Newer devices and improved formulations of inhaled insulin

Not all nebulizers are created equal: Considerations in choosing a nebulizer for aerosol delivery during mechanical ventilation

INTRODUCTION

Aerosol therapy is commonly prescribed in the mechanically ventilated patient. Jet nebulizers (JN) and vibrating mesh nebulizers (VMN) are the most common nebulizer types, however, despite VMN's well established superior performance, JN use remains the most commonly used of the two. In this review, we describe the key differentiators between nebulizer types and how considered selection of nebulizer type may enable successful therapy and the optimization of drug/device combination products.

AREAS COVERED

Following a review of the published literature up to February 2023, the current state of the art in relation to JN and VMN is discussed under the headings of in vitro performance of nebulizers during mechanical ventilation, respective compatibility with formulations for inhalation, clinical trials making use of VMN during mechanical ventilation, distribution of nebulized aerosol throughout the lung, measuring the respective performance of nebulizers in the patient and non-drug delivery considerations in nebulizer choice.

EXPERT OPINION

Whether for standard care, or the development of drug/device combination products, the choice of nebulizer type should not be made without consideration of the unique needs of the combination of each of drug, disease and patient types, as well as target site for deposition, and healthcare professional and patient safety.

Active pulmonary targeting against tuberculosis (TB) via triple-encapsulation of Q203, bedaquiline and superparamagnetic iron oxides (SPIOs) in nanoparticle aggregates

Tuberculosis (TB) has gained attention over the past few decades by becoming one of the top ten leading causes of death worldwide. This infectious disease of the lungs is orally treated with a medicinal armamentarium. However, this route of administration passes through the body’s first-pass metabolism which reduces the drugs’ bioavailability and toxicates the liver and kidneys. Inhalation therapy represents an alternative to the oral route, but low deposition efficiencies of delivery devices such as nebulizers and dry powder inhalers render it challenging as a favorable therapy. It was hypothesized that by encapsulating two potent TB-agents, i.e. Q203 and bedaquiline, that inhibit the oxidative phosphorylation of the bacteria together with a magnetic targeting component, superparamagnetic iron oxides, into a poly (D, L-lactide-co-glycolide) (PDLG) carrier using a single emulsion technique, the treatment of TB can be a better therapeutic alternative. This simple fabrication method achieved a homogenous distribution of 500 nm particles with a magnetic saturation of 28 emu/g. Such particles were shown to be magnetically susceptible in an in-vitro assessment, viable against A549 epithelial cells, and were able to reduce two log bacteria counts of the Bacillus Calmette-Guerin (BCG) organism. Furthermore, through the use of an external magnet, our in-silico Computational Fluid Dynamics (CFD) simulations support the notion of yielding 100% deposition in the deep lungs. Our proposed inhalation therapy circumvents challenges related to oral and respiratory treatments and embodies a highly favorable new treatment regime.

Inhaled loxapine for the urgent treatment of acute agitation associated with schizophrenia or bipolar disorder

BACKGROUND

Acute agitation is a serious complication of schizophrenia and bipolar disorder, which may escalate quickly to aggressive behavior. Rapid treatment is therefore important to calm and stabilize the patient, reducing the potential for harm to the patient and others, and allowing further assessment. Current guidelines suggest that where pharmacologic intervention is indicated, medication should preferably be non-invasive, should have a rapid onset and should control aggressive behavior in the short term without compromising the physician-patient relationship in the long term.

OBJECTIVES

This article presents an overview of a new inhaled formulation of the established antipsychotic loxapine, which aims to provide a more rapidly acting agent for the treatment of acute agitation without the disadvantages of intramuscular or intravenous injection.

DISCUSSION

Inhaled loxapine is rapidly absorbed with intravenous-like pharmacokinetics, with a time to maximum plasma concentration of 2 minutes and a plasma half-life of approximately 6 hours. In phase III studies, loxapine reduced agitation within 10 minutes of inhalation; agitation was decreased at all subsequent assessments during a 24-hour evaluation period. Inhaled loxapine was generally well tolerated with no undue sedation. The most common adverse events were dysgeusia, mild sedation, and dizziness. Inhaled loxapine is contraindicated in patients with asthma, COPD or other pulmonary disease associated with bronchospasm.

CONCLUSIONS

Inhaled loxapine rapidly reduces acute agitation in patients with schizophrenia or bipolar disorder and is generally well tolerated. The non-invasive route of delivery respects the patient's autonomy, reducing the perception of coercion or forced medication. Inhaled loxapine is therefore an effective and appropriate option for use in the emergency setting in patients with acute agitation.

