Inhalers for copd


  • COPD Patient Assistance Programs
  • Triple Combination Inhalers in Chronic Obstructive Pulmonary Disease and Asthma
  • COPD fixed-dose combination (FDC) inhalers: PBS listing changes
  • A Review of the 2019 GOLD Guidelines for COPD
  • Inhalers Used for Treating COPD
  • Variability of COPD Inhaler Coverage in Medicare Part D
  • COPD Patient Assistance Programs

    These inhalers may contain short-acting beta2 agonists, long-acting beta2 agonists, short-acting muscarinic antagonists, long-acting muscarinic antagonists, or inhaled corticosteroids. In recent years, novel inhalers have entered the market in a variety of delivery devices, active ingredients, and costs. Improper inhaler technique and cost may pose a barrier to medication adherence. Chronic obstructive pulmonary disorder COPD develops over time as the small airways become inflamed due to the inhalation of cigarette smoke or other noxious particles.

    The chronic inflammatory response may induce parenchymal tissue destruction resulting in emphysema, the disruption of normal repair and defense mechanisms resulting in small airway fibrosis. Generally, the inflammatory and structural changes of the small airways increase with disease severity.

    Patients with COPD typically present with progressive shortness of breath, a chronic cough or recurrent wheeze, and chronic sputum production. Classification of airflow limitation grades and symptom burden with exacerbation risk groups A-D is patient-specific and can occur in a variety of combinations. Pharmacologic therapy for COPD is used to decrease symptoms, reduce the frequency and severity of exacerbations, and improve exercise intolerance.

    Common classes of medications used in treatment of COPD include beta2 agonists, antimuscarinics, inhaled corticosteroids ICS , and combination therapy. Identification and reduction of exposure to risk factors, such as cigarette smoke, air pollutants, and occupational fumes, are also important in treatment and prevention of COPD.

    Short-acting bronchodilators short-acting muscarinic antagonist [SAMA] or short-acting inhaled beta2 agonist [SABA] should be prescribed to all patients for immediate symptom relief, regardless of their GOLD classification. For Group B patients, the guidelines do not recommend one class of long-acting bronchodilator over another for initial symptoms; initial therapy with two long-acting bronchodilators may be considered in patients who are experiencing severe breathlessness on monotherapy.

    Preventive measures recommended by the GOLD guidelines include vaccinations and smoking cessation. Smoking cessation has the greatest ability to influence COPD disease progression. OTC quit aids include nicotine gum, lozenges, and patches. FEV1 decline was found to be greater in current smokers, those with lower BMI, males, and patients with established cardiovascular disease.

    In patients with moderate COPD and heightened cardiovascular risk, fluticasone furoate alone or in combination with vilanterol significantly reduced the rate of FEV1 decline. Patients receiving once-daily treatment with QVA or glycopyrronium were both double-blinded, while the once-daily tiotropium treatment group was open-label. There were no statistically significant differences between treatment groups with regard to adverse medication events such as bacterial upper-respiratory tract infection, nasopharyngitis, and viral upper-respiratory tract infection.

    Overall, the dual bronchodilator QVA was superior in preventing moderate-to-severe COPD exacerbations as compared with glycopyrronium and tiotropium. These results indicate a potential benefit in dual bronchodilation as a treatment option for patients with severe and very severe COPD. Results demonstrated an incidence of moderate or severe exacerbations as 1.

    In the average COPD population, yearly exacerbations are between two and three. Hypokalemia can occur, especially when beta2 agonists are combined with thiazide diuretics, as can increased oxygen consumption in patients with heart failure, but these effects decrease over time. The main side effect of inhaled antimuscarinics includes dry mouth. Some patients using ipratropium reported a bitter, metallic taste following use.

    There have also been reports of a small increase in cardiovascular events in COPD patients treated with ipratropium.

    The novel inhalers on the market come in a variety of delivery devices such as Ellipta, Pressair, Respimat, and Neohaler. To use an Ellipta inhaler: Slide the cover down until a click is heard, breathe out gently away from inhaler , put the mouthpiece in the mouth and close the lips, to form a good seal but do not cover vents , breathe in steadily and deeply, hold the breath for 5 seconds, breathe out gently, and slide the cover upward as far as it will go to cover the mouthpiece.

