Satisfaction with and use of inhalation devices in patients with bronchial asthma v1

Introduction:Greater patient satisfaction with his or her inhalation device is associated with better adherence to pharmacological therapy and better clinical outcomes, such as improved quality of life, greater asthma control and fewer exacerbations. Objective: To determine the satisfaction level of a group of patients diagnosed with bronchial asthma with respect to their devices for inhalation of bronchodilators and glucocorticoids. Methods: This was a cross-sectional study of patients treated in the Colombian health system. Satisfaction with inhalation devices was evaluated with the FSI-10 instrument (Evaluation of Satisfaction with the Inhaler). A score of ≥ 44 points indicated high satisfaction. Results: In total, 362 patients from 59 cities were identified, their median age was 55 years, and 74.6% were women. The average score was 44.6; 68.5% of patients showed high satisfaction, especially with metered-dose inhalers, and 63.4% did not use them with an inhalocamera. Users of metered-dose inhalers (OR: 1.80; 95% CI: 1.05–3.10) and those who received training by medical specialists (OR: 2.29; 95% CI: 1.33–3.97) had high satisfaction, while patients who were older (40–64 vs. <40 years: OR: 0.38; 95% CI: 0.19–0.78 and ≥ 65 vs. <40 years: OR: 0.35; 95% CI: 0.15–0.81), resided in the Caribbean region (OR: 0.48; 95% CI: 0.29–0.81) and had a university education (OR: 0.54; 95% CI: 0, 32–0.90) had lower satisfaction. Conclusions: The majority of patients with asthma used metered-dose inhalers without an inhalocamera, and their overall satisfaction was higher than that of patients using other inhalation devices. Patients who received special training from medical specialists showed better satisfaction.

The environmental impact of inhaled therapy: making informed treatment choices

When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual, or organisation, is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of CO2 equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we will examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives.

Correlation of Metered Dose Inhaler Use Technique and Asthma Control Level in Asthma Patients at a Hospital in Bandung, West Java, Indonesia.

Background: Asthma is still a major health problem in global population, including Indonesia. Antiasthma drugs available in various dosage forms, including inhaler. However, several problems related to inhalation route were found due to its unique device form and spesific use technique. One of the major problems related to inhalation route is inappropriate use technique of inhaler device, which could lead to treatment failure. Therapy outcome can be measured through Asthma Control Test (ACT). Objectives: This study was aimed to evaluate correlation between metered dose inhaler (MDI) use technique and asthma control level in patients. Material and Methods: A cross-sectional analytic study was conducted in May - June 2021. Thirty patients who met inclusion criteria were enrolled in this study. Patients’ MDI use technique and asthma control level were evaluated using a valid and standardized questionnaire. Statistics analysis was performed to determine the correlation between MDI use technique and asthma control level. Results: This study showed that most of asthmatic patients were women in older age, with mild asthma severity for more than 10 years. The most prevalent medication used was Fenoterol HBr, followed by salbutamol, and salmeterol/fluticasone combination. Inappropriate MDI use was found in 70,0% patients, with major problem found in patients’ breathing technique before and during MDI use. Asthma control test was performed and showed that 90,0% of asthmatic patients involved in this study have an uncontrolled asthma. Statistical analysis using Pearson product-moment correlation test showed a positive correlation between proper use of MDI and asthma control level (r=0.425, p<0.05). Conclusions: Patient who properly use MDI may have a higher score in asthma control test, thus have a better control of asthma. This study emphasized pharmacist role as patient educator in ensuring appropriate inhaler use in order to achieve therapeutic goals.

Evaluating Technical Knowledge of Using Inhalation Devices Amongst Medical Students and Pediatrics Residents in Iran

Background: Asthma is a common chronic respiratory disorder in children and adults worldwide. Inhalers are vital medications that are prescribed to control the disease and reduce its mortality and morbidity. Objectives: This study aimed to assess the knowledge and skills of Medical Students (MSs) and pediatric residents (PRs) in using different inhaler devices (IDs). Methods: This cross-sectional study included 243 MSs and PRs at Shiraz University of Medical Sciences, Iran, from March 2018 to March 2019. The MSs were divided into the senior medical students (SMSs) and junior medical students (JMSs). Data regarding participants’ knowledge on metered dose inhalers (MDIs), dry powder inhalers (DPIs), and nebulizers (NBs) were gathered using questionnaires and a face-to-face interview. Results: Of the 243 participants in the study, 113 (46.5%) were SMSs, 87 (35.8%) were JMSs, and 43 (17.7%) were PRs. The mean age of the participants was 26/20 ± 4/25 years. There was no significant difference between studied groups regarding recognition of MDI device (P = 0.072). PRs were more familiar with the DPIs than MSs (P < 0.001). They also could recognize the NBs better than the MSs (P < 0.001). In terms of using DPIs correctly, PRs executed all the steps better than MSs (P < 0.001) except for the third step which all the participants had the same knowledge (P = 0.13). Regarding correct use of NBs, PRs had better performance compared to MSs (P < 0.001). Conclusions: According to our results, there was an educational vacancy in training MSs regarding using IDs correctly, which can lead to poor compliance in asthmatic patients and deteriorating their lifestyle. The current research supports the need to redesign the educational curriculum of MSs and PRs in Iran to teach them sufficient knowledge and skills about how to use different types of inhalers properly.