Current management of diabetes mellitus and future directions in care

The last 90 years have seen considerable advances in the management of type 1 and type 2 diabetes. Prof MacLean of Guy's Hospital wrote in the Postgraduate Medical Journal in 1926 about the numerous challenges that faced patients and their healthcare professionals in delivering safe and effective diabetes care at that time. The discovery of insulin in 1922 heralded a new age in enabling long-term glycaemic control, which reduced morbidity and mortality. Thirty years later, the first oral agents for diabetes, the biguanides and sulfonylureas, appeared and freed type 2 patients from having to inject insulin following diagnosis. Improvements in insulin formulations over the decades, including rapid-acting and long-acting insulin analogues that more closely mimic physiological insulin secretion, have increased the flexibility and efficacy of type 1 diabetes management. The last two decades have seen major advances in technology, which has manifested in more accurate glucose monitoring systems and insulin delivery devices ('insulin pump'). Increased understanding of the pathophysiological deficits underlying type 2 diabetes has led to the development of targeted therapeutic approaches such as on the small intestine (glucagon-like peptide-1 receptor analogues and dipeptidyl-peptidase IV inhibitors) and kidneys (sodium-glucose cotransporter-2 inhibitors). A patient-centred approach delivered by a multidisciplinary team is now advocated. Glycaemic targets are set according to individual circumstances, taking into account factors such as weight, hypoglycaemia risk and patient preference. Stepwise treatment guidelines devised by international diabetes organisations standardise and rationalise management. Structured education programmes and psychological support are now well-established as essential for improving patient motivation and self-empowerment. Large multicentre randomised trials have confirmed the effectiveness of intensive glycaemic control on microvascular outcomes, but macrovascular outcomes and cardiovascular safety remain controversial with several glucose-lowering agents. Future directions in diabetes care include strategies such as the 'bionic pancreas', stem cell therapy and targeting the intestinal microbiome. All of these treatments are still being refined, and it may be several decades before they are clinically useful. Prevention and cure of diabetes is the Holy Grail but remain elusive due to lack of detailed understanding of the metabolic, genetic and immunological causes that underpin diabetes. Much progress has been made since the time of Prof MacLean 90 years ago, but there are still great strides to be taken before the life of the patient with diabetes improves even more significantly.

Understanding sharps injuries in home healthcare: The Safe Home Care qualitative methods study to identify pathways for injury prevention

Background

Home healthcare is one of the fastest growing sectors in the United States. Percutaneous injuries from sharp medical devices (sharps) are a source of bloodborne pathogen infections among home healthcare workers and community members. Sharps use and disposal practices in the home are highly variable and there is no comprehensive analysis of the system of sharps procurement, use and disposal in home healthcare. This gap is a barrier to effective public health interventions. The objectives of this study were to i) identify the full range of pathways by which sharps enter and exit the home, stakeholders involved, and barriers for using sharps with injury prevention features; and ii) assess the leverage points for preventive interventions.

Methods

This study employed qualitative research methods to develop two systems maps of the use of sharps and prevention of sharps injuries in home healthcare. Twenty-six in-depth interview sessions were conducted including home healthcare agency clinicians, public health practitioners, sharps device manufacturers, injury prevention advocates, pharmacists and others. Interview transcripts were audio-recorded and analyzed thematically using NVIVO qualitative research analysis software. Analysis of supporting archival material also was conducted. All findings guided development of the two maps.

Results

Sharps enter the home via multiple complex pathways involving home healthcare providers and home users. The providers reported using sharps with injury prevention features. However, home users’ sharps seldom had injury prevention features and sharps were commonly re-used for convenience and cost-savings. Improperly discarded sharps present hazards to caregivers, waste handlers, and community members. The most effective intervention potential exists at the beginning of the sharps systems maps where interventions can eliminate or minimize sharps injuries, in particular with needleless treatment methods and sharps with injury prevention features. Manufacturers and insurance providers can improve safety with more affordable and accessible sharps with injury prevention features for home users. Sharps disposal campaigns, free-of-charge disposal containers, and convenient disposal options remain essential.

Conclusions

Sharps injuries are preventable through public health actions that promote needleless treatment methods, sharps with injury prevention features, and safe disposal practices. Communication about hazards regarding sharps is needed for all home healthcare stakeholders.