    To use a Pressair inhaler: Remove the protective cap by gently squeezing the arrows on the side of each cap, hold the inhaler with the mouthpiece facing you with the green button facing up, press the green button down and release before placing mouthpiece in mouth, assure the control window has changed from red to green, breathe out gently away from inhaler , put the mouthpiece between the lips, and breathe in quickly and deeply. To use a Respimat: After initial priming, hold inhaler upright and turn base in direction of arrows on the label until it clicks half of a turn , open cap until it snaps fully open, breathe out away from inhaler , put mouthpiece between the teeth and close the lips to form a good seal but do not cover vents , breathe in slowly and deeply through the mouth while pressing down on the dose button, hold the breath for 5 seconds and remove the inhaler from the mouth, breathe out gently, and replace the cap.

    To use a Neohaler inhaler: Remove the cap, tilt the mouthpiece to open the inhaler, remove one capsule from the blister card, place the capsule into the capsule chamber, close the mouthpiece fully, hold the inhaler with the mouthpiece facing up and press both piercing buttons at the same time, release buttons, breathe out gently away from inhaler , place the mouthpiece in the mouth, breathe in steadily and deeply, hold the breath for 5 seconds, breathe out gently, and remove the capsule from the capsule chamber.

    Umeclidinium Incruse Ellipta is a LAMA monotherapy inhaler that provides a once-daily dosing option for patients as compared with aclidinium bromide Tudorza Pressair , which is dosed twice daily.

    There are several other monotherapy and combination inhalers that provide the option for once-daily dosing, which may be favorable for patients. Novel inhalers released within the past decade vary in cost and dosing frequency. These provide patients with more options to treat their COPD based on individual preferences.

    Inhalers used in the treatment of COPD are generally well tolerated. It is important for the pharmacist to assess inhaler technique and understand how each inhaler is used with each follow-up or encounter with patients.

    Other strategies to manage COPD include the pneumococcal vaccine, yearly influenza vaccine, and smoking cessation. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report.

    Accessed March 22, Recommended adult immunization schedule Treating tobacco use and dependence: update. Clinical practice guideline. Rockville, Maryland: U. Department of Health and Human Services. Public Health Service; May Fluticasone furoate, vilanterol, and lung function decline in patients with moderate chronic obstructive pulmonary disease and heightened cardiovascular risk. Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA compared with glycopyrronium and tiotropium SPARK : a randomised, double-blind, parallel-group study.

    Lancet Respir Med. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. The natural history of chronic airflow obstruction revisited: an analysis of the Framingham offspring cohort. Effects of water-pipe smoking on lung function: a systematic review and meta-analysis. Association between exposure to ambient particulate matter and chronic obstructive pulmonary disease: results from a cross-sectional study in China.

    The effect of air pollution on lung development from 10 to 18 years of age. Secretory IgA deficiency in individual small airways Is associated with persistent inflammation and remodeling. Incruse Ellipta umeclidinium package insert. Tudorza Pressair aclidinium bromide package insert. Louis, MO: Almirall; Striverdi Respimat olodaterol package insert. Ridgefield, CT: Boehringer Ingelheim; East Hanover, NJ: Novartis; Wilmington, DE: AstraZeneca; Red Book Online [database on Internet].

    Accessed March 24,

    Triple Combination Inhalers in Chronic Obstructive Pulmonary Disease and Asthma

    As there is well-documented evidence that triple therapy is effective in improving lung function and reducing the risk of exacerbation in patients with asthma and those with COPD, single-inhaler triple therapies have been developed mainly to increase adherence to treatment that often is low because of complexity introduced by the additional inhaler s. Pivotal trials have shown that there is a role for triple therapy, mainly for single-inhaler triple therapy, in both COPD and asthma management.

    In this article, we critically review the literature in order to determine, if possible, the real role of triple therapy in the treatment of asthma and COPD. We supplemented the bibliographic database searches with backward citation tracking of relevant publications. We also searched www. The information thought to be more significant has been selected and commented upon.

