.1111/ijcp.14413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Spacers are equipped with either facemask or mouthpiece as an interface through which patient inhale their dose. The present study aimed to evaluate the effect of advanced counselling using training devices and smartphone applications on inhalation techniques from the metered-dose inhaler (MDI) with a spacer equipped with different interfaces. METHODS 100 paediatric asthmatic children (8-18 years) were divided into two groups. Group one was a spacer with a mouthpiece (n = 50) and group two was a spacer with a facemask group (n = 50). Both groups had three visits one month apart. At each visit, patients were asked to show the investigator their inhalation technique using MDI with spacer, and mistakes were recorded and then patients were trained on the proper inhalation technique of using MDI with a spacer. In the spacer with mouthpiece group, Flo-Tone was attached to the mouthpiece to allow the Trainhaler smartphone application to detect the duration of inhalation. In the spacer with facemask group, there was no need to use the Flo-Tone training device since the facemask was equipped with a built-in whistle detected by the Trainhaler smartphone application. RESULTS The total number of mistakes in the inhalation technique decreased significantly (P < .05) in visits 2 and 3 for both groups. Duration of inhalation increased significantly (P < .05) in the mouthpiece group at visit 2 and in the facemask group at visit 3. Achieving 5 seconds of slow deep inhalation, breath-holding for 5 seconds after inhalation and the tight fit of facemask represented the major obstacles in most children especially the youngest subjects. Breath out as far as comfortable had the highest number of mistakes in the first visit in both groups. CONCLUSION The Flo-Tone with its positive reinforcement whistle and the Trainhaler smartphone application significantly improved the inhalation technique by decreasing the total number of mistakes especially in important steps eg, shaking MDI, maintaining slow inhalation rate, breath-holding after inhalation and appropriate facemask fitting. Also, they increased the duration of inhalation of asthmatic children from MDI with a spacer. Both spacer interfaces are easy to handle once taught well.
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Affiliation(s)
- Sara M Tony
- Clinical pharmacy department, Beni-Suef Specialized Hospital, Beni-Suef, Egypt
- Technical Office of Deputy Minister of Health in Beni-Suif Directorate of Health Affairs, Beni-Suef, Egypt
| | - Mona A Abdelrahman
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hasnaa Osama
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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12
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Usmani OS, Roche N, Jenkins M, Stjepanovic N, Mack P, De Backer W. Consistent Pulmonary Drug Delivery with Whole Lung Deposition Using the Aerosphere Inhaler: A Review of the Evidence. Int J Chron Obstruct Pulmon Dis 2021; 16:113-124. [PMID: 33500616 PMCID: PMC7822085 DOI: 10.2147/copd.s274846] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/24/2020] [Indexed: 11/23/2022] Open
Abstract
Metered dose inhalers (MDIs) are one of the most common device types for delivering inhaled therapies. However, there are several technical challenges in development and drug delivery of these medications. In particular, suspension-based MDIs are susceptible to suspension heterogeneity, in vitro drug–drug interactions, and patient handling errors, which may all affect drug delivery. To overcome these challenges, new formulation approaches are required. The AerosphereTM inhaler, formulated using co-suspension delivery technology, combines drug crystals with porous phospholipid particles to create stable, homogenous suspensions that dissolve once they reach the airways. Two combination therapies using this technology have been developed for the treatment of COPD: glycopyrrolate/formoterol fumarate (GFF MDI; dual combination) and budesonide/glycopyrrolate/formoterol fumarate (BGF MDI; triple combination). Here, we review the evidence with a focus on studies assessing dose delivery, lung deposition, and effects on airway geometry. In vitro assessments have demonstrated that the Aerosphere inhaler provides consistent dose delivery, even in the presence of simulated patient handling errors. Combination therapies delivered with this technology also show a consistent fine particle fraction (FPF) and an optimal particle size distribution for delivery to the central and peripheral airways even when multiple drugs are delivered via the same inhaler. Studies using gamma scintigraphy and functional respiratory imaging have demonstrated that GFF MDI is effectively deposited in the central and peripheral airways, and provides clinically meaningful benefits on airway volume and resistance throughout the lung. Overall, studies suggest that the Aerosphere inhaler, formulated using co-suspension delivery technology, may offer advantages over traditional formulations, including consistent delivery of multiple components across patient handling conditions, optimal particle size and FPF, and effective delivery to the central and peripheral airways. Future studies may provide additional evidence to further characterize the clinical benefits of these technical improvements in MDI drug delivery.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute (NHLI), Imperial College London, and Royal Brompton Hospital, London, UK
| | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, University Paris Descartes, Paris, France
| | | | | | | | - Wilfried De Backer
- Department of Pulmonary Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
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13
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Popov TA, Passalacqua G, González-Díaz SN, Plavec D, Braido F, García-Abujeta JL, Dubuske L, Rouadi P, Morais-Almeida M, Bonini S, Cheng L, Ansotegui IJ. Medical devices in allergy practice. World Allergy Organ J 2020; 13:100466. [PMID: 33024482 PMCID: PMC7529824 DOI: 10.1016/j.waojou.2020.100466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/22/2020] [Accepted: 09/03/2020] [Indexed: 12/12/2022] Open
Abstract
Medical devices provide people with some health benefits in terms of diagnosis, prevention, treatment, and monitoring of disease processes. Different medical specialties use varieties of medical devices more or less specific for them. Allergology is an interdisciplinary field of medical science and teaches that allergic reactions are of systemic nature but can express themselves at the level of different organs across the life cycle of an individual. Subsequently, medical devices used in allergology could be regarded as: 1) general, servicing the integral diagnostic and management principles and features of allergology, and 2) organ specific, which are shared by organ specific disciplines like pulmonology, otorhinolaryngology, dermatology, and others. The present position paper of the World Allergy Organization (WAO) is meant to be the first integral document providing structured information on medical devices in allergology used in daily routine but also needed for sophisticated diagnostic purposes and modern disease management. It is supposed to contribute to the transformation of the health care system into integrated care pathways for interrelated comorbidities.
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Key Words
- AAP, Asthma Action Plan
- ATS, American Thoracic Society
- Airway inflammation
- Allergic rhinitis
- Allergology
- Allergy
- Allergy diagnosis
- Asthma
- CE mark, Conformité Européenne mark
- CO, Carbon monoxide
- DPIs, Dry Powder Inhalers
- EAI/AAI, Epinephrine/Adrenaline Auto-Injector
- EBC, Exhaled Breath Condensate
- EBT, Exhaled Breath Temperature
- EDS, Exhalation Delivery Systems
- EMA, European Medicines Agency
- ERS, European Respiratory Society
- ERV, Expiratory Reserve Volume
- FDA, Food and Drug Administration
- FEF, Forced Expiratory Flows
- FEV1, Forced Expiratory Volume in 1 second
- FOT, Forced Oscillation Technique
- FRC, Functional Residual Capacity
- FVC, Forced Vital Capacity
- FeNO, Fractional Exhaled Nitric Oxide
- GLI, Global Lung Function Initiative
- IOS, Impulse Oscillometry
- IRV, Inspiratory Reserve Volume
- Lung function tests
- MDPS, Metered-Dose Pump Sprays
- Medical devices
- NDDD, Nasal Drug Delivery Device
- NO, Nitric oxide
- PDMI, Pressurized Metered Dose Inhaler
- PEF, Peak Expiratory Flow
- PNIF, Peak Nasal Inspiratory Flow
- PT, Patch Tests
- PhPT, Photopatch tests
- Ppb, part per billion
- RV, Residual Volume
- SPT, Skin Prick Test
- Skin tests
- TLC, Total Lung Capacity
- UV, Ultra Violet
- VC, Vital Capacity
- VT, Tidal Volume
- WAO, World Allergy Organization
- WHO, World Health Organization
- m-health
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Affiliation(s)
| | | | | | | | | | | | - Lawrence Dubuske
- The George Washington University School of Medicine, Washington DC, USA
| | | | | | - Sergio Bonini
- Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy
| | - Lei Cheng
- Nanjing Medical University, First Affiliated Hospital, Nanjing, China
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14
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Efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler delivered using co-suspension delivery technology in Japanese patients with moderate-to-very severe chronic obstructive pulmonary disease. Respir Investig 2020; 59:135-144. [PMID: 32917556 DOI: 10.1016/j.resinv.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 06/12/2020] [Accepted: 06/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND PINNACLE-4 evaluated the efficacy and safety of the long-acting muscarinic antagonist/long-acting β2-agonist fixed-dose combination glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI) in patients from Asia, Europe, and the USA with moderate-to-very severe chronic obstructive pulmonary disease (COPD). This pre-specified analysis included Japanese patients in PINNACLE-4. METHODS In this double-blind randomized study (NCT02343458), patients received GFF MDI (18/9.6 μg), glycopyrrolate (GP) MDI (18 μg), formoterol fumarate (FF) MDI (9.6 μg), or placebo MDI twice daily for 24 weeks. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) over Weeks 12-24. Secondary lung function endpoints, patient-reported outcomes, and safety were assessed. The Japanese subpopulation (n = 150) analyses were exploratory. RESULTS GFF MDI improved change from baseline in morning pre-dose trough FEV1 over Weeks 12-24 versus GP MDI, FF MDI, and placebo MDI (least squares mean [LSM] differences [95% confidence interval]: 69 [8-131], 60 [-1 to 121], and 275 [180-370] mL, respectively). GFF MDI numerically improved Transition Dyspnea Index focal score and change from baseline in St George's Respiratory Questionnaire total score versus placebo MDI (LSM differences 0.19 and -3.78, respectively). Treatment-related adverse events occurred in ≤4.5% of patients in any treatment group. CONCLUSIONS GFF MDI improved lung function versus monocomponents and placebo MDI in the Japan subpopulation of PINNACLE-4. The efficacy and safety results were generally consistent with those of the global study population, supporting the use of GFF MDI in Japanese patients with moderate-to-very severe COPD.
