Clinical implications of the tiotropium/olodaterol inhaler for patients with chronic obstructive pulmonary disease

Oral inhalation is the recommended delivery method of medications for the treatment of patients with chronic obstructive pulmonary disease (COPD). However, patients may struggle when using the various available inhaler platforms, and, as a result, may fail to achieve the benefit of the prescribed medication. Propellant-based, pressurized metered-dose inhaler and powder-based, dry powder inhaler devices are currently the most commonly prescribed delivery systems. Each of these devices has its own advantages and challenges. The Respimat® Soft Mist? inhaler (SMI) (Boehringer Ingelheim) is a delivery system that incorporates features intended to improve orally inhaled drug delivery to these patients. These features include simple device actuation, patient inspiratory effort-independent aerosol generation, and a slower spray emission with a longer spray duration, helping to mitigate issues with precise aerosol release and breath coordination. We review the clinical trials assessing lung deposition, efficacy, and safety, and patient satisfaction for the Respimat® SMI. These data indicate that the Respimat® SMI is a device capable of delivering a consistent, clinically effective dose of medication that patients can use and prefer, which may provide significant clinical benefits for patients with COPD.     

Comparing inhaled corticosteroids

There are currently available 5 different inhaled corticosteroids, in a variety of different inhalation delivery devices. In the near future there will certainly be more inhaled corticosteroids in newer inhalation delivery devices available in the United States. Tremendous amounts of information will be made available about the relative advantages and disadvantages of these new products. Most of this information will relate to measures of potency, pharmacokinetic profiles, and technical issues about the ease of use. The respiratory care practitioner should be aware that estimating the clinical benefits from the topical anti-inflammatory effects of these newer products will be difficult to determine from this information. Also difficult to understand will be the effects of easier to use inhalation delivery devices on patient adherence to prescribed inhaled corticosteroid dosing regimens. Information from well designed clinical trials should be the basis for comparing presently available and newly developed inhaled corticosteroids.     

Optimizing chronic obstructive pulmonary disease management in primary care

Diagnosis of chronic obstructive pulmonary disease (COPD) in primary care is complex, as many clinical symptoms are similar to asthma and heart disease, which may lead to misdiagnosis and suboptimal disease management. Spirometry is the best method for diagnosing COPD and distinguishing between COPD, asthma, and cardiovascular diseases. Airway obstruction is fully reversible in asthma, but not in COPD, and can be confirmed when the postbronchodilator ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is <0.7. Knowledge of COPD treatment guidelines and a proactive attitude toward disease management by primary care physicians are key to improving symptom control and patients' quality of life. Identification of the appropriate drug/inhaler combination, patient education, training on inhaler use followed by regular monitoring, and pulmonary rehabilitation are also vital to successful COPD management. This review outlines steps to aid physicians in devising and implementing an optimal management plan for COPD patients.     

Determinants of patient adherence to an aerosol regimen

Patient adherence with prescribed inhaled therapy is related to morbidity and mortality. The terms "compliance" and "adherence" are used in the literature to describe agreement between prescribed medication and patient practice, with "adherence" implying active patient participation. Patient adherence with inhaled medication can be perfect, good, adequate, poor, or nonexistent, although criteria for such levels are not standardized and may vary from one study to another. Generally, nonadherence can be classified into unintentional (not understood) or intentional (understood but not followed). Failing to understand correct use of an inhaler exemplifies unintentional nonadherence, while refusing to take medication for fear of adverse effects constitutes intentional nonadherence. There are various measures of adherence, including biochemical monitoring of subjects, electronic or mechanical device monitors, direct observation of patients, medical/pharmacy records, counting remaining doses, clinician judgment, and patient self-report or diaries. The methods cited are in order of more to less objective, although even electronic monitoring can be prone to patient deception. Adherence is notoriously higher when determined by patient self-report, compared to electronic monitors. A general lack of adherence with inhaled medications has been documented in studies, and adherence declines over time, even with return clinic visits. Lack of correct aerosol-device use is a particular type of nonadherence, and clinician knowledge of correct use has been shown to be imperfect. Other factors related to patient adherence include the complexity of the inhalation regimen (dosing frequency, number of drugs), route of administration (oral vs inhaled), type of inhaled agent (corticosteroid adherence is worse than with short-acting beta2 agonists), patient awareness of monitoring, as well as a variety of patient beliefs and sociocultural and psychological factors. Good communication skills among clinicians and patient education about inhaled medications are central to improving adherence.     

