Prescription of inhalers in asthma and COPD: Towards a rational, rapid and effective approach

Abstract

Inhaled medication is the cornerstone of the pharmacological treatment of patients with asthma and COPD. The major two classes of inhaled medication include corticosteroids (ICS) and bronchodilators. There is a wide diversity in molecules in both classes. Moreover, there is a wide variation in delivery systems. The correct use of inhalers is not granted and patients often incur in many mistakes when using pMDIs and DPIs, despite repeated instructions. A better matching between patient and device could be accomplished if the physician is aware of: (1) the patient characteristics (disease, severity, fluctuation in airflow obstruction, etc); (2) what class of medication is indicated; (3) where in the lung the medication should be delivered; and, (4) how this can be best achieved by a given device in this specific patient. We focus on the prescription of pMDIs and DPIs at the GP office or at the outpatient clinic of the hospital, and we propose an evidence based approach enabling the caregiver to make a rational choice in only a few minutes by just considering the following four simple questions: Who?, What? Where? and How? (the so-called 3W-H approach).

Inhalation therapy in the next decade: Determinants of adherence to treatment in asthma and COPD

“…Device-related factors, as the optimal inhalation profile differs between pMDIs (slow inspiration is preferable) and DPIs (fast flow inhalation is required). For instance, observational comparative effectiveness studies suggest that pMDIs delivering small droplet aerosols could improve treatment effectiveness compared to standard pMDIs [179], due to the more limited influence of errors in coordination/inhalation technique on lung deposition with these devices; and, finally; 4. Caregivers-related factors, accounting for the availability and knowledge of professionals involved in information and education.…”

Patients’ perspectives and preferences in the choice of inhalers: the case for Respimat^®or HandiHaler^®

“…12 The algorithm considers three questions: 1) Is the patient capable of conscious inhalation? 2) Is the patient likely to reliably generate and control sufficient inspiratory flow?…”

“…Using this algorithm, patients evaluated as having sufficient inspiratory flow with good coordination would be suited to a pMDI (with or without spacer), DPI, or SMI (ie, Respimat ® , Boehringer Ingelheim); those with poor coordination may require a breath-actuated pMDI with spacer, DPI, or SMI 12. For patients with insufficient inspiratory flow but adequate coordination (eg, patients with severe COPD or asthma and recurrent exacerbations), a pMDI (with or without spacer) or SMI would be suitable 12.…”

“…For patients with insufficient inspiratory flow but adequate coordination (eg, patients with severe COPD or asthma and recurrent exacerbations), a pMDI (with or without spacer) or SMI would be suitable 12. Options for patients with both insufficient inspiratory flow and poor inhaler coordination include a breath-actuated pMDI (with spacer), SMI, or nebulizer 12.…”

“…Clinical respiratory practice in the majority of patients is to first select the class of medication, followed by the specific agent, and then the inhaler device itself. However, the importance of inhaler selection as part of the treatment decision is becoming increasingly recognized,2,9,12–14 and this article proposes that careful consideration of inhaler selection warrants greater priority among prescribers.…”