1. Inhaler technique in COPD management: The cost of getting it wrong Zinc code: UKACL1878da Date of preparation May 2015 AstraZeneca provided funding & reviewed for technical accuracy

2. Bateman et al. Overall asthma control : the relationship between current control and future risk JACI 2010 March 125 (3)600-608 Postma et al. The goal of COPD management control versus future risk Primary Care Resp Journal 2011;20 (2)2011 20 (2) Overall COPD Control` Current Control Future Risk AchievingReducing Symptoms Activity Defined by Reliever use Lung function Instability/worsen ing Lung function loss Exacerbations Medication adverse effects

3. Management of COPD NICE clinical guideline 101, 2010 www.nice.org.uk/guidance/CG101www.nice.org.uk/guidance/CG101

4. Why is device choice and inhaler technique so important?

5. Inhaler techniques and device use 1.2.2.11 In most cases bronchodilator therapy is best administered using a hand-held inhaler device (including a spacer device if appropriate). 1.2.2.12 If the patient is unable to use a particular device satisfactorily, it is not suitable for him or her, and an alternative should be found. 1.2.2.13 Inhalers should be prescribed only after patients have received training in the use of the device and have demonstrated satisfactory technique. 1.2.2.14 Patients should have their ability to use an inhaler device regularly assessed by a competent healthcare professional and, if necessary, should be re-taught the correct technique. What do the Guidelines say? NICE clinical guideline 101, 2010 www.nice.org.uk/guidance/CG101www.nice.org.uk/guidance/CG101

6. What do the guidelines say? NICE clinical guideline 101, 2010 www.nice.org.uk/guidance/CG101www.nice.org.uk/guidance/CG101

7. What does DH, NHS Improvement say? Department of Health 2010, 2011 and 2012

8. Pulmonary Rehabilitation£119m Self management£235m Home oxygen£19.6m Early discharge from hospital£34m Non-invasive ventilation£9m Impact Report – Potential 10 year savings of implementing best practice DH 2012

9. Poor inhaler technique Check at each review Check before increasing medication

10. Factors influencing the choice of inhaler device Patient Acceptance of the diagnosis Age Lifestyle Ease of use Inspiration flow rate Dexterity Taste Appearance of device Nurse or Practitioner Appropriate treatment – symptomatic control & risk prevention Cost Consistency of delivery Availability of various drugs in the same device Compatibility with other devices Easy to teach technique Effectiveness of the device Vincken W., et al. The ADMIT series- Issues in inhalation therapy (4) Prim Care Respir J 2010; 19(1): 10-20

11. The main issue to consider? The technique Good, moderate, poor

12. Critical errors* What do patients do wrong? Inhaler misuse associated with: Older age (p=0.008) Lower schooling (p=0.001) Lack of instruction (p=0.001) *E.g. failure to remove cap, failure of priming or loading Melani et al. Inhaler mishandling remains common in real life and is associated with reduced disease control Respiratory Medicine 2011: 105: 930-938

13. Elderly patients Inspiratory flow Co-ordination Manual dexterity Hand strength Visual acuity Less likely to retain instructions 30x risk of errors vs tablets Barrons et al Inhaler device selection: special considerations in elderly patients with COPD AJHP 2011; 68: 1221-1232 Broeders et al The ADMIT series 2) Improving technique and clinical effectiveness PCRJ 2009; 18: 76-82

14. In 2011 in England: 961.5m prescriptions dispensed in the community a 3.8% increase from 2010 Average number of items per head per annum is 18.3 The total net ingredient cost of prescriptions was £8.8b 45% medicines not taken as prescribed 20% not taken at all WHO: Non-adherence a worldwide problem of striking magnitude (2004) In COPD non adherence is a common problem Prescriptions dispensed in the community, Statistics for England 201-2011(NS) Bourbeau J & Bartlett SJ Patient adherence in COPD Thorax 2008; 63:831-838

15. Elderly patients Poly pharmacy can lead to Reduced adherence Drug interactions Increase in geriatric syndromes Decrease in ADLs NICE 2010

16. Dementia and inhaler use Compliance with therapy – MMSE > 24/30 – usual therapy – MMSE 20-23/30 – may manage inhaled therapy – MMSE <20/30 – unable to manage Symptom recognition Susceptibility to Delirium Some older people are unable to use an MDI despite having a normal abbreviated mental score (AMT) Allen SC et al Age and Ageing 1997; Allen SC & Ragab S Postgrad Med J 2002

17. Factors affecting patient concordance 60% of COPD patients do not adhere to their prescribed treatment Restrepo, R.D., et al. Int Journal of COPD 2008;3(3):371–384 2008; World Health Organization, Adherence Report 2003.