Assessment of hospice nurses' technique in the use of inhalers and nebulizers

Dyspnea, a common distressing end-of-life symptom, is treated with oral (i.e., opioids and anxiolytics) and inhaled medications (anti-inflammatory and bronchodilator agents). Health care providers and patients have demonstrated an inability to use inhaler devices correctly, which can lead to suboptimal drug delivery and poor symptom relief. Hospice nurses are the primary health care providers educating patients, making it critical that they convey accurate device technique. This study assessed hospice nurses' ability to demonstrate proper inhaler device technique and their knowledge of agents used to treat dyspnea. Forty-seven nurses participated. Participants completed a written questionnaire, which gathered demographic data, as well as information regarding previous training with an inhaler device, administration, pharmacokinetics, mechanism of action, patient assessment, and nursing technique. Additionally, each nurse demonstrated the use of a metered dose inhaler, spacer, dry powder inhaler, and a nebulizer, while being observed by a pharmacist trained in the use of inhalers. A standardized evaluation form was used to ensure consistency between evaluators and subjects. Percentage of steps completed correctly by the study participants ranged from 34.9% with the dry powder inhaler to 67.6% with the metered dose inhaler. Years of experience, presence of hospice certification, personal use of inhaler, and nursing comfort level significantly impacted ability to use inhalation devices. This study demonstrated the existence of knowledge gaps regarding patient assessment, pharmacology and pharmacokinetics of inhaled medications, and inhalation device technique among hospice nurses. Formal education of hospice practitioners regarding inhaled medications and inhalation delivery devices is needed.     

Primary care perspective on chronic obstructive pulmonary disease management

Chronic obstructive pulmonary disease (COPD), which affects > 24 million adults in the United States, is expected to become the third leading cause of mortality by 2030. Because primary care physicians (PCPs) form the frontline in treating patients with COPD, it is vital for them to comprehend the key issues associated with COPD management. The initial step is identifying the "right patient" by making a correct diagnosis, which should involve a targeted respiratory history, physical examination, and spirometry. Following diagnosis, the patient should be treated for the "right reason," with the "right therapy." The right reasons for treating patients diagnosed with COPD include symptom relief, prevention of exacerbations and disease progression, and reduction of mortality. Treatment of patients with COPD through smoking cessation and appropriate medications can help achieve these goals. A range of therapies, such as bronchodilators (β2-agonists and anticholinergics) and inhaled corticosteroids are available for disease management. Tailoring treatment plans, which include both pharmacological and nonpharmacological therapies, to suit each patient's needs will enable PCPs to provide patients with optimal disease control and treat "the right patient for the right reason with the right therapy."     

Current strategy of bronchodilator therapy for chronic obstructive pulmonary disease (COPD)]

The COPD is slowly but progressive disease, the main purpose of the treatment for COPD is considered to produce a significant bronchodilating effect for maintaining lung functions for long period. Inhaled anticholinergic drug is currently used as the first-line therapy of patients with COPD. The beta 2-adrenergic agonists used be the other choice of bronchodilator for treatment of COPD. The benefit of inhalational steroid on the treatment of COPD is still a matter of debate. The accurate procedure of inhalational device and appropriate use of spacer are particularly important for older patients with COPD. The older patients with COPD can be better treated by the inhaled anticholinergic drug or its combination with beta 2-adrenergic agents.     

The Diskus: a review of its position among dry powder inhaler devices

The use of dry powder inhalers (DPIs) to administer treatments for respiratory diseases has increased significantly in recent years. There is now a wide range of DPIs available that vary considerably in design, required operational techniques, output characteristics and drug delivery across a range of inhalation patterns. Different patient populations may find individual types of DPI easier to use correctly than others and selecting the right DPI for particular patient requirements will improve compliance with therapy. For example, some DPIs offer a greater resistance against inspirational flow rate than others which affects the total emitted dose and also fine particle mass of the aerosol released. An individual patient may therefore receive different amounts of drug when inhaling from different DPIs. Therefore, it is important that the prescriber is fully aware of the characteristics of the different types of DPI, so that he or she can prescribe the device that is most appropriate to an individual patient's needs. This review explores the characteristics of currently available DPIs and evaluates their efficacy and patient acceptability. The differences in output characteristics, ease of use and patient preferences between available devices is shown to affect treatment efficacy and patient compliance with therapy. Changing the DPI prescribed to a patient to a cheaper or generic device may therefore adversely affect disease control and thereby increase the cost of treatment.     