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15
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Albertson TE, Pugashetti JV, Chau-Etchepare F, Chenoweth JA, Murin S. Pharmacotherapeutic management of asthma in the elderly patient. Expert Opin Pharmacother 2020; 21:1991-2010. [PMID: 32686969 DOI: 10.1080/14656566.2020.1795131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines. AREAS COVERED A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed. EXPERT OPINION Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Florence Chau-Etchepare
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
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16
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Moore D. Management of COPD exacerbations: pharmacotherapeutics of medications. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:738-743. [PMID: 32649242 DOI: 10.12968/bjon.2020.29.13.738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is widely established as a health challenge, with predictions that it will be the third leading cause of global mortality and reduced health status within the next 10 years. Exacerbations of COPD are now the second largest cause of emergency hospitalisation in the UK. The respiratory clinical nurse specialist has an active role in the acute management of COPD exacerbations in the hospital setting, and it is essential that prescribing decisions are made based on the best available evidence. This article critically evaluates the pharmacotherapeutics and evidence base for the use of two medications, salbutamol and amoxicillin, in treating unstable COPD, and discusses implications for clinical practice.
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Affiliation(s)
- David Moore
- Respiratory Nurse Specialist and Independent Nurse Prescriber, Mater Hospital, Belfast
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17
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Rodríguez-Martínez CE, Sossa-Briceño MP, Sinha IP. Commercial valved spacers versus home-made spacers for delivering bronchodilator therapy in pediatric acute asthma: a cost-effectiveness analysis. J Asthma 2020; 58:1340-1347. [PMID: 32546110 DOI: 10.1080/02770903.2020.1784195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: Although valved spacers are the preferred method for administering metered-dose inhaler bronchodilators such as albuterol in pediatric acute asthma, their high cost and their lack of availability have limited their use, especially in low- and middle-income countries (LMICs). Because of this, it is a common practice to use home-made spacers, although a formal analysis evaluating their cost-effectiveness is lacking. Therefore, the objective of this study was to analyze the cost-effectiveness of home-made spacers compared to commercial valved spacers for delivering bronchodilator therapy in pediatric acute asthma.Methods: A decision-analysis model was used to estimate health outcomes and costs of a simulated cohort of pediatric patients treated for acute asthma. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was avoidance of hospital admission.Results: Base-case analysis showed that compared to commercial valved spacers, administering bronchodilators with home-made spacers results in lower overall treatment costs (US$126.75 vs. US$128.59 average cost per patient) without a significant difference in the probability of hospitalization avoided (0.8500 vs. 0.8500).Conclusions: The present study shows that in Colombia, an MIC, compared with commercial valved spacers, the use of home-made spacers for administering bronchodilator therapy is more cost-effective because it yields a similar probability of hospital admission at lower overall treatment costs.
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Affiliation(s)
- Carlos E Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia Bogota, Colombia
| | - Ian P Sinha
- Respiratory Department, Alder Hey Childrens Hospital Liverpool, Liverpool, UK
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18
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Chen R, Zhong N, Wang HY, Zhao L, Mei X, Qin Z, Huang J, Assam PN, Maes A, Siddiqui S, Martin UJ, Reisner C. Efficacy And Safety Of Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler (GFF MDI) Formulated Using Co-Suspension Delivery Technology In Chinese Patients With COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:43-56. [PMID: 32021143 PMCID: PMC6956867 DOI: 10.2147/copd.s223638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/30/2019] [Indexed: 12/03/2022] Open
Abstract
Background Glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI) is a long-acting muscarinic antagonist/long-acting β2-agonist fixed-dose combination therapy delivered by MDI, formulated using innovative co-suspension delivery technology. The PINNACLE-4 study evaluated the efficacy and safety of GFF MDI in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD) from Asia, Europe, and the USA. This article presents the results from the China subpopulation of PINNACLE-4. Methods In this randomized, double-blind, placebo-controlled, parallel-group Phase III study (NCT02343458), patients received GFF MDI 18/9.6 µg, glycopyrrolate (GP) MDI 18 µg, formoterol fumarate (FF) MDI 9.6 µg, or placebo MDI (all twice daily) for 24 weeks. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 second at Week 24. Secondary lung function endpoints and patient-reported outcome measures were also assessed. Safety was monitored throughout the study. Results Overall, 466 patients from China were included in the intent-to-treat population (mean age 63.6 years, 95.7% male). Treatment with GFF MDI improved the primary endpoint compared to GP MDI, FF MDI, and placebo MDI (least squares mean differences: 98, 104, and 173 mL, respectively; all P≤0.0001). GFF MDI also improved daily total symptom scores and time to first clinically important deterioration versus monocomponents and placebo MDI, and Transition Dyspnea Index focal score versus placebo MDI. Rates of treatment-emergent adverse events were similar across the active treatment groups and slightly higher in the placebo MDI group. Conclusion GFF MDI improved lung function and daily symptoms versus monocomponents and placebo MDI and improved dyspnea versus placebo MDI. All treatments were well tolerated with no unexpected safety findings. Efficacy and safety results were generally consistent with the global PINNACLE-4 population, supporting the use of GFF MDI in patients with COPD from China.