18. WHY? >80% Restrepo, R.D., et al. Int Journal of COPD 2008;3(3):371–384 ; Bourbeau J. & Bartlett SJ. Thorax 2008;63:831-838 doi:10.1136; Melani, AS. Acta Biomed 2007; 78: 233-245; Rand C.S. Patient adherence with COPD therapy Eur Respir Rev 2005; 14: 96, 97–101

19. Who is educating patients? 20% HCPs unaware of who is educating patient Not on QOF register 1 Pharmacist limitations 2 Falls to GPs/nurses to educate and re-assess 3 What should we consider? 1.Quality and Outcomes Framework guidance 2011/2012 2.DoH New Medicines Service 2011 3.Restrepo, R.D., et al. Int Journal of COPD 2008;3(3):371–384

20. Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? Baverstock et al Thorax 2010;65:A117

21. The GPs view MDI 50% BA-MDI66% DPI80% What % of patients do GPs think have good inhaler technique? Molimard et al J Aerosol Med 2003; 16: 249-254

22. So what about other HCP’s? Incorrect inhaler technique of between 31-85% in ALL HCP’s Similar levels between Doctors, Nurses and Pharmacists! Basheti et al 2008 Evaluation of novel educational strategy American Journal of Pharmaceutical Education 2008 ‘73(2) Article 32

23. Devices, demonstration and discussion Device use in COPD

24. Patient and Healthcare Professional feedback characteristics Ideally an inhaler device would have inbuilt safety and feedback features for the patient and healthcare professional showing that the device is being used correctly: –Safety mechanism preventing double-dosing –End-of-dose lock-out mechanism –Dose indicator Ref: Chrystyn H and Niederland C. The Genuair ® inhaler: a novel, multidose dry powder inhaler. Int J Clin Pract 2012;66:309

25. Drugs delivered via MDI licensed for COPD patients

26. Pressurised MDIs High levels of prescribing – dictated by perceived costs – despite patient difficulties 51% - co-ordination of actuation with inspiration 24% - stop inhalation after actuation 12% - aerosol released into mouth whilst inhaling through the nose Reflex arrest of inspiration - cold Freon effect – can further complicate the situation Ability to use pMDIs is lost with time Cochrane et al Chest 2000; 117: 542-50 ; Broeders et al PCRJ 2009; 18: 76 - 82

27. Melani et al Respiratory Medicine 2011: 105: 930-938 Commonest error with pMDI

28. …….add a spacer? Reduce problems of co-ordinating actuation and inhalation Particle size optimised by larger particle impaction on walls of device and droplet evaporation Side effects related to oropharyngeal deposition and gut absorption reduced Optimal technique variable – e.g. multiple actuation, delay in inhalation, disuse Inspiratory flow ≤ 30 l/min needed Care/cleaning issues Broeders et al PCRJ 2009; 18: 76-82

29. Volumatic & MDI

30. MDI Volumatic & Haleraid

31. Adult ‘standard’ aerochamber

32. Breath Actuated Devices Flow triggered system No difference between “good” and “bad” users Co-ordination of inspiration and puff release needed ≥ 20 - 30 l/min inspiratory flow needed to trigger drug release Fewer critical errors than pMDI Broeders et al PCRJ 2009; 18: 76-82

33. Dry Powder Devices Multi-dose devices and single dose capsules All DPIs require the patient to prepare the dose prior to inhalation Failure to do this correctly results in no dose irrespective of inhalation technique More critical errors with single dose than multi dose devices Failure to exhale to FRC and exhaling into the device are the most common critical errors Azouz and Chrystyn PCRJ 2011; 21: 208-13

34. Melani et al Respiratory Medicine 2011: 105: 930-938 Commonest errors in DPI

35. Dry Powder Devices Turbulent energy = patient inhalation flow x DPI internal resistance Azouz and Chrystyn PCRJ 2011; 21: 208-13

36. Accuhaler

37. Turbohaler

38. Respimat or Handihaler

39. Genuair ® Protective Cap Mouthpiece Coloured control window Green button Dose indicator The Genuair® device is also available in other colours

40. Breezhaler

41. Summary Delivering Quality and value is possible for our patients Treatment is about more than medicines Cost effective treatment means – Evidence based intervention – Involving patients in decisions – Responsible prescribing

42. Resources

43. The impact of getting it right Evidence and efficacy: The algorithm jigsaw

44. NICE Guidelines 101 COPD Algorithm 2a: Use of inhaled therapies Please note: This algorithm should be used within the wider context of the management of COPD, including algorithms 1, 2 and 3 Early use of Long acting bronchodilators Appropriate use of ICS/LABA to reduce exacerbations and hospital admissions Triple therapy Risk/benefit of treatment

45. Bronchodilators in COPD VC FEV 1 VC RV Large residual volume Flat diaphragm Inefficient respiratory movements Reproduced with permission from Education for Health Increased vital capacity Reduced hyperinflation Diaphragm able to work more efficiently Less breathlessness

46. Treatment is also… Smoking cessation interventions Pulmonary Rehabilitation Self management Inhaler technique End of life care Patient engagement – The most expensive medicine is the one that the patient cannot or does not use

47. Cost of Respiratory Medication by BNF Chapters ~£1 billion on respiratory medication not including antibiotics… Source: NHS Information Centre

48. Volume of Respiratory Medication but a relatively low volume of respiratory prescriptions... Source: NHS Information Centre

49. Item cost of Respiratory Medication Source: NHS Information Centre …inhalers Respiratory items are the most expensive category of item prescribed

50. Responsible respiratory prescribing Understand costs Ensure optimal drug therapy for COPD patients Optimise use of prescribed therapy Right care Minimise waste Maximise value Minimise unwarranted variation IMPRESS; Better for less 2012. www.impressresp.com

51. Optimise treatment and management to reduce risk of exacerbation Triple Therapy ICS/LABA LAMA/LABA Stop Smoking Support with pharmacotherapy Flu vaccination in “at risk” population www.impressresp.com