慢性阻塞性肺疾病患者健康教育视频的制作与应用

目的探讨COPD患者健康教育视频的制作与应用方法。方法 COPD患者健康教育视频内容包括入院宣教、呼吸功能锻炼方法及沙美特罗替卡松粉吸入剂使用方法,通过撰写文稿、录制、剪辑、配音完成视频制作后,在常规健康教育的基础上,每天在病房的健康教育区定时与按需结合播放。通过接受健康教育后患者对相应内容的掌握程度及对健康教育的满意度来评价效果。结果 COPD患者对入院宣教内容掌握的优良率为94.13%;呼吸功能锻炼的掌握率为93.14%;使用沙美特罗替卡松粉吸入剂的合格率为86.27%;患者及家属对健康教育的满意度为98.04%。结论 COPD患者健康教育视频是常规健康教育的有效补充,健康教育效果较好,值得优化推广。     

Dry powder inhalers for optimal drug delivery

Dry powder inhalers (DPIs) have been available for delivering drugs to the lungs for over 30 years. In the last decade there has been a big increase in DPI development, resulting partly from recognised limitations in other types of inhaler device. Many companies are developing DPIs for asthma and chronic obstructive pulmonary disease (COPD) therapy, and there is increasing recognition of the potential role of DPI systems for other therapies, such as inhaled antibiotics and peptides/proteins. Optimised drug delivery may be achieved not only by improvements to devices, but also via more sophisticated formulations that disperse easily in the inhaled air-stream and which may often be delivered by relatively simple inhaler devices. DPIs could become the device category of choice for a wide range of inhaled therapies, involving both local and systemic drug delivery.     

Metatarsalgia

Abstract

Recognition of chronic obstructive pulmonary disease (COPD) is often missed or delayed in primary care. Once recognized, COPD is often undertreated or episodically treated, focusing on acute exacerbations without establishing maintenance treatment to control ongoing disease. Diagnostic and therapeutic pessimism result in missed opportunities to reduce exacerbations, maintain physical functioning, and reduce emergent health care requirements. Proactive diagnosis and evidence-based management can alleviate the impact of COPD on patients' lives. Smoking cessation has been proven to slow the rate of lung function decline. Maintenance pharmacotherapy and immunizations reduce exacerbations. Pulmonary rehabilitation improves respiratory symptoms and physical functioning and reduces rehospitalizations after exacerbations. Self-management education improves health-related quality of life and reduces inpatient and emergency care usage. Maintenance treatment with long-acting inhaled bronchodilators is appropriate beginning in moderate COPD to maintain airway patency and reduce exacerbations. Tiotropium is US Food and Drug Administration (FDA) approved to treat bronchospasm and reduce exacerbations in patients with COPD; salmeterol/fluticasone is FDA approved to treat airflow obstruction in COPD and reduce exacerbations in patients with a history of exacerbations. Other maintenance long-acting bronchodilators—salmeterol, formoterol, and budesonide/formoterol—are FDA approved to treat airway obstruction in COPD but lack an approved indication against exacerbations. FDA warnings on the use of long-acting beta-adrenergic agents (LABAs) in asthma specifically exempt COPD and do not apply to LABA/inhaled corticosteroid combinations used in COPD. The actual effectiveness achieved in practice with any COPD therapies depends on patients' inhaler technique, adherence, and persistence. Medication usage rates and inhaler proficiency may be improved by concordance, in which the health care provider and patient collaborate to make treatment plans sustainable in the patient's daily life. Practice redesign for whole-patient primary care provides additional tools for comprehensive COPD management. Innovations such as group visits and the patient-centered medical home provide newer ways to interact with COPD patients and their families. Patient-focused and evidence-based options enable primary care practices to manage COPD longitudinally and improve patient outcomes through the course of the disease.     

