The Aerosol Drug Management Improvement Team ADMIT Slide Deck 2018

Part 1 Inhaled therapy in asthma and COPD A general introduction Richard Dekhuijzen Radboud University Medical Center Nijmegen, the Netherlands

History of inhaled medications Aerosol therapy has been used for thousands of years. Asthma cigarettes containing Datura strammonium, an anticholinergic, were available for purchase up until the 1970s. The modern era of aerosol therapy began in 1778 with Dr John Mudge and the Mudge inhaler. The first pressurized inhaler was the Sales-Giro´ns Pulverisateur in 1858. Just over 50 years ago, Charlie Thiel and colleagues at Riker Laboratories (now 3M) invented the pressurized metered-dose inhaler (pMDI) after Susie Maison, the daughter of a Riker Vice-President asked, “Why can’t you make my asthma medicine like mother’s hair spray? Rubin B.K. Respir Care 2010

Advantages of inhaled therapy in asthma and COPD Directly to the target organ Lower dosages needed in comparison with systemic therapy

Currently available devices Pressurised, metered-dose inhalers (pMDIs) pMDIs with spacers or valves holding chambers (VHCs) Breath-actuated (BA-) pMDIs Dry powder inhalers (DPIs) Soft mist inhalers (SMIs) Nebulisers

Available inhaled medications in asthma and COPD Beta-2 agonists (SABA, LABA) Anticholinergics (SAMA, LAMA) Inhaled corticosteroids (ICS) Combinations of ICS and/or LABA and/or LAMA in one inhaler Antibiotics Mucolytics

Issues with inhaled medication Correct use of inhalers is difficult Errors (both minor/non-critical and critical) are frequent This impacts on drug delivery and lung deposition Local side effects may occur Adherence to inhaled medication is low As a consequence, short-term and long-term disease control may be affected

Less than 25% of asthma and COPD patients use their inhaler at the right time and in the correct way

Slow inhalation and (almost) simultaneous activation of the canister is the correct way to use pMDIs

Reasons for poor technique with MDIs1–3 Incorrect inhaler technique: MIDs Reasons for poor technique with MDIs1–3 Failure to use slow and deep inhalation (reported in 92% of patients;1 more common mistake than poor coordination2,4) Failure to coordinate inhalation with actuation (reported in 54% of patients3) Premature cessation of inhalation (cold-freon effect; reported in 24% of patients3) Inhale through nose (reported in 12% of patients3) Failure to shake inhaler before actuation Failure to hold inhaler upright 1. Al-Showair RA, Chest 2007;131(6):1776–82; 2. Hesselink AE, Scand J Prim Health Care 2001;19(4):255–60; 3. Crompton GK. Eur J Respir Dis 1982;63(6):489–92; 4. Nimmo CJ, Ann Pharmacother. 1993;27(7-8):922–7

The correct use of DPIs is the generation of a forceful and deep inhalation

Reasons for poor technique with DPIs1 Incorrect inhaler technique: DPIs Reasons for poor technique with DPIs1 Failure to inhale deeply and forcibly at the start of inhalation Drug particles too large to enter the lungs, are deposited in the mouth and oropharynx where they have no clinical efficacy Dependence of fine particle mass on inspiratory effort is pronounced with Turbuhaler® and less pronounced with Diskus2 Failure to achieve adequate inhalation volume (inhalers with single dose in a capsule) Failure to orientate the device correctly . Everard ML Respir Med 1997;91(10):624–8 2. Bisgaard H Eur Respir J 1998; 11(5):1111–5

72–83% demonstrated device handing errors 77% poorly controlled 90% ‘non-adherent’ 72–83% demonstrated device handing errors

How does incorrect inhaler technique impact on asthma and COPD control?

“Errors may lead to insufficient drug delivery, which adversely influences drug efficacy and may contribute to inadequate control of asthma and COPD”