    However, no synergistic interaction was detected in non-sensitized bronchi. The exact nature of the interactions between these pathways is not fully understood, but there are interferences at many levels in airway smooth muscle cells that are also regulated by the activity of potassium channels activated by calcium and protein tyrosine kinases. However, it is still unknown whether triple therapy synergizes the anti-inflammatory activity of the ICSs.

    Therefore, the results of such studies should be treated with caution. Correctly, it has been pointed out that the differences in the rate of pneumonia observed in studies with different ICSs may vary both because of the diversity in the design of the studies and their duration, or in the reporting of adverse events, as well as differences in patient characteristics that may increase the rate of pneumonia.

    Surprising, and in a way alarming, is the documentation resulting from a study that provided insights into the real-world use of tiotropium bromide in asthma in the USA, which showed that patients initiating triple therapy were among the most severe, but had high post-treatment ICS discontinuation rates. Adherence to each individual triple therapy component was demonstrably higher, suggesting that patients are not using all three therapy components simultaneously.

    However, in a retrospective, observational cohort study of adults with persistent asthma from Japan, adherence after initiation of triple therapy was moderate to high compared with previously reported real-world evidence studies.

    In fact, umeclidinium bromide and glycopyrronium bromide also appear effective in asthma,37,38 and, although they are not yet approved for use in this pathology, they are currently included in the clinical development of triple therapies that also include a LABA and an ICS.

    There is evidence that a single combination inhaler is preferred to concurrent therapy for patients with asthma with low adherence to controller therapies, likely because of the increased complexity introduced by the additional inhaler s.

    Also, quality of life, assessed using the St. Furthermore, it can also reduce the possibility of LABA overuse and ICS underuse that have the potential to cause serious adverse effects. QVM, whose approval has been recommended by the Committee for Medicinal Products for Human Use of the European Medicines Agency, is administered using a Breezhaler device with an optional digital sensor, which can be attached to the base of the inhaler.

    Conclusion Solid evidence indicates that there is a role for triple therapy, mainly for single-inhaler triple therapy, in COPD management.

    As the goal of therapy is to offer the patient the minimum level of therapy capable of maintaining asthma control, also the intensity of treatment must change with the change of the severity of asthma. This means that de-escalation of triple therapy is often a need, but it could be problematic especially in patients who, well controlled, will be reluctant to stop a treatment that they perceive effective. This opinion stems from the evidence that, as already mentioned, co-administration of a LAMA and a LABA synergistically relaxes human isolated airways at the level of the medium and small bronchi.

    Her department has received funding from GlaxoSmithKline and Novartis. Luigino Calzetta has participated as an advisor in scientific meetings under the sponsorship of Boehringer Ingelheim and Novartis; received non-financial support by AstraZeneca; received a research grant partially funded by Chiesi Farmaceutici, Boehringer Ingelheim, Novartis, and Almirall; and is, or has been, a consultant to ABC Farmaceutici, Recipharm, Zambon, Verona Pharma, and Ockham Biotech.

    Compliance With Ethics This article involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors. Review Process Double-blind peer review Authorship The named authors meet the International Committee of Medical Journal Editors ICMJE criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published. E-mail: mario.

    Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: report. Global strategy for asthma management and prevention updated Barnes PJ.

    Eur Respir J. Cazzola M, Dahl R. Pharmacology and therapeutics of bronchodilators revisited. Pharmacol Rev. Beclomethasone dipropionate and formoterol fumarate synergistically interact in hyperresponsive medium bronchi and small airways. Respir Res. Interaction between corticosteroids and muscarinic antagonists in human airways. Pulm Pharmacol Ther.

    Pharmacological mechanisms leading to synergy in fixed-dose dual bronchodilator therapy. Curr Opin Pharmacol. Beclomethasone dipropionate, formoterol fumarate and glycopyrronium bromide: synergy of triple combination therapy on human airway smooth muscle ex vivo.

    Br J Pharmacol. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease TRINITY : a double-blind, parallel group, randomised controlled trial.

    Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease TRIBUTE : a double-blind, parallel group, randomised controlled trial.

    Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. Lancet Respir Med. Triple inhaled therapy at two glucocorticoid doses in moderate-to-very-severe COPD. Single-inhaler triple therapy in patients with chronic obstructive pulmonary disease: a systematic review. Comparative effectiveness of triple therapy versus dual bronchodilation in COPD.

    ERJ Open Res. Triple therapy versus single and dual long-acting bronchodilator therapy in COPD: a systematic review and meta-analysis. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial.

    Pulm Ther. Inhaled corticosteroids in COPD: friend or foe? Inhaled corticosteroids and pneumonia mortality in COPD patients. Pneumonia risk with inhaled fluticasone furoate and vilanterol compared with vilanterol alone in patients with COPD.

    Ann Am Thorac Soc. A potential role of triple therapy for asthma patients. Expert Rev Respir Med. Tiotropium improves lung function, exacerbation rate, and asthma control, independent of baseline characteristics including age, degree of airway obstruction, and allergic status. Respir Med. Tiotropium Respimat add-on is efficacious in symptomatic asthma, independent of T2 phenotype.

    J Allergy Clin Immunol Pract. Tiotropium is efficacious in 6- to year-olds with asthma, independent of T2 phenotype. Mansfield L, Bernstein JA. Tiotropium in asthma: from bench to bedside. What is the role of tiotropium in asthma? A systematic review with meta-analysis. Association of inhaled corticosteroids and long-acting muscarinic antagonists with asthma control in patients with uncontrolled, persistent asthma: a systematic review and meta-analysis. Characterizing real-world use of tiotropium in asthma in the USA.

    J Asthma Allergy. Treatment patterns and disease burden of triple therapy in asthma. Curr Med Res Opin. Efficacy, safety, and dose response of glycopyrronium administered by metered dose inhaler using co-suspension delivery technology in subjects with intermittent or mild-to-moderate persistent asthma: a randomized controlled trial. Triple therapy vs. Arch Bronconeumol. Medication adherence and persistence in chronic obstructive pulmonary disease patients receiving triple therapy in a USA commercially insured population.

    A randomized, open-label, single-visit, crossover study simulating triple-drug delivery with Ellipta compared with dual inhaler combinations in patients with COPD.

    Persistence, adherence, and effectiveness of combination therapy among adult patients with asthma. J Allergy Clin Immunol. The use of multiple respiratory inhalers requiring different inhalation techniques has an adverse effect on COPD outcomes.

    Patient Prefer Adherence. Impact of single combination inhaler versus multiple inhalers to deliver the same medications for patients with asthma or COPD: a systematic literature review. Suissa S, Ariel A. Triple therapy in COPD: only for the right patient.

    Management of patients with asthma or COPD and cardiovascular disease: risks versus benefits. Cardiovascular Complications of Respiratory Disorders. Efficacy and cardiovascular safety profile of dual bronchodilation therapy in chronic obstructive pulmonary disease: a bidimensional comparative analysis across fixed-dose combinations. Fluticasone furoate and vilanterol and survival in chronic obstructive pulmonary disease with heightened cardiovascular risk SUMMIT : a double-blind randomised controlled trial.

    Inhaled corticosteroids and risk of tuberculosis in patients with obstructive lung diseases: a systematic review and meta-analysis of non-randomized studies. Eosinophils in COPD: just another biomarker? Ernst P.

    Blood eosinophils in COPD and the future risk of pneumonia. International consensus on ICON pediatric asthma. Ultra-LABAs for the treatment of asthma. May 2, Available at: www.

    COPD fixed-dose combination (FDC) inhalers: PBS listing changes

    A Review of the 2019 GOLD Guidelines for COPD

    Correct inhaler technique is essential for the optimal use of all inhaled medications Melani [evidence level I] and is associated with fewer severe exacerbations. Ease of operating and dose preparation were rated as being the most important inhaler features leading to higher patient satisfaction and fewer critical errors in a randomised, open-label, multicentre, cross-over study of two inhaler devices van der Palen [evidence level II].

