Download An Inhaler Therapy Review - Idaho Society of Health

You Can Breath Easy,
We Have You Covered
(An Inhaler Therapy Review)
Mikaela Elwell, PharmD
Andrea Brauer, PharmD
PGY1 Pharmacy Resident
St. Luke’s Health System – Boise, ID
03/04/2016
Disclosures
• The presenter has no disclosures to report
• No medications will be discussed off-label in this presentation
Learning Objectives
1.
Describe inhalers by their modes of aerosol delivery:
metered dose inhalers, dry powder inhalers, propellant free
liquid inhalers, or nebulizers.
2.
List the desired properties of inhalers as well as patient
specific factors that impact medication delivery to the
airways and the purpose of a spacer as an accessory device.
3.
Identify the common disease states in which inhaler therapy
is utilized for respiratory conditions.
Anderson PJ. Respir Care. 2005;50(9):1139-49
Inhaler Therapy
Advantages
• Targeted drug delivery
• Fewer side effects
• Smaller doses required
• Rapid onset of action
• Less invasive portal
Disadvantages
• Dose estimation
• How much really gets into
the lungs?
• Consistency hard to
achieve
• Patient’s use is variable
• Age / physical ability
• Technique dependent
Aerosols in the Health Care Field. Accessed Online at: http://aerosol.ees.ufl.edu/healthaerosol/section02-1.html. 1/9/2016
Inhaler Considerations
Fig.2 Taken from: Ibrahim M. et al. Med Devices: Evidence and Research. 2015;8:131-9
Image: http://pubs.rsc.org/services/images/RSCpubs.ePlatform.Service.FreeContent.ImageService.svc/ImageService/Articleimage/2013/NR/c3nr01525d/c3nr01525d-f5.gif
A spacer should only be used
with what type of inhaler to
help enhance a patient’s use?
A. Metered dose inhalers
B. Dry powdered inhalers
C. Nebulizers
D. A & B
E. All of the above
Pressurized Metered Dose
Inhaler (pMDI)
Propellant = Hydroflorocarbon (HFA)
Drug in suspension = Must Shake
Technique:
1. Shake 5 sec (suspension)
2. Take off cap, hold upright
3. Breath out (all the way)
4. While pressing inhaler – Breathe in
SLOW & DEEP (Propellant is doing the
work)
5. Hold breath as long a possible (10 sec)
Image: http://www.asthma.ca/adults/treatment/meteredDoseInhaler.php
Spacer Use with pMDI
Advantages
• pMDI Coordination is
difficult
• No need to time breath
• Reduces speed of aerosol
• Children & elderly
• Create aerosol faster than
a person can inhale
• Medication deposits in
mouth and does not reach
lungs
• Prevent thrush
• From inhaled
corticosteroids
• Indicate correct
inhalation speed
• Whistles if too quick
Image: http://www.aaaai.org/conditions-and-treatments/library/asthma-library/spacers-asthma.aspx
Dry Powdered Inhalers (DPIs)
Rotate / Twist
Drug in loose powder form
• Micronized drug particles
• 1-5µm
Pierce tablet
Slide / Click
Dry Powdered Inhalers (DPI)
Advantages
Contain NO propellant
• Breath Activated
• Fewer coordination issues
• No spacer needed
No need to hold breath
Disadvantages
Must have adequate inhalation
• Age dependent
• Progression of disease state
Technique
1. Open/Load device
2. Breath out (all the way)
3. Quick & Forceful Inhale
• Breath must do the work
Nebulizers
Ultrasonic
Sound waves atomize liquid
Jet
Compressed air atomizes liquid
Vibrating Mesh
Laser drilled mesh
vibrates to atomize
liquid
Ibrahim M. et al. Med Devices: Evidence and Research. 2015;8:131-9
Images: http://omnisurge.co.za/what-are-nebulizers-and-how-do-they-work/
Nebulizers
Advantages
• No coordination required
• Allows large doses of
medicine
• Option for those who
cannot use pMDI or DPI
•
•
•
•
Pediatric
Elderly
Unconscious
Too ill
• Soft mist
Image: http://www.rtmagazine.com/2011/07/liquid-nebulizers/
Disadvantages
• Less portable /
convenient
• Longer time to set-up /
use
• Expensive
Soft Mist Liquid Inhaler
(Respimat®)
Advantages
• Small / Portable
• No power supply
needed
• No chemical
propellant
• Soft mist – less
deposition in throat
Right Image: https://www.respimat.com/functions_and_use/howitworks.html
Left Image: http://www.europeanpharmaceuticalreview.com/35012/news/industry-news/fda-approves-asthma-treatment-spiriva-respimat/
Disadvantages
• Not breath
activated
• Expensive
RESPIRATORY CONDITIONS
Inhaler therapy is used in
patients with the following
conditions?