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Affiliation(s)
- Rongchang Chen
- Shenzhen Institute of Respiratory Diseases, Shenzhen People's Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Nanshan Zhong
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Diseases, National Clinical Research Centre for Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Hao-Yan Wang
- Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Li Zhao
- Sheng Jing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Xiaodong Mei
- Anhui Provincial Hospital, Hefei, Anhui, People's Republic of China
| | - Zhiqiang Qin
- The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning City, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Juan Huang
- Formerly of AstraZeneca, Shanghai, People's Republic of China
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19
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Lavorini F, Barreto C, van Boven JFM, Carroll W, Conway J, Costello RW, Dahl BH, Dekhuijzen RPN, Holmes S, Levy M, Molimard M, Roche N, Román-Rodriguez M, Scichilone N, Scullion J, Usmani OS. Spacers and Valved Holding Chambers-The Risk of Switching to Different Chambers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1569-1573. [PMID: 31927099 DOI: 10.1016/j.jaip.2019.12.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/09/2019] [Accepted: 12/29/2019] [Indexed: 10/25/2022]
Abstract
Spacers are pressurized metered-dose inhaler (pMDI) accessory devices developed to reduce problems of poor inhaler technique with pMDIs. Spacers that feature a 1-way inspiratory valve are termed valved holding chambers (VHCs); they act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a 2-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. Both spacers and VHCs have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce corticosteroid-related side effects such as throat irritation, dysphonia, and oral candidiasis commonly seen with the use of pMDIs alone. Spacers and VHCs are not all the same, and also are not interchangeable: the performance may vary according to their size, shape, material of manufacture and propensity to become electrostatically charged, their mode of interface with the patient, and the presence or otherwise of valves and feedback devices. Thus, pairing of a pMDI plus a spacer or a VHC should be considered as a unique delivery system. In this Rostrum we discuss the risk potential for a patient getting switched to a spacer or VHC that delivers a reduced dose medication.
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Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Celeste Barreto
- Departamento de Pediatria, Hospital de Santa Maria (CHLN), Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Job F M van Boven
- University of Groningen, University Medical Centre Groningen, Groningen Research Institute for Asthma and COPD, Department of General Practice and Elderly Care Medicine, Groningen, The Netherlands
| | - Will Carroll
- Department of Paediatrics, University Hospital of North Midlands NHS Trust, Stoke-On-Trent, United Kingdom
| | - Joy Conway
- Computationally Intensive Imaging, University of Southampton, Southampton, United Kingdom
| | | | - Birthe Hellqvist Dahl
- Department of Respiratory Diseases & Allergy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Stephen Holmes
- Park Medical Practice, Shepton Mallet, Somerset, United Kingdom
| | - Mark Levy
- Harrow Primary Care Trust, London, United Kingdom
| | - Mathieu Molimard
- Département de Pharmacologie, CHU de Bordeaux, Universite Bordeaux, Bordeaux, France
| | - Nicholas Roche
- Respiratory Medicine, Cochin Hospital APHP, University Paris Descartes, Paris, France
| | - Miguel Román-Rodriguez
- Primary Care Respiratory Research Unit, Instituto de Investigación Sanitaria de las Islas Baleares, Mallorca, Spain
| | - Nicola Scichilone
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Jane Scullion
- University Hospitals of Leicester, Leicester, United Kingdom
| | - Omar S Usmani
- Imperial College London & Royal Brompton Hospital, London, United Kingdom
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20
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Maltais F, Ferguson GT, Feldman GJ, Deslee G, Bourdin A, Fjällbrant H, Siwek-Posłuszna A, Jenkins MA, Martin UJ. A Randomized, Double-Blind, Double-Dummy Study of Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler Relative to Umeclidinium/Vilanterol Dry Powder Inhaler in COPD. Adv Ther 2019; 36:2434-2449. [PMID: 31267366 DOI: 10.1007/s12325-019-01015-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), formulated using co-suspension delivery technology, is the only approved fixed-dose combination long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) delivered via MDI. Direct comparisons of GFF MDI versus other LAMA/LABAs have not previously been performed. We assessed the efficacy and safety of GFF MDI relative to umeclidinium/vilanterol dry powder inhaler (UV DPI) in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD). METHODS In this phase IIIb randomized, double-blind, double-dummy, multicenter, 24-week study, patients received GFF MDI 18/9.6 μg (equivalent to glycopyrronium/formoterol fumarate dihydrate 14.4/10 μg; two inhalations per dose, twice-daily; n = 559) or UV DPI 62.5/25 μg (one inhalation, once-daily; n = 560). Primary endpoints were change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) and peak change from baseline in FEV1 within 2 h post-dose, both over 24 weeks. Additional lung function, symptom and safety endpoints were also assessed. RESULTS For the primary endpoints, GFF MDI was non-inferior to UV DPI (using a margin of - 50 mL) for peak FEV1 (least squares mean [LSM] difference - 3.4 mL, 97.5% confidence interval [CI] - 32.8, 25.9) but not for trough FEV1 (LSM difference - 87.2 mL; - 117.0, - 57.4). GFF MDI was nominally superior to UV DPI for onset of action (p < 0.0001) and was nominally non-inferior to UV DPI for all symptom endpoints (Transition Dyspnea Index focal score, Early Morning/Night-Time Symptoms COPD instrument scores, and COPD Assessment Test score). Exacerbation and safety findings were similar between groups. CONCLUSIONS Over 24 weeks of treatment, GFF MDI was non-inferior to UV DPI for peak FEV1, but not for morning pre-dose trough FEV1. GFF MDI had a faster onset of action versus UV DPI. There were no clinically meaningful differences between treatments in symptom endpoints. Both treatments were well tolerated with similar safety profiles. TRIAL REGISTRATION NCT03162055 (Clinicaltrials.gov) FUNDING: AstraZeneca.
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21
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Singh D, van den Berg F, Leaker B, Corradi M, Jabbal S, Collarini S, Mongelli V, Santoro L, Piccinno A, Biondaro S, Lipworth B. Comparison of the effect of beclometasone/formoterol in asthma patients after methacholine-induced bronchoconstriction: A noninferiority study using metered dose vs. dry powder inhaler. Br J Clin Pharmacol 2019; 85:729-736. [PMID: 30586199 PMCID: PMC6422816 DOI: 10.1111/bcp.13847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/29/2018] [Accepted: 12/18/2018] [Indexed: 11/29/2022] Open
Abstract
Aims To demonstrate the noninferiority of extrafine beclomethasone/formoterol fumarate (BDP/FF) dry powder inhaler (DPI) vs. extrafine BDP/FF pressurized metered dose inhaler (pMDI; Foster® 100/6 μg NEXThaler and pMDI, respectively) in the onset of reliever effect after methacholine induced bronchospasm in asthmatic patients, evaluated in terms of forced expiratory volume in 1 s (FEV1) at 5 min postdose. The DPI provides an alternative device option for patients who cannot use a pMDI properly during an acute asthma attack. Methods Sixty‐five patients received one inhalation of BDP/FF DPI, BDP/FF pMDI or placebo after methacholine challenge, according to a double‐blind, double‐dummy, cross‐over design. Lung function and Borg dyspnoea score were assessed up to 30 min postdose. Results FEV1 adjusted mean difference between BDP/FF DPI and BDP/FF pMDI at 5 min postdose was 2 ml (95% confidence interval: –0.060; 0.065). A similar result was observed at the other time points. Median time to 85% recovery in FEV1 was 8 min for BDP/FF DPI, 7.5 min for BDP/FF pMDI and 28 min for placebo (P = 0.554 DPI vs. pMDI). The Borg score improved after treatment with both BDP/FF DPI and pMDI and the effect was greater than after placebo. Median time to reach 50% recovery was 4.2 min for BDP/FF DPI, 4.0 min for BDP/FF pMDI and 10.0 min for placebo (P = 0.609 DPI vs. pMDI). Conclusions Extrafine Foster® NEXThaler, a flow‐independent DPI, is comparable to extrafine Foster® pMDI when administered as reliever therapy after methacholine challenge, thus supporting the maintenance and reliever therapy approach also with Foster® NEXThaler.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
| | | | | | - Massimo Corradi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, Dundee, UK
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22
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Srour-Alphonse P, Cvetkovski B, Rand CS, Azzi E, Tan R, Kritikos V, Cheong LHM, Bosnic-Anticevich S. It takes a village - asthma networks utilized by parents when managing childhood asthma medications. J Asthma 2019; 57:306-318. [PMID: 30669905 DOI: 10.1080/02770903.2019.1568456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: We are yet to understand how widely parents seek asthma medication management information for their children, how they are used for health information, how parents engage with them and their influence on parent's decision-making. This study aimed to gauge the current level of asthma knowledge and skills of parents of children with asthma and gain insight into who and what influences their child's asthma medication management decisions. Method: Social network theory was used to map parents' asthma networks and identify the level of influence of each individual/resource nominated. Parents of children with asthma (aged 4-18 years) were interviewed, completed an asthma network map, questionnaires and an inhaler technique assessment. Results: Twenty-six parents participated and had significant gaps in asthma knowledge and inhaler technique skills. The asthma networks of participants ranged from two to ten individuals/resources, with an average number of five. The most commonly nominated individual/resource was general practitioners followed by family members and the internet. Professional connections represented 44% of individuals/resources in networks, personal connections 42% and impersonal connections 14%. When parents were asked about how influential individuals/resources were, professional connections represented 53% of parents influences, personal connections 36% and impersonal connections 11%. Conclusion: This study highlights the priority and co-influence of non-medical sources of information/support on parent's behaviors and decision-making with regards to their child's asthma medicine taking. In further understanding the complexities surrounding these connections and relationships, HCPs are better positioned to assist parents in addressing their needs and better supporting them in the management of their child's asthma.