Environmental risk of pharmaceuticals: let´s look at the whole package

Concern about potential deleterious effects of pharmaceuticals in the environment is growing fast. From wiping out vulture populations in Asia, to feminization of fish, pharmaceuticals have shown to provoke important consequences albeit at very low concentrations. A recent article addresses the environmental impact of metered-dose inhalers for asthma in the United Kingdom due to the greenhouse effects hydrofluorocarbons they contain. Since 2005, it is mandatory for all new drugs in Europe to be assessed for their environmental impact. Crucially, this regulation solely refers to the active pharmaceutical ingredient, not the “whole medicine” or finished medical product. This can sometimes lead to incongruences. For instance, it does not consider the environmental impact of the hydrofluorocarbons contained in MDIs. Another example is Adasuve®, an antipsychotic (loxapine) aimed at the rapid control of agitation in patients suffering from psychotic disorders. The device was developed as a rapid systemic delivery of loxapine by inhalation of a thermally generated aerosol for single use. Apart from the active substance it holds a medical-grade plastic housing and a lithium battery. Therefore, after every single use, a lithium battery waste is produced. We envision that we are on a brink of a new era in pharmacotherapy, in which environmental aspects of drugs are taken into account. In definitive, we agree with Wilkinson & Woodcock. When considering the environmental impact of pharmaceuticals, we need to take into account the whole package.

The Potential Use of Cyclosporine Ultrafine Solution Pressurised Metered-Dose Inhaler in the Treatment of COVID-19 Patients

Introduction: Serious COVID-19 respiratory problems start when the virus reaches the alveolar level, where type II cells get infected and die. Therefore, virus inhibition at the alveolar level would help prevent these respiratory complications. Method: A literature search was conducted to collect physicochemical properties of small molecule compounds that could be used for the COVID-19 treatment. Compounds with a low melting point were selected along with those soluble in ethanol, hydrogen-bond donors, and acceptors. Results : There are severe acute respiratory syndrome coronavirus inhibitors with physicochemical properties suitable for the formulation as an ultrafine pressurised metered-dose inhaler (pMDI). Mycophenolic acid, Debio 025, and cyclosporine A are prime candidates among these compounds. Cyclosporine A (hereafter cyclosporine) is a potent SARS-CoV-2 inhibitor, and it has been used for the treatment of COVID-19 patients, demonstrating an improved survival rate. Also, inhalation therapy of nebulised cyclosporine was tolerated, which was used for patients with lung transplants. Finally, cyclosporine has been formulated as a solution ultrafine pMDI. Although vaccine therapy has been started in most countries, inhalation therapies with non-immunological activities could minimise the spread of the disease and be used in vaccine-hesitant individuals. Conclusion: Ultrafine pMDI formulation of cyclosporine or Debio 025 should be investigated for the inhalation therapy of COVID-19.

Turning green: the impact of changing to more eco-friendly respiratory healthcare. A carbon and cost analysis of Dutch prescription data.

Objectives Dry powder inhalers (DPIs) have a substantially lower global warming potential than pressurized metered-dose inhalers (MDIs). To help mitigate climate change, we assessed the potential reduction in CO2-equivalents when replacing MDIs by DPIs in the Netherlands, and estimated the associated cost. Design We performed a four-step analysis based on data from two national databases of two independent governmental bodies (Dutch National Healthcare Institute and the Dutch Healthcare Authority). First, we calculated the number of patients with Chronic Obstructive Pulmonary Disease (COPD) and asthma that were using inhalation medication (2020). Second, we calculated the number and total of daily defined doses of MDIs, DPIs, and soft mist inhalers and the number of spacers per patients, dispensed by non-hospital based pharmacies in 2020. Third, we estimated the potential reduction in CO2-equivalents (eq.) if all eligible patients (≥7 years old; COPD with ≤exacerbation per year) would switch from using MDIs to using DPIs as eco-friendly alternatives. Fourth, we performed a cost-effectiveness analysis. Results In 2020, 1.4 million patients used inhalers for COPD or asthma treatment. A total of 460 million defined daily doses (DDDs) from inhalers were dispensed, of which, after the exclusion of nebulisers, 50.4% were from MDIs. We estimated that this use could be reduced by 70% leading to annual reduction in emissions of 77 - 84 million kg CO2eq. saving at best EUR 49.8 million annually. Conclusions In the Netherlands, substitution of MDIs to DPIs for eligible patients is theoretically safe and in accordance with medical guidelines, while reducing emissions by 80 million kg.CO2eq. on average and saving at best EUR 49.8 million per year. This study confirms the potential climate and economic benefit of delivering eco-friendlier respiratory care.