A. Cystic Fibrosis
B. Chronic Obstructive Pulmonary Disease
C. Asthma
D. Diabetes
E. All of the above
Asthma
Chronic Obstructive Pulmonary Disease
Cystic Fibrosis
Diabetes
RESPIRATORY CONDITIONS
Asthma
Image: http://www.nhlbi.nih.gov/health/health-topics/topics/asthma
Asthma
Triggers
Symptoms
Allergens – Pollen, mold
Wheezing
Drugs – Beta blockers, NSAIDs
Breathlessness
Environmental – smoke, cold air
Chest tightness
Respiratory Infections
Coughing
Short-acting beta-2 agonists
(SABA)
Used for an exacerbation
“Rescue Inhaler”
Drug
albuterol
Mechanism
• Beta-2 receptors on
bronchial smooth muscles
• Agonist = stimulation =
Relaxation
Onset: 5-15min
Duration: 3-4 hrs
Drug Facts and Comparisons. [database online] St. Louis, MO: Wolters Kluwer Health, Inc.; 2016
levalbuterol
Brand
Inhaler Type
Ventolin HFA
Proventil HFA
ProAir HFA
pMDI
Xopenex HFA
pMDI
nebulizer
nebulizer
Long-Acting beta-2 agonists
(LABA)
Used for preventing an exacerbation
“Maintenance Inhaler”
• Mechanism
Drug
Brand
Inhaler Type
Salmeterol
Serevent
Diskus
DPI
Formoterol
Foradil
Aerolizer
DPI
• Same as SABA
e.g. Salmeterol
Peak Onset: 2-5 hours
Duration: 12 hours
Black Box Warning: monotherapy in asthma is contraindicated –
increased risk of asthma-related deaths
Drug Facts and Comparisons. [database online] St. Louis, MO: Wolters Kluwer Health, Inc.; 2016
Corticosteroids
“Maintenance Inhaler”
Barnes PJ et al. Ann Intern Med. 2003; 129:359-370
Mechanism:
Inhibit inflammatory
response
Corticosteroids
First line for long-term control of
asthma
Mechanism:
• Inhibit inflammatory
response
• Decreased immune
response
Drug
•
Must rinse mouth and throat
with water and spit out after use
OR
Use a spacer device with pMDI
to prevent oral candidiasis (thrush)
Inhaler Type
Beclamethasone QVAR
HFA
pMDI – no
need to shake
Budesonide
Pulmicort
Flexhaler /
Respules
DPI / nebulizer
Ciclesonide
Alvesco
pMDI – no
need to shake
Flunisolide HFA
Aerospan
HFA
pMDI – built in
spacer
Fluticsasone
Flovent HFA / pMDI / DPI
Diskus
Anuity Ellipta DPI
Mometasone
Asmanex HFA pMDI / DPI
/ Twisthaler
Technique:
•
Brand
Combination products = LABA +
Steroid
Drug
Brand
Inhaler Type
Salmeterol +
Fluticasone
Advair HFA /
Diskus
pMDI / DPI
Formoterol +
Budesonide
Symbicort
pMDI
Formoterol +
Mometasone
Dulera
pMDI
Combination Therapy AVOIDS LABA BBW
Black Box Warning: monotherapy in asthma is contraindicated – increased risk of
asthma-related deaths
Chronic Obstructive
Pulmonary Disease (COPD)
SMOKE
• Cigarette
• Noxious particles
• Chemicals
• Increased mucus production
• Tissue damage
Inflammation
Chronic
Inflammation
Tissue
Destruction
COPD.Health Topics.NHLBI.NIH.Updated July 31, 2013. Accessed at: http://www.nhlbi.nih.gov/health/health-topics/topics/copd
Image: http://sphweb.bumc.bu.edu/otlt/MPH-Modules/PH/Ph709_RespiratoryHealth/PH709_RespiratoryHealth5.html
• Airway narrowing
• Fibrosis
• Emphysema
COPD
Drug Therapy
Symptoms
Dyspnea (Shortness of Breath)
Sputum Production
Chronic Cough
• NOT shown to modify longterm progression
• only decreases symptoms
and/or complications
Inhalers used based on:
• Symptoms
• Degree of Airflow limitation
• Spirometry
• Risk of Exacerbations
• Comorbidities
COPD Inhaler Therapy
Vilanterol + Fluticasone
Aclidinium
Umecliinium
Taken from: Improving Outcomes in COPD Patients. Medscapre CME. 11/25/2010 Online at: http://www.medscape.org/viewarticle/712114
Anticholinergic Inhaler
Used for symptom control