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Affiliation(s)
- Pamela Srour-Alphonse
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Biljana Cvetkovski
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Cynthia S Rand
- Pulmonary and Critical Care Medicine Department, John Hopkins University, Baltimore, MD, USA
| | - Elizabeth Azzi
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Rachel Tan
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Lynn H M Cheong
- Faculty of Health, University of Canberra, Canberra, Australia
| | - Sinthia Bosnic-Anticevich
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Central Sydney Local Area Health District, Sydney, Australia
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Abstract
Inhalation therapy is one of the oldest approaches to the therapy of diseases of the respiratory tract. It is well recognised today that the most effective and safe means of treating the lungs is to deliver drugs directly to the airways. Surprisingly, the delivery of therapeutic aerosols has a rich history dating back more than 2,000 years to Ayurvedic medicine in India, but in many respects, the introduction of the first pressurised metered-dose inhaler (pMDI) in 1956 marked the beginning of the modern pharmaceutical aerosol industry. The pMDI was the first truly portable and convenient inhaler that effectively delivered drug to the lung and quickly gained widespread acceptance. Since 1956, the pharmaceutical aerosol industry has experienced dramatic growth. The signing of the Montreal Protocol in 1987 to reduce the use of CFCs as propellants for aerosols led to a surge in innovation that resulted in the diversification of inhaler technologies with significantly enhanced delivery efficiency, including modern pMDIs, dry powder inhalers and nebuliser systems. There is also great interest in tailoring particle size to deliver drugs to treat specific areas of the respiratory tract. One challenge that has been present since antiquity still exists, however, and that is ensuring that the patient has access to the medication and understands how to use it effectively. In this article, we will provide a summary of therapeutic aerosol delivery systems from ancient times to the present along with a look to the future.
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Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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Lavorini F, Janson C, Braido F, Stratelis G, Løkke A. What to consider before prescribing inhaled medications: a pragmatic approach for evaluating the current inhaler landscape. Ther Adv Respir Dis 2019; 13:1753466619884532. [PMID: 31805823 PMCID: PMC6900625 DOI: 10.1177/1753466619884532] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/12/2019] [Indexed: 12/16/2022] Open
Abstract
Inhaled therapies are the cornerstone of treatment in asthma and chronic obstructive pulmonary disease, and there are a multitude of devices available. There is, however, a distinct lack of evidence-based guidance for healthcare providers on how to choose an appropriate inhaler. This review aims to summarise recent updates on topics related to inhaler choice, and to offer practical considerations for healthcare providers regarding currently marketed devices. The importance of choosing the right inhaler for the right patient is discussed, and the relative merits of dry powder inhalers, pressurised metered dose inhalers, breath-actuated pressurised metered dose inhalers, spacers and soft mist inhalers are considered. Compiling the latest studies in the devices therapy area, this review focuses on the most common types of handling errors, as well as the comparative rates of incorrect inhalation technique between devices. The impact of device-specific handling errors on inhaler performance is also discussed, and the characteristics that can impair optimal drug delivery, such as inhalation flow rate, inhalation volume and particle size, are compared between devices. The impact of patient perceptions, behaviours and problems with inhalation technique is analysed, and the need for appropriate patient education is also highlighted. The continued development of technology in inhaler design and the need to standardise study assessment, endpoints and patient populations are identified as future research needs. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Federico Lavorini
- Careggi University Hospital, Department of
Experimental and Clinical Medicine, Largo Brambilla 3, 50134, Florence,
Italy
| | - Christer Janson
- Department of Medical Sciences: Respiratory,
Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset,
Uppsala, Sweden
| | - Fulvio Braido
- Allergy and Respiratory Disease Clinic,
DIMI-University of Genova, IRCCS AOU San Martino-IST, Genova, Italy
| | - Georgios Stratelis
- Department of Medical Sciences: Respiratory,
Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset,
Uppsala, Sweden
- AstraZeneca Nordic-Baltic, Astraallén,
Sødertälje, Sweden
| | - Anders Løkke
- Department of Respiratory Diseases and Allergy,
Aarhus University Hospital, Aarhus C, Denmark
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Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res 2018; 4:00065-2018. [PMID: 29928649 PMCID: PMC6004521 DOI: 10.1183/23120541.00065-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/18/2018] [Indexed: 11/05/2022] Open
Abstract
We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.
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Affiliation(s)
- Walter Vincken
- Respiratory Division, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | - Chris J Corrigan
- Faculty of Life Sciences and Medicine, King's College London/Guy's and St Thomas's NHS Foundation Trust, London, UK
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26
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Abstract
Pulmonary drug delivery is relatively complex because the respiratory tract has evolved defense mechanisms to keep inhaled drug particles out of the lungs and to remove or inactivate them once deposited. In addition to these mechanical, chemical and immunological barriers, pulmonary drug delivery is adversely affected by the behavioral barriers of poor adherence and poor inhaler technique. Strategies to mitigate the effects of these barriers include use of inhaler devices and formulations that deliver drug to the lungs efficiently, appropriate inhaler technique and improved education of patients. Owing to the advantages offered by the pulmonary route, the challenges that the route poses are worth addressing, and if successfully addressed, the pulmonary route offers huge opportunities, often fulfilling unmet clinical needs.
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27
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Fakih F, Spangenthal S, Sigal B, Darken P, Maes A, Siddiqui S, Gillen M, Reisner C, Martin UJ. Randomized study of the effects of Aerochamber Plus ® Flow-Vu ® on the efficacy, pharmacokinetics and safety of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler in patients with chronic obstructive pulmonary disease. Respir Med 2018; 138:74-80. [DOI: 10.1016/j.rmed.2018.03.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/14/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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McIvor RA, Devlin HM, Kaplan A. Optimizing the Delivery of Inhaled Medication for Respiratory Patients: The Role of Valved Holding Chambers. Can Respir J 2018; 2018:5076259. [PMID: 29849831 PMCID: PMC5904796 DOI: 10.1155/2018/5076259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 02/02/2023] Open
Abstract
Valved holding chambers (VHCs) have been used with pressurized metered-dose inhalers since the early 1980s. They have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce side effects such as throat irritation, dysphonia, and oral candidiasis that are common with use of pressurized metered-dose inhalers (pMDIs) alone. VHCs act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a two-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. The design of VHC devices can have an impact on performance. Features such as antistatic properties, effective face-to-facemask seal feedback whistles indicating correct inhalation speed, and inhalation indicators all help improve function and performance, and have been demonstrated to improve asthma control, reduce the rate of exacerbations, and improve quality of life. Not all VHCs are the same, and they are not interchangeable. Each pairing of a pMDI device plus VHC should be considered as a unique delivery system.