Single dose of inhaled procaterol has a prolonged effect on exercise performance of patients with COPD

The aim of this study was to examine the prolonged effect of procaterol, a short-acting bronchodilator, on lung function and exercise performance in patients with moderate to severe COPD. A randomized crossover trial was conducted. We recruited 19 patients with COPD aged 71.6+/-5.5 years. Patients were randomly assigned to receive either 20 mug inhaled procaterol followed by no-treatment or no-treatment followed by 20 mug inhaled procaterol separated by a washout period of 3+/-2 days. Lung function and exercise performance, using the incremental shuttle walking test (ISWT), were measured at baseline and 4 hours after receiving each treatment. Baseline forced expiratory volume in 1 second (FEV(1)) was 38.5%+/-17% predicted. There were no significant changes in FEV(1) following inhaled procaterol. However, walking distance increased by 294+/-113 meters at baseline to 331+/-119 meters after inhaled procaterol (p<0.001). These findings support the beneficial effects of inhaled procaterol on exercise performance in the absence of any change in FEV(1) when measured at 4 hours following inhalation in subjects with moderate to severe COPD. The inhaled procaterol may be useful for enhancing the effects of exercise training in patients with COPD.     

Pharmacist‐led intervention study to improve inhalation technique in asthma and COPD patients

Rational and aims Inhaled therapy is the mainstay of treatment in patients with asthma and chronic obstructive pulmonary disease (COPD). For effectiveness of pharmacotherapy, correct use of medication is required. The aims of this study were to survey the quality of inhalation technique in patients and to determine the effect of a single intervention in community pharmacies by means of standardized procedures. Methods A total of 757 patients with asthma or COPD were randomly selected by 55 community pharmacies. At baseline, patients were interviewed and their inhalation technique was assessed with a 21‐items checklist. Any error was recorded and, if necessary, patients were instructed in the proper use of their device. After 4–6 weeks, demonstration of inhalation technique was repeated in the community pharmacies and a pre–post comparison was performed. Results A total of 597 patients (78.9%) made at least one mistake in performing the inhalation technique at baseline. This number dropped to 214 (28.3%) from the first to the second appointment. All patients did benefit from the pharmacists' intervention regardless of their former training experiences. Conclusions Inhalation technique of asthma and COPD patients is poor. In daily practice, community pharmacy‐based pharmacists are well suited to significantly supplement doctor‐based education in inhalation technique.     

Safety of inhaled long-acting anti-muscarinic agents in COPD

Evidence-based guidelines recommend inhaled long-acting anti-muscarinic agents (LAMAs) as first-line maintenance therapy for symptomatic patients with COPD. Several LAMAs are now available for use either as monotherapy or in combination with other COPD medications, including long-acting β₂-agonists (LABAs) or inhaled corticosteroids (ICS). The efficacy and long-term safety of these medications have been evaluated in multiple clinical trials and real-life studies. This review evaluates the evidence available on the safety of existing LAMAs alone or in combination with LABAs and ICS in patients with COPD.     

Inhaled insulin: extending the horizons of inhalation therapy

Targeted glycemic control in patients with type 1 and type 2 diabetes is grossly inadequate, despite data demonstrating reduced microvascular and macrovascular diabetic complications with intensive treatment. A significant proportion of individuals with poorly-controlled type 2 diabetes are resistant to initiating treatment with insulin. Several decades-long search for alternative forms of insulin delivery has finally resulted in the U.S. Food and Drug Administration's approval of the first inhaled insulin delivery system, Exubera. Inhaled insulin provides hope that minimizing barriers to initiating insulin therapy will improve the overall glycemic control in both type 1 and type 2 diabetic patients. Inhaled insulin is a powder formulation that has been approved for pre-meal administration in both type 1 and type 2 diabetic patients. The delivery system for Exubera employs compressed air for producing an aerosol, which is then inhaled by the patient. Insulin is transported across the alveolar-epithelial barrier into the blood and has onset of glucose-lowering activity within 10-20 min of inhalation. The duration of action of inhaled insulin is similar to that of subcutaneous regular insulin. Although there are some limitations to the use of inhaled insulin, the potential to improve adherence and thereby achieve target glycohemoglobin levels (< or = 6.5-7.0%) in poorly controlled diabetic patients outweigh its disadvantages.     