Mechanism
• Relax bronchial smooth
muscle
• Blocks action of
acetylcholine
Systemic Anticholinergic
Side Effects
• Constipation
• Blurred vision
• Dry Eyes
• Dry mouth
• Urinary retention
• Nasal congestion
Image: http://intranet.tdmu.edu.ua/data/kafedra/internal/pharmakologia/classes_stud/en/stomat/ptn/Pharmacology/2%20year/07%20Drugs%20acting%20on%20the%20respiratory%20organs%20function-1.htm
Anticholinergic Inhaler
Drug
Brand
Inhaler Type
Atrovent HFA
pMDI &
nebulizer
Short-acting
Ipratropium
Ipratropium + Combivent
Albuterol
Respimat
DuoNeb
Respimat
Nebulizer
Long-acting
Aclidinium
Tudorza
Pressair
DPI
Tiotropium
Spiriva
Handihaler /
Respimat
DPI
Respimat
Umeclidinium Incruse Ellipta DPI
Long-Acting beta-2 agonists
(LABA)
COPD Only
Approved for both
asthma and COPD
and Combination with Steroids
Drug
Brand
Inhaler Type
Salmeterol
Serevent
Diskus
DPI
Salmeterol +
Fluticasone
Advair HFA / pMDI / DPI
Diskus
Formoterol
Foradil
Aerolizer
DPI
Formoterol +
Budesonide
Symbicort
pMDI
Arformoterol
Brovana
Nebulizer
Indacaterol
Arcapta
Neohaler
DPI
Vilanterol +
Fluticasone
Breo Ellipta
DPI
Which of the following comes
as a dry powdered inhaler?
A. Fluticasone/Salmeterol (Advair Diskus)
B. Albuterol HFA (ProAir HFA , Proventil
HFA , Ventolin HFA )
C. Tiotropium (Spiriva Respimat )
D. Tiotropium (Spiriva Handihaler )
E. A & D
Cystic Fibrosis (CF)
Genetic disorder
• Abnormal transport of
chloride, bicarbonate,
and sodium
• Causes thick mucus
production
• Effects lungs
• Difficulty breathing
• Infections
(Also effects pancreas, liver,
and intestines)
Cystic Fibrosis.Health Topics.NHLBI.NIH.Updated Dec 26, 2013. Accessed at: http://www.nhlbi.nih.gov/health/health-topics/topics/cf
Image: http://discovermagazine.com/2013/september/14-doorway-to-a-cure
CF Inhaler Therapy
Bronchodilators
Mucolytics
Inhaled
Antibiotics
CF Inhaler Therapy
Bronchodilators
• Albuterol
• Levalbuterol (Xopenex)
• Ipratropium/albuterol
(Combivent)
Opens the airway
• Used to facilitate the
delivery of other inhaled
medications
• Mucolytics
CF Inhaler Therapy
Bronchodilators
Mucolytics
• Hypertonic saline
• Dornase alfa
(Pulmozyme)
• Recombinant human
deoxyribonuclease 1
• cleaves DNA – thins mucus
• Produced by genetically
engineered Chinese
Hamster Ovary cells
• Requires a jet nebulizer
Pulmozyme Package Insert, Genetech 2014
Image: http://learn.genetics.utah.edu/content/disorders/singlegene/cf/
CF Inhaler Therapy
Inhaled Antibiotics
• Most commonly CF patients
have chronic Pseudomonas
aeruginosa infections
Drug
Brand
Inhaler Type
Tobramycin
solution
TOBI,
Bethkis
nebulizer
Tobramycin
powder
TOBI
Podhaler
DPI
Aztreonam
Cayston
nebulizer
Top Image from: Sousa AM.. Pathogens. 2014; 3(3):60-703
Diabetes – Type 1 & 2
Drug
Brand
Inhaler Type
Rapid-acting
insulin
Afrezza
DPI
Peak Effect:
• Inhaled: 53 min
• SQ: ~1 hrs
Duration:
• Inhaled: 160-180 min
• SQ: 2-4 hrs
Black Box Warning: risk of acute bronchospasm in patients with chronic
lung disease – contraindicated in patients with asthma or COPD
Afrezza. Package Insert. Sanofi. 2014
Image from: http://www.houstonchronicle.com/news/nation-world/nation/article/Drug-firm-launches-inhaled-insulin-product-6060301.php
What the future may hold…
Future Inhaled Therapy
•
•
•
•
Vaccines
Antibodies
Hormones
…
Ibrahim M. et al. Med Devices: Evidence and Research. 2015;8:131-9
Image from: http://www.rtmagazine.com/2015/10/smart-inhalers-future-respiratory-health-management/