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Affiliation(s)
- R. Andrew McIvor
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | | | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Health Quality Ontario COPD Community Standards Project, Toronto, ON, Canada
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29
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Anderson G, Johnson N, Mulgirigama A, Aggarwal B. Use of spacers for patients treated with pressurized metered dose inhalers: focus on the VENTOLIN™ Mini Spacer. Expert Opin Drug Deliv 2018; 15:419-430. [PMID: 29415579 DOI: 10.1080/17425247.2018.1437414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Spacers offer a multitude of benefits by reducing the requirement to coordinate inhalation with actuation and improving inhaler technique in patients using a pressurized metered dose inhaler (pMDI). Spacers improve drug targeting by retaining within the spacer large particles normally deposited in the oropharynx, and by creating a prolonged aerosol cloud of fine particles to give the user increased time to inhale after actuation. This is particularly important in young children and the elderly to effectively deliver medication to the airways. AREAS COVERED By investigating the history and features of spacers, we demonstrate that the advantages of using spacers far outweigh their limitations. We also discuss the optimal characteristics of spacers in terms of shape, volume, presence of valve and static charge, and present a detailed discussion of the VENTOLIN™ Mini Spacer. EXPERT OPINION Generally, the shape and size of spacers makes them inherently inconvenient. Consideration of human factors and modern design may make them more attractive to patients. However, the incentive to use spacers should be their ability to help patients correctly use inhaled medications delivered by pMDIs. Understanding of these principles through education is key to their acceptance by patients.
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Affiliation(s)
- Gregor Anderson
- a GSK, Respiratory Centre of Excellence, Global Manufactory & Supply , Ware, Herts , UK
| | - Neil Johnson
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Aruni Mulgirigama
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Bhumika Aggarwal
- c GSK , Respiratory, Global Classic & Established Products , Singapore
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30
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Yawn BP, Han MK. Practical Considerations for the Diagnosis and Management of Asthma in Older Adults. Mayo Clin Proc 2017; 92:1697-1705. [PMID: 29101938 DOI: 10.1016/j.mayocp.2017.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 11/29/2022]
Abstract
Although often considered a disease of childhood, the prevalence of asthma in US adults aged 65 years or older is similar to that in children, with the number of older patients needing care for asthma likely to continue to increase. As with most chronic diseases, there are challenges associated with the diagnosis and management of asthma in an older population. This review discusses these challenges, suggesting practical management strategies for primary care physicians and their teams. Asthma comprises a spectrum of phenotypes, some associated with adult onset. The symptoms and characteristics of patients with late-onset asthma can differ from those of patients with early-onset disease. Furthermore, older patients may fail to recognize respiratory symptoms as abnormal and have other comorbidities, complicating the differential diagnosis of asthma. Once diagnosed, the long-term goals of asthma management are no different in older adults than in anyone with asthma, with inhaled corticosteroids being the cornerstone of therapy. Comorbid conditions become more common with age and have a direct impact on a patient's respiratory symptoms and potential adverse effects of therapy, thereby influencing the choice of therapies and delivery systems and potentially increasing the likelihood of complex polypharmacy. In conclusion, asthma, although traditionally considered a disease of the young, should be considered as a potential diagnosis in older adults with respiratory symptoms, even without a history of asthma or allergies. As with all patients, the primary goals of asthma management in older adults are symptom control and exacerbation reduction.
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Affiliation(s)
- Barbara P Yawn
- Department of Family Medicine and Community Health, University of Minnesota, Blaine, MN.
| | - MeiLan K Han
- Women's Respiratory Clinic, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
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31
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Johnson JLH, Guthrie D, Hyde J, Hanson T, Karlage K, Myrdal PB. The effect of a holding chamber on albuterol metered-dose inhaler product differences. Ann Allergy Asthma Immunol 2017; 117:246-50. [PMID: 27613457 DOI: 10.1016/j.anai.2016.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/08/2016] [Accepted: 07/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Three albuterol sulfate metered-dose inhaled (MDI) products (Ventolin HFA, Proventil HFA, and ProAir HFA) are marketed in the United States to provide the same total dose of albuterol sulfate. However, it is widely known that the fine particle dose (<5 μm) is the portion of the particle distribution that actually reaches the lungs and provides therapeutic benefit. OBJECTIVE To examine the differences in particle size between products and how a valved holding chamber (VHC) can mitigate possible adverse effects. METHODS Particle size distributions in each product were measured, with and without a VHC, and were analyzed by high-performance liquid chromatography. RESULTS The only significant mean (SD) difference in total dose was between Proventil (75 [21] μg) and ProAir (107 [12] μg) (P < .01). The fine particle doses of all 3 products were significantly different: 21 (5) μg of albuterol sulfate for Ventolin, 40 (4) μg of albuterol sulfate for Proventil, and 64 (7) μg of albuterol sulfate for ProAir (P < .001 for all 3 cases). The VHC successfully removed the larger particle dose delivered by all 3 products (P ≤ .01) without reducing the fine particle dose (P > .05). CONCLUSION Ventolin, Proventil, and ProAir should not be considered interchangeable products. In this study, the dose of albuterol sulfate likely to reach the lungs with Proventil or ProAir is 2 to 3 times that of Ventolin. As such, patients with asthma may require 3 additional puffs of Ventolin to achieve a clinical benefit similar to Proventil or ProAir. Because all 3 products contain 200 actuations, it also follows that Proventil or ProAir products may last a user 2 to 3 times longer than Ventolin.
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Affiliation(s)
| | | | - Joel Hyde
- Thayer Medical Corporation, Tucson, Arizona
| | - Thomas Hanson
- Thayer Medical Corporation, Tucson, Arizona; Department of Pharmacy Practice and Sciences, The University of Arizona College of Pharmacy, Tucson, Arizona
| | - Kelly Karlage
- Department of Pharmaceutical Sciences, The University of Arizona College of Pharmacy, Tucson, Arizona
| | - Paul B Myrdal
- Department of Pharmaceutical Sciences, The University of Arizona College of Pharmacy, Tucson, Arizona
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32
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Lavorini F, Pistolesi M, Usmani OS. Recent advances in capsule-based dry powder inhaler technology. Multidiscip Respir Med 2017; 12:11. [PMID: 28536654 PMCID: PMC5439154 DOI: 10.1186/s40248-017-0092-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/12/2017] [Indexed: 11/26/2022] Open
Abstract
Pulmonary drug delivery is currently the focus of accelerated research and development because of the potential to produce maximum therapeutic benefit to patients by directly targeting drug to the site of pathology in the lungs. Among the available delivery options, the dry powder inhaler (DPI) is the preferred device for the treatment of an increasingly diverse range of diseases. However, because drug delivery from a DPI involves a complex interaction between the device and the patient, the engineering development of this medical technology is proving to be a great challenge. Development of DPI systems that target the delivery of fine drug particles to the deeper airways in the lungs using a combination of improved drug formulations and enhanced delivery device technologies means that each of these factors contributes to overall performance of the aerosol system. There are a large range of devices that are currently available, or under development, for clinical use, however no individual device shows superior clinical efficacy. A major concern that is very relevant in day-to-day clinical practice is the inter- and intra-patient variability of the drug dosage delivered to the deep lungs from the inhalation devices, where the extent of variability depends on the drug formulation, the device design, and the patient’s inhalation profile. This variability may result in under-dosing of drug to the patient and potential loss of pharmacological efficacy. This article reviews recent advances in capsule-based DPI technology and the introduction of the ‘disposable’ DPI device.