Underuse of anticoagulation in patients with atrial fibrillation

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. Guidelines recommend anticoagulation for patients with intermediate and high stroke risk (CHA₂DS₂-VASc score ≥2). Underuse of anticoagulants among eligible patients remains a persistent problem. Evidence demonstrates that the psychology of the fear of causing harm (omission bias) results in physicians’ hesitancy to initiate anticoagulation and an inaccurate estimation of stroke risk. The American Heart Association (AHA) initiated the Get With The Guidelines-AFIB (GWTG-AFIB) module in June 2013 to enhance guideline adherence for treatment and management of AF. Better quality of care for AF patients can be provided by increasing adherence to anticoagulation guidelines and improving patient compliance with anticoagulation therapy through education and established protocols. Nonvitamin K antagonist oral anticoagulants may facilitate better patient adherence due to ease of administration and reduced monitoring burden. In this review, we discuss the reasons for underuse, omission bias contributing to underuse, and different strategies to address this issue.     

Delivery of Inhaled Drugs for Infants and Small Children: A Commentary on Present and Future Needs

Although the manufacture of inhaled medications is a multibillion dollar industry, virtually no pharmaceutical drug/device combination has been approved for inhalation across the range of pediatric patient ages and sizes. The clinician who treats neonates, infants, or toddlers is often faced with the dilemma of prescribing inhaled medications that may be disease appropriate but have not been approved for use in patients in these age categories. Their use is thus technically “off label,” with limited empirical data to guide both dose and device selection. This dilemma requires the prescribing physician to go beyond the limitations of the product label, often without benefit of appropriately designed clinical trials, in an attempt to select safe and effective doses for use with these smallest of patients. The vast majority of drugs approved for inhalation were studied by using aerosol devices designed for older children and adults using a mouthpiece interface, which may not be practical for use in infants and patients aged <4 years. The selection of the most age-appropriate device and interface is critical for the effective administration of the prescribed therapy. In the absence of industry-sponsored clinical trials in neonates, infants, and toddlers, in vitro and in vivo strategies may help guide age-appropriate dosing, device, and interface selection to better inform clinical practice. In this commentary, the challenges in developing and prescribing effective formulations for aerosol delivery across the range of pediatric ages and sizes are explored, with guidance for device and interface selection. Recommendations for future collaborative sharing of in vitro models and age-specific breathing patterns between academic and industry researchers could help regulators and clinicians better understand the impact age and size have on pulmonary drug delivery.     

Recent updates in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), characterized by chronic airways inflammation and progressive airflow limitation, is a common, preventable and treatable disease. Worldwide, COPD is a major cause of morbidity and mortality; smoking tobacco is the most important risk factor. This translational review of recent updates in COPD care for the primary care audience, includes recommendations from the 2015 Global Initiative for chronic obstructive lung disease (GOLD) report on diagnosis, pharmacological and non-pharmacological treatment, prevalence of comorbidities, management of exacerbations and the asthma and COPD overlap syndrome, with a focus on the importance and benefit of physical activity and exercise in COPD patients. Exacerbations and comorbidities contribute to the overall severity of COPD in individual patients. Management of exacerbations includes reducing the impact of the current exacerbation and preventing development of subsequent episodes. Healthcare professionals need to be alert to comorbidities, such as cardiovascular disease, anxiety/depression, lung cancer, infections and diabetes, which are common in COPD patients and can have a significant impact on HRQoL and prognosis. Pulmonary rehabilitation is recommended by a number of guidelines for all symptomatic COPD patients, regardless of severity, and involves exercise training, patient education, nutritional advice and psychosocial support. At all stages of COPD, regular physical activity and exercise can aid symptom control, improve HRQoL, reduce rates of hospitalization, and improve morbidity and respiratory mortality. Healthcare professionals play a pivotal role in improving HRQoL and health-related outcomes in COPD patients to meet their specific needs and in providing appropriate diagnosis, management and advice on smoking cessation.     

Current challenges in diabetes management

The burden of diabetes on the health care system mandates efforts to more optimally treat those with the disease and to prevent its development in those at risk. Early and intensive intervention in patients with diabetes reduces the risk of microvascular and macrovascular complications and disease progression. Current challenges in diabetes management include: (1) optimizing the use of currently available therapies to ensure adequate glycemic, blood pressure, and lipid control and to reduce complications; (2) educating patients on diabetes self-management; (3) improving patient adherence to lifestyle and pharmacologic interventions; (4) reducing barriers to the early use of insulin; and (5) improving the delivery of health care to people with chronic conditions.