    The pooled summary results for pMDI estimated an overall error rate of With the proliferation of new inhaler devices, inhaler device poly-pharmacy is becoming an increasing problem amongst COPD patients and has a negative impact on outcomes Bosnic-Anticevich Those in the similar device cohort experienced fewer exacerbations adjusted IRR 0.

    These data support the recommendation to minimise the number of different devices prescribed in COPD patients. Lung Foundation Australia has developed a series of inhaler device technique videos and factsheets for patients which provide step-by-step instructions on correct inhaler technique.

    These are linked directly to the video and factsheets page on the Lung Foundation website via the Zappar app.

    The app allows the user to scan the images on either the hard copy or on-screen using their mobile device and the videos will automatically open on their device. The cost of inhaler devices varies between products. As there are no differences in patient outcomes for the different devices, the cheapest device the patient can use adequately should be prescribed as first line treatment NHS Centre for Reviews and Dissemination The range of devices currently available, the products and dosage, as well as their advantages or disadvantages, are listed in Appendix 2.

    These findings suggest that patients and providers should carefully assess their needs for inhalers before selecting a plan.

    Inhalers Used for Treating COPD

    Congress should consider the effect that different incentive systems for the S-PDPs and MA-PD plans have on patient adherence, because the Medicare program is responsible for the medical costs in fee-for-service Medicare. Although our study focuses on COPD, the same financial incentives likely affect other diseases. The Medicare program should add minimum affordability requirements for the drugs offered by the Part D plans. Acknowledgments The authors would like to thank Dr Robert A.

    Source of Funding: This research is generously funded by a grant from Arnold Ventures, which did not have any role in the design or analysis of the study.

    Prior Presentation: Partial findings from this research were presented as a poster presentation at the AcademyHealth Health Policy Conference, February 10, Email: ben. An overview of the Medicare Part D prescription drug benefit. Kaiser Family Foundation.

    Variability of COPD Inhaler Coverage in Medicare Part D

    October 14, Accessed February 21, Drug plan design incentives among Medicare prescription drug plans. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol.

    Prescription drug cost sharing: associations with medication and medical utilization and spending and health. How patient cost-sharing trends affect adherence and outcomes: a literature review. Sensitivity of medication use to formulary controls in Medicare beneficiaries: a review of the literature.

    Am Health Drug Benefits. Association between drug insurance cost-sharing strategies and outcomes in patients with chronic diseases: a systematic review. PLoS One. Health Serv Res. Inhaler costs and medication nonadherence among seniors with chronic pulmonary disease.

    A systematic literature review assessing the directional impact of managed care formulary restrictions on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization. J Manag Care Spec Pharm. The effect of formulary restrictions on patient and payer outcomes: a systematic literature review. Expert Rev Pharmacoeconomics Outcomes Res. Pharmacoeconomic evaluation of COPD. Medicare population. Respir Med. Rising costs of COPD and the potential for maintenance therapy to slow the trend.

    The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res.

    S Simoens S. Cost-effectiveness of pharmacotherapy for COPD in ambulatory care: a review. J Eval Clin Pract. Adherence to inhaled therapy, mortality and hospital admission in COPD. Treatment of COPD: relationships between daily dosing frequency, adherence, resource use, and costs.

    Clinical and economic impact of non-adherence in COPD: a systematic review. The clinical impact of different adherence behaviors in patients with severe chronic obstructive pulmonary disease. Adherence and healthcare utilization among older adults with COPD and depression.

    Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: report. Accessed November 5, FDA approves first generic Advair Diskus. News release. January 30, Accessed December 28, Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease report.

    GOLD executive summary. National Drug Code directory. Accessed March 11, Trelegy Ellipta approved as the first once-daily single inhaler triple therapy for the treatment of appropriate patients with COPD in the US.

    September 18, Accessed December 5, Updated December 15, Accessed January 17, Updated January 5, Prescription Drug Benefit Manual. Updated October 13, Accessed March 31, Updated January Diagnosis and outpatient management of chronic obstructive pulmonary disease: a review. Mojtabai R, Olfson M.


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