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Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Massimo Pistolesi
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London& Royal Brompton Hospital, London, UK
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Schor D, Rizzo JÂ, Medeiros D, Dela Bianca AC, Silva AR, Nunes C, Morais-Almeida M, Sarinho E. Home-made spacer as an auxiliary device in administration of beclomethasone via pressurized metered dose inhaler for asthma control. A randomized controlled pragmatic trial. Respir Med 2017; 126:52-58. [PMID: 28427550 DOI: 10.1016/j.rmed.2017.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/16/2017] [Accepted: 03/21/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Holding chambers or spacers can enhance the efficacy of pressurized metered dose inhalers (pMDI) in delivering inhaled medications, as they reduce the need for hand-breath coordination and improve lower airways deposition. Nevertheless, their cost can be high for patients in low-income countries. OBJECTIVE To compare asthma control achieved with beclomethasone-dipropionate administered through a hydrofluoroalkane-driven pMDI (BDp-pMDI) coupled to a home-made spacer (HmS) or to a valved commercial spacer (VCS) as auxiliary devices. METHODS Sixty-three patients with poorly controlled asthma that had a BDp-pMDI prescription were randomized to use the inhaler coupled to a HmS made of 500 ml plastic bottles (Group HmS, n = 32) or to a VCS (Group VCS, n = 31) for 60 days. All were given training sessions. Asthma control was assessed through the Asthma Control Test (ACT) and forced expiratory volume in the first second (FEV1), both measured before, and 30 and 60 days after treatment began. RESULTS Both groups showed significant improvement in ACT scores after 30 and 60 days compared to baseline values (an increase of 7 and 7.8 points for the HmS group and 5.9 and 7.0 points for the VCS group, respectively, p < 0.001). There was no statistically significant difference in ACT scores between groups at any observation time (P = 0.261). FEV1 showed the same behavior. CONCLUSIONS A similar level of asthma control was achieved with beclomethasone-dipropionate administered through a pMDI whether the inhaler was coupled to the HmS or VCS. These results are significant for asthma control planning strategies in low-income communities. (Trial Register Number: RBR-5x4dc9).
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Affiliation(s)
- Deborah Schor
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - José Ângelo Rizzo
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil; Pneumology Department, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Decio Medeiros
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Ana Carolina Dela Bianca
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Almerinda Rego Silva
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Carlos Nunes
- Algarve Immuno-Allergology Center, Portimão, Portugal.
| | - Mário Morais-Almeida
- CUF Descobertas Hospital, Immuno-Allergy Department, Lisbon and CINTESIS (Center for Research in Health Technologies and Information Systems), Faculdade de Medicina Do Porto, Portugal.
| | - Emanuel Sarinho
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
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Selecting the best device to deliver inhaled chronic obstructive pulmonary disease therapy in elderly patients requires an individualized approach. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0379-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bartolo K, Balzan M, Schembri EL, Asciak R, Mercieca Balbi D, Pace Bardon M, Montefort S. Predictors of correct technique in patients using pressurized metered dose inhalers. BMC Pulm Med 2017; 17:47. [PMID: 28245825 PMCID: PMC5331728 DOI: 10.1186/s12890-017-0386-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 02/15/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Corret inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients. METHODS Two hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical. RESULTS 23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63-8.54, p = 0.001), male gender 2.70(1.35-5.39, p = 0.004), self-score 1-10 1.21(1.05-1.39, p = 0.007), spacer use 0.38(0.19-0.79, p = 0.007), inhaled steroid 3.71(1.34-10.25, p = 0.01), heart disease 0.31(0.13-0.77, p = 0.01), pneumococcal vaccine 2.48(1.0-6.15, p = 0.043), education level 1-4 1.44(1.00-2.06, p = 0.05) and respiratory physician explained 0-7 times, 1.11(0.99-1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0-4, were: technique self-score 1-10 1.2(1.05-1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1-7.31, p = 0.03) and education level 1-4 1.41(1.02-1.95, p = 0.03 Times respiratory physician explained inhaler technique 0-7 1.1(0.98-1.24, p = 0.1), married status 1.55(0.85-2.82, p = 0.15), hypercholesterolaemia 0.52(0.25-1.01, p = 0.054) and male gender 1.76(0.97-3.18, p = 0.06). CONCLUSIONS Known predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients' self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.
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Affiliation(s)
- Kyra Bartolo
- Mater Dei Hospital, Dun Karm Street, Msida, Malta
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36
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Rogliani P, Calzetta L, Coppola A, Cavalli F, Ora J, Puxeddu E, Matera MG, Cazzola M. Optimizing drug delivery in COPD: The role of inhaler devices. Respir Med 2017; 124:6-14. [PMID: 28284323 DOI: 10.1016/j.rmed.2017.01.006] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Inhaled medication is the cornerstone of the pharmacological treatment for patients with asthma and chronic obstructive pulmonary disease (COPD). Several inhaler devices exist, and each device has specific characteristics to achieve the optimal inhalation of drugs. The correct use of inhaler devices is not granted and patients may incur in mistakes when using pressurized metered-dose inhalers (pMDIs) or dry-powder inhaler (DPIs). The incorrect use of inhaler devices can lead to a poorly controlled disease status. Unfortunately, guidelines provide limited guidance regarding the choice of devices. This article presents a review of the literature on different inhaler device requirements. Data from literature (PubMed and Google Scholar) on the commercially available inhaler devices have been evaluated and the history of inhaler medicine described. Furthermore, advantages and disadvantages of each type of device have been analyzed. The evaluation of literature indicated the availability of robust data on the devices characteristics and factors influencing selection of delivery devices. Each type of device has its own pro and cons. The age, cognitive status, visual acuity, manual dexterity, manual strength and ability to coordinate the inhaler actuation with inhalation may be as important as the disease severity in determining the correct approach to delivery of respiratory medication. The administration of effective therapies via a device that is simple to use and accepted by patients may help to improve treatment outcomes in patients with COPD.
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Affiliation(s)
- Paola Rogliani
- University of Rome Tor Vergata, Department of Systems Medicine, Rome, Italy.
| | - Luigino Calzetta
- University of Rome Tor Vergata, Department of Systems Medicine, Rome, Italy
| | - Angelo Coppola
- University of Rome Tor Vergata, Department of Systems Medicine, Rome, Italy
| | - Francesco Cavalli
- University of Rome Tor Vergata, Department of Systems Medicine, Rome, Italy
| | - Josuel Ora
- University of Rome Tor Vergata, Department of Systems Medicine, Rome, Italy
| | - Ermanno Puxeddu
- University of Rome Tor Vergata, Department of Systems Medicine, Rome, Italy
| | - Maria Gabriella Matera
- Second University of Naples, Department of Experimental Medicine, Unit of Pharmacology, Naples, Italy
| | - Mario Cazzola
- University of Rome Tor Vergata, Department of Systems Medicine, Rome, Italy
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Lavorini F, Pedersen S, Usmani OS. Dilemmas, Confusion, and Misconceptions Related to Small Airways Directed Therapy. Chest 2016; 151:1345-1355. [PMID: 27522955 DOI: 10.1016/j.chest.2016.07.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 07/20/2016] [Accepted: 07/30/2016] [Indexed: 11/26/2022] Open
Abstract
During the past decade, there has been increasing evidence that the small airways (ie, airways < 2 mm in internal diameter) contribute substantially to the pathophysiologic and clinical expression of asthma and COPD. The increased interest in small airways is, at least in part, a result of innovation in small-particle aerosol formulations that better target the distal lung and also advanced physiologic methods of assessing small airway responses. Increasing the precision of drug deposition may improve targeting of specific diseases or receptor locations, decrease airway drug exposure and adverse effects, and thereby increase the efficiency and effectiveness of inhaled drug delivery. The availability of small-particle aerosols of corticosteroids, bronchodilators, or their combination enables a higher total lung deposition and better peripheral lung penetration and provides added clinical benefit, compared with large-particle aerosol treatment. However, a number of questions remain unanswered about the pragmatic approach relevant for clinicians to consider the role of small airways directed therapy in the day-to-day management of asthma and COPD. We thus have tried to clarify the dilemmas, confusion, and misconceptions related to small airways directed therapy. To this end, we have reviewed all studies on small-particle aerosol therapy systematically to address the dilemmas, confusion, and misconceptions related to small airways directed therapy.
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Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy.
| | - Søren Pedersen
- Pediatric Research Unit, University of Southern Denmark, Kolding Hospital, Kolding, Denmark
| | - Omar S Usmani
- Airways Disease Section, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, England
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38
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Mitchell JP, Suggett J, Nagel M. Clinically Relevant In Vitro Testing of Orally Inhaled Products-Bridging the Gap Between the Lab and the Patient. AAPS PharmSciTech 2016; 17:787-804. [PMID: 27173990 DOI: 10.1208/s12249-016-0543-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022] Open
Abstract
Current pharmacopeial methods for in vitro orally inhaled product (OIP) performance testing were developed primarily to support requirements for drug product registration and quality control. In addition, separate clinical studies are undertaken in order to quantify safety and efficacy in the hands of the patient. However, both laboratory and clinical studies are time-consuming and expensive and generally do not investigate either the effects of misuse or the severity of the respiratory disease being treated. The following modifications to laboratory evaluation methodologies can be incorporated without difficulty to provide a better linkage from in vitro testing to clinical reality: (1) examine all types of OIP with patient-representative breathing profiles which represent normal inhaler operation in accordance with the instructions for use (IFU); (2) evaluate OIP misuse, prioritizing the importance of such testing on the basis of (a) probability of occurrence and (b) consequential impact in terms of drug delivery in accordance with the label claim; and (3) use age-appropriate patient-simulated face and upper airway models for the evaluation of OIPs with a facemask. Although it is not necessarily foreseen that these suggestions would form part of future routine quality control testing of inhalers, they should provide a closer approximation to the clinical setting and therefore be useful in the preparation for in vivo studies and in improving guidance for correct use.
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Haidl P, Heindl S, Siemon K, Bernacka M, Cloes RM. Inhalation device requirements for patients' inhalation maneuvers. Respir Med 2016; 118:65-75. [PMID: 27578473 DOI: 10.1016/j.rmed.2016.07.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/19/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inhaled drugs are the mainstay of treatment for lung diseases such as asthma and chronic obstructive pulmonary disease. However, failure to use inhalation devices correctly can lead to a poorly controlled status. A vast number of inhalation devices exist and each device has specific requirements to achieve optimum inhalation of the drug. Currently, there is no overview of inhalation requirements considering all devices. This article presents a review of the literature on different inhalation device requirements and incorporates the data into a new inhalation flow algorithm. METHODS Data from literature on commercially available inhalation devices were evaluated and parameters, such as inhalation flow rate, flow acceleration, inhalation volume, and inspiration time assessed for the required inhalation maneuver specific to the device. All agreed upon data points were used to develop an inhalation flow algorithm. RESULTS The literature analysis revealed availability of robust data for the required inhalation flow characteristics for most devices and thus for the development of an algorithm. For those devices for which these parameters are not published, the minimum required flow criteria were defined based on published data regarding individual aspects of aerosol quality. CONCLUSIONS This review provides an overview of inhalation devices available on the market regarding requirements for an acceptable inhalation maneuver and shows which goals should be achieved in terms of inhalation flows. The presented algorithm can be used to develop a new computer based measurement system which could help to test and train patients' individual inhalation maneuvers with their inhalation devices.
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40
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Optimising Inhaled Pharmacotherapy for Elderly Patients with Chronic Obstructive Pulmonary Disease: The Importance of Delivery Devices. Drugs Aging 2016; 33:461-73. [DOI: 10.1007/s40266-016-0377-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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41
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Dubus JC, Gachelin E, Baravalle-Einaudi M, Carsin A, Vecellio L. [Asthma: the jungle of holding chambers]. Arch Pediatr 2016; 22:157-8. [PMID: 26112569 DOI: 10.1016/s0929-693x(15)30078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J-C Dubus
- Unité de pneumo-allergologie pédiatrique, CHU Timone-Enfants, 13385 Marseille Cedex 5, France.
| | - E Gachelin
- Service de pédiatrie, CHU Félix Guyon, Saint Denis, France
| | - M Baravalle-Einaudi
- Unité de pneumo-allergologie pédiatrique, CHU Timone-Enfants, 13385 Marseille Cedex 5, France
| | - A Carsin
- Unité de pneumo-allergologie pédiatrique, CHU Timone-Enfants, 13385 Marseille Cedex 5, France
| | - L Vecellio
- EA6305, CEPR, Faculté de médecine, Université François Rabelais, et DTF-Aerodrug, Faculté de Médecine, Tours, France
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Mehta R, Montembault M, Warren F, Gupta A, Brealey N, Moore A. Systemic Exposures of Fluticasone Propionate and Salmeterol Following Inhalation via Metered Dose Inhaler with the Mini Spacer Compared with the Aerochamber Plus Spacer. J Aerosol Med Pulm Drug Deliv 2016; 29:386-92. [PMID: 26824933 DOI: 10.1089/jamp.2015.1236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Mini Spacer has been developed for use with Ventolin(®) metered dose inhalers (MDIs) to improve accessibility to affordable spacers in developing countries. To ensure patient safety is not compromised if the Mini Spacer is used off-label with fluticasone propionate (FP) or salmeterol/FP combination (SFC) MDIs (currently not recommended), this study compared the systemic exposure of FP and salmeterol following delivery of FP and SFC MDIs with the Mini Spacer and the Aerochamber Plus(®) spacer (Aerochamber). METHODS This was an open-label, randomized, single dose, crossover study in healthy subjects that evaluated four treatments: i) FP 250 μg MDI with Mini Spacer; ii) FP 250 μg MDI with Aerochamber; iii) SFC 25/250 μg with Mini Spacer; iv) SFC 25/250 μg with Aerochamber. There was a minimum 7 day washout between treatments. Pharmacokinetic samples were collected over 24 hours post-dose. The co-primary endpoints were FP area under the concentration-time curve from time zero to 24 h [FP AUC(0-24)] and salmeterol maximum plasma concentration [Cmax]. RESULTS FP systemic exposure in terms of AUC(0-24) was lower following inhalation with the Mini Spacer compared with the Aerochamber for both FP 250 μg (Mini Spacer/Aerochamber Ratio 0.76 [90% CI: 0.57-1.01]) and SFC 25/250 μg (Ratio 0.74 [90% CI: 0.56-0.99]). Salmeterol systemic exposure was also lower following SFC 25/250 μg with Mini Spacer compared with Aerochamber (Cmax Ratio 0.90 [90% CI 0.48-1.66]). The incidence of adverse events was low and similar with each treatment. CONCLUSIONS In the event of use of the Mini Spacer with FP and SFC MDIs, which is not recommended, FP and salmeterol systemic exposure is unlikely to be higher than if MDIs were to be used with the Aerochamber. However, these data do not indicate that the Mini Spacer and Aerochamber are interchangeable.
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Affiliation(s)
- Rashmi Mehta
- 1 GlaxoSmithKline, Research Triangle Park , North Carolina, United States
| | | | - Francis Warren
- 2 GlaxoSmithKline , Stockley Park, Uxbridge, United Kingdom
| | - Ashutosh Gupta
- 3 Quantitative Sciences India , GlaxoSmithKline, Bangalore, India
| | | | - Alison Moore
- 2 GlaxoSmithKline , Stockley Park, Uxbridge, United Kingdom
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Roche N, Dekhuijzen PNR. The Evolution of Pressurized Metered-Dose Inhalers from Early to Modern Devices. J Aerosol Med Pulm Drug Deliv 2016; 29:311-27. [PMID: 26824873 DOI: 10.1089/jamp.2015.1232] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pressurized metered-dose inhalers (pMDIs) are sometimes viewed as old-fashioned and as having been superseded by dry powder inhalers (DPIs). Here, we review the technological advances that characterize modern pMDIs, and consider how they can influence the effectiveness of drug delivery for patients with asthma and chronic obstructive pulmonary disease. Compared with old chlorofluorocarbon (CFC)-based inhalers, many hydrofluoroalkane (HFA)-driven pMDIs have more favorable plume characteristics such as a reduced velocity and a higher fine particle fraction; together, these advances have resulted in the development of pMDIs with reduced oropharyngeal deposition and increased lung deposition. In addition, the plume from many HFA-pMDIs is warmer, which may facilitate their use by patients; moreover, devices are equipped with dose counters, which improves their reliability. As well as reviewing the technological advances of pMDIs, we also discuss the importance of individualizing inhaler therapies to each patient by accounting for their personal preferences and natural breathing patterns. Because pMDIs and DPIs differ considerably in their handling characteristics, matching the right inhaler to the right patient is key to ensuring effective therapy and good compliance. Finally, the majority of patients can be trained successfully in the correct use of their pMDI; training and regular monitoring of inhalation technique are essential prerequisites for effective therapy. While the 'ideal inhaler' may not exist, pMDIs are an effective device option suitable for many patients. pMDIs, together with other types of devices, offer opportunities for the effective individualization of treatments.
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Koehorst-ter Huurne K, Movig K, van der Valk P, van der Palen J, Brusse-Keizer M. The influence of type of inhalation device on adherence of COPD patients to inhaled medication. Expert Opin Drug Deliv 2016; 13:469-75. [DOI: 10.1517/17425247.2016.1130695] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hussein RRS, M. A. Ali A, Salem HF, Abdelrahman MM, Said ASA, Abdelrahim MEA. In vitro/in vivo correlation and modeling of emitted dose and lung deposition of inhaled salbutamol from metered dose inhalers with different types of spacers in noninvasively ventilated patients. Pharm Dev Technol 2015; 22:871-880. [DOI: 10.3109/10837450.2015.1116567] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Raghda R. S. Hussein
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
| | - Ahmed M. A. Ali
- Pharmaceutics and Industrial Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
- Pharmaceutics Department, Faculty of Pharmacy, Taif University, Taif, Saudi Arabia, and
| | - Heba F. Salem
- Pharmaceutics and Industrial Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
| | - Maha M. Abdelrahman
- Analytical Chemistry Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt
| | - Amira S. A. Said
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
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Traitements inhalés : critères de choix des dispositifs, absorption systémique des médicaments par voie inhalée et récepteurs pulmonaires à l’amertume. Rev Mal Respir 2015; 32:791-9. [DOI: 10.1016/j.rmr.2014.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/12/2014] [Indexed: 11/18/2022]
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47
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Dhar R, Salvi S, Rajan S, Dalal S, Tikkiwal S, Bhagat R, Ahmed MM, Balki A, Jain M, Gogtay J. Salmeterol/fluticasone through breath-actuated inhaler versus pMDI: a randomized, double-blind, 12 weeks study. J Asthma 2015; 52:1065-72. [PMID: 26288199 DOI: 10.3109/02770903.2015.1050499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Salmeterol/fluticasone combination (SFC) formulated in a breath-actuated inhaler (BAI) overcomes the co-ordination problem associated with the pressurized-metered dose inhaler (pMDIs). Our aim was to compare the efficacy and the safety of SFC given through the BAI versus the conventional pMDI in moderate-to-severe asthmatics. METHODS In this randomized, double-blind, double-dummy, prospective, active-controlled, parallel group, multicenter, 12 weeks study, 150 asthmatics were randomized to receive SFC (25/125 mcg) through either BAI or pMDI. The primary efficacy endpoint was mean change in pre-dose morning PEFR value at 12 weeks and the secondary efficacy endpoints included, mean change in FEV(1), pre-bronchodilator FVC, pre-dose morning and evening PEFR, symptom scores at 2, 4, 8, and 12 weeks. Patient preferences for device and safety were also assessed. RESULTS At 12 weeks, the mean change in pre-dose morning PEFR in BAI and pMDI groups was 50.72 L/min and 48.82 L/min, respectively (p < 0.0001; both groups) and the difference between the two groups was not significant. Both the treatment groups showed a statistically significant improvement in secondary endpoints at all-time points compared with baseline. The usability questionnaire assessment results showed that the BAI device was preferred by 75% of patients as compared with 25% preferring pMDI. SFC in both BAI and pMDI devices was found to be safe and well tolerated. CONCLUSION This is the first study to demonstrate that SFC given through the BAI produces comparable efficacy and safety endpoints as pMDI. Additionally, BAI was the preferred inhaler by patients compared to conventional pMDI.
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Affiliation(s)
- Raja Dhar
- a Department of Pulmonology and Critical Care , Fortis Hospital , Kolkata , India
| | | | | | | | | | - Raj Bhagat
- f Dr. Bhagat's Allergy - Asthma Clinic & Respiratory Care Centre , Ahmedabad , India
| | | | - Akash Balki
- h Shree Hospital and Critical Care Centre , Nagpur , India
| | - Manish Jain
- i Swaash Clinic, Navkar Hospital , Jaipur , India , and
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Gachelin E, Vecellio L, Dubus JC. [Critical evaluation of inhalation spacer devices available in France]. Rev Mal Respir 2015; 32:672-81. [PMID: 26163392 DOI: 10.1016/j.rmr.2015.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/19/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify the spacer devices sold in France and to provide a critical evaluation in the light of the published data. MATERIALS AND METHODS We contacted the pharmaceutical companies, manufacturers and distributors of each spacer in order to obtain their technical parameters and the results of any in vitro or in vivo studies. A review of the literature via PubMed completed the first set of data. We were interested in the quantity of fine particles (less than 5 μm diameter) obtained with a cascade impactor at paediatric flow rates, for all inhaled drugs available in France. RESULTS Eleven spacer devices were available in 2013 in France (Ablespacer®, Aerochamber Plus®, Babyhaler®, VHC Arrow®, L'Espace®, Funhaler®, Inhaler®, Itinhaler®, OptiChamber Diamond®, Tipshaler® and Vortex®), but three are no longer manufactured (Babyhaler®, Funhaler® and Inhaler®). All were small volume spacers, sold with facial masks of several different sizes. Four were antistatic (Aerochamber Plus®, Intinhaler®, OptiChamber Diamond® and Vortex®). Only salbutamol was tested with all the devices. Inhaled corticosteroids were tested with some and combinations were studied only with Ablespacer®, Aerochamber Plus®, Itinhaler®, and Vortex®. The results were difficult to interpret because the studies were conducted with very different protocols. The only clinical studies were conducted with Aerochamber Plus®, L'Espace® and Vortex®. CONCLUSION There was a great disparity between commercialized spacer devices in terms of the available data describing their in vitro performance.
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Affiliation(s)
- E Gachelin
- Unité de pneumologie pédiatrique, CHU Timone-Enfants, AP-HM, 13000 Marseille, France
| | - L Vecellio
- DTF-Aerodrug, faculté de médecine, 37032 Tours, France; Inserm U1100/EA6305, centre d'étude des pathologies respiratoires, faculté de médecine, université François-Rabelais, 37032 Tours, France
| | - J-C Dubus
- Unité de pneumologie pédiatrique, CHU Timone-Enfants, AP-HM, 13000 Marseille, France.
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Thakkar K, Mhatre S, Jadhav M, Goswami S, Shah R. Pharmacokinetic studies for proving bioequivalence of orally inhaled drug products-critical issues and concepts. Front Pharmacol 2015; 6:117. [PMID: 26089798 PMCID: PMC4452802 DOI: 10.3389/fphar.2015.00117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/19/2015] [Indexed: 12/30/2022] Open
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Nikander K, Nicholls C, Denyer J, Pritchard J. The evolution of spacers and valved holding chambers. J Aerosol Med Pulm Drug Deliv 2015; 27 Suppl 1:S4-23. [PMID: 25054481 DOI: 10.1089/jamp.2013.1076] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Spacers and valved holding chambers (VHCs) are pressurized metered dose inhaler (pMDI) accessory devices, designed to overcome problems that patients commonly experience when administering aerosol via a pMDI. Spacers were developed in direct response to patient-related issues with pMDI technique, particularly, poor coordination between actuation and inhalation, and local side-effects arising from oropharyngeal deposition. Current clinical guidelines indicate the need for widespread prescription and use of spacers, but, despite their apparent ubiquity, the devices themselves are, unfortunately, all too commonly "disused" by patients. An understanding of the background from which spacers developed, and the key factors influencing the optimization of the spacer and the later VHC, is crucial to developing an appreciation of the potential of these devices, both contemporary and future, for improving the delivery of pressurized aerosols to patients. This review, informed by a full patent search and an extensive scientific literature review, takes into account the clinical and laboratory evidence, commercial developments, and the sometimes serendipitous details of scientific anecdotes to form a comprehensive perspective on the evolution of spacers, from their origins, in the early days of the pMDI, up to the present day.
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