Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD

Lavorini, Federico; Magnan, A.; Dubus, J.-C.; Voshaar, Thomas; Corbetta, Lorenzo; Broeders, M.E.A.C.; Dekhuijzen, Richard; Sanchís, J.; Viejo, José Luís; Barnes, Peter J.; Corrigan, Christopher; Levy, Mark L; Crompton, G.K.

doi:10.1016/j.rmed.2007.11.003

Cited by 521 publications

(528 citation statements)

References 39 publications

(95 reference statements)

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“…Proper inhalation techniques and use of spacer devices, as well as rinsing the mouth after ICS inhalation, are effective [24][25][26] in lowering oropharyngeal ICS deposition, and thereby may reduce the occurrence of oral candidiasis [4]. Unfortunately, patient education about inhaler devices and inhalation techniques is not always given and when given, instruction is often rushed, of poor quality or not reinforced [27,28]. This is further complicated by suggestions that knowledge of correct inhalation techniques decreases quickly after use in clinical practice [29].…”

Section: Discussionmentioning

confidence: 99%

Inhaled Corticosteroids and the Occurrence of Oral Candidiasis: A Prescription Sequence Symmetry Analysis

2013

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Objectives The primary aim of the study was to gain insight into the relative risk of clinically relevant oral candidiasis following inhaled corticosteroid (ICS) initiation over time. A secondary aim was to analyse the influence of patient characteristics and co-medication on the occurrence of this adverse effect. Methods Drug prescription data from 1994 to 2011 were retrieved from the IADB.nl database. To study the influence of ICS use on occurrence of oral candidiasis, a prescription symmetry analysis was used, including patients using medication for oral candidiasis up to 1 year before or after ICS initiation. The relative risk was calculated by dividing the number of patients receiving medication for oral candidiasis after ICS initiation by the number of patients receiving the same medication before ICS initiation. Sub-analyses were conducted to compare the relative risks at several time points after ICS initiation and to account for therapy persistence by only including chronic users of ICS. A multivariate logistic regression model was used to identify predictive factors. Results A total of 52,279 incident users of ICS therapy were identified, of which 1,081 received medication for oral candidiasis up to 1 year before or after ICS initiation. A total of 701 patients received medication for oral candidiasis after ICS initiation, while 361 received these medications in the reversed sequence, resulting in a sequence ratio (SR) of 1.94 (95 % CI 1.71-2.21). In the first 3 months after ICS initiation, the SR was 2.72 (95 % CI 2.19-3.38) and then decreased to 1.47 (95 % CI 1.11-1.95) 9-12 months after ICS initiation. Predictive factors were higher daily dose of ICS and concomitant use of oral corticosteroids. Conclusions This study found a significant and clinically relevant increased number of patients receiving medication for oral candidiasis in the first year after therapy initiation with ICS. Relative risk is highest in the first 3 months, but remains increased up to at least 1 year after ICS initiation. This study stresses the need for patient education and inhalation instruction.

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Section: Discussionmentioning

confidence: 99%

Inhaled Corticosteroids and the Occurrence of Oral Candidiasis: A Prescription Sequence Symmetry Analysis

2013

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“…In this case the average use over time is meaningless unless data on the technique of use is also incorporated into the calculation of the adherence. Most electronic recording devices usually do not assess if the inhaler was taken correctly (5)(6)(7)(8)(9)(10)(11)(12). Hence, there is a need to develop a method to quantify adherence that accounts for variations in dosing schedules as well as inhaler user technique.…”

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confidence: 99%

A Method to Calculate Adherence to Inhaled Therapy that Reflects the Changes in Clinical Features of Asthma

et al. 2016

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Written permission has been obtained from all persons named in the acknowledgment.Author Contributions: EM, SOD and SR were primarily involved in patient recruitment. SD, VR, IK and RBR were primarily involved in the audio analysis required for this manuscript. FB was primarily involved in the statistical analysis for this manuscript. BC, and MCM were involved in data collection and data analysis for this manuscript. IS, JS and RWC were involved in all aspects required for this manuscript including patient recruitment, data management, data analysis and were the primary leads in the design of the work. All co-authors were involved in writing and editing this manuscript. Methods:We attached a digital audio device (INCA TM ) to a dry powder inhaler. This recorded when the inhaler was used and analysis of the audio data indicated if the inhaler had been used correctly. These aspects of inhaler use were combined to calculate adherence over time, as an AUC measure. Over a 3 month period a cohort of asthma patients were studied. Adherence to a twice-daily inhaler preventer therapy using this device and clinical measures were assessed. Measurements and Results:Recordings from 239 patients with severe asthma were analysed.Average Adherence, based on the dose counter was 84.4%, whereas the ratio of expected to observed accumulated AUC, Actual Adherence, was 61.8% (p<0.01). Of all adherence measures, only adherence calculated as AUC reflected changes in asthma quality of life, beta agonist reliever use and PEF, over the three months (p<0.05 compared to other measures of adherence). Conclusion:Adherence that incorporates the interval between doses and inhaler technique, and calculated as AUC, is more reflective of changes in quality of life and lung function than the currently used measures of adherence. Electronic monitors are considered to be the gold standard for objectively quantifying adherence (1). Most studies using electronic recording devices have reported adherence as the mean adherence or, the Mean Daily Dose, over the study period (2) (3) (4) The aim of this study was to test the hypothesis that by including the time of use, the interval between doses and accounting for inhaler technique, we could quantify adherence as an Area Under the Curve (AUC) and, furthermore, determine whether adherence calculated using AUC was more reflective of patient outcomes than current methods of assessing adherence. Some of the results of this study have been previously reported in the form of an abstract(18). Methods

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“…To our knowledge, the drop in delivered dose resulting from actuation of Turbuhaler or Easyhaler in a non-upright manner has not been reported, with the exception of one study that described an 8% drop resulting from horizontal actuation of the Turbuhaler [16]. However, reports of several studies of inhaler technique have underscored the importance of holding the Turbuhaler upright [6, 7, 11, 17–20]…”

Section: Discussionmentioning

confidence: 99%

Comparison of correct technique and preference for Spiromax®, Easyhaler® and Turbuhaler®: a single-site, single-visit, crossover study in inhaler-naïve adult volunteers

Rönmark

Jagorstrand

Safioti

et al. 2018

European Clinical Respiratory Journal

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Background: Many patients do not use inhalers correctly. Inhalers associated with good technique have the potential to improve symptom control and are often preferred by patients. Methods: Inhaler-naïve, adult volunteers were randomized to use empty Spiromax®, Easyhaler®, and Turbuhaler® dry powder inhalers (DPIs) in one of six possible sequences in this single-site, single-visit, crossover study conducted in Sweden. Randomization was stratified by age and gender. Participants attempted to use each device intuitively (no instructions) and after reading the instructions for use from the patient information leaflet. Device preference was surveyed after using all devices. Mastery of device handling (i.e. dose preparation) or inhalation was defined as having no healthcare-professional-observed errors. The primary endpoint was mastery of device handling after reading the instructions. Results: More participants mastered device handling with Spiromax vs Easyhaler or Turbuhaler, both intuitively (44%, 0%, and 10%, respectively) and after reading the instructions (99%, 56%, and 81%, respectively). Fewer participants had ≥1 device-handling error with Spiromax than with the other devices. The percentage of participants still showing inhalation errors after reading the instructions ranged between 21% for Spiromax and 40% for Easyhaler. After reading instructions, mastery of handling and inhalation was numerically lower among older (aged >60 years) vs younger participants across all devices. Most participants preferred Spiromax for device handling (59%) and intuitiveness/ease of use (61%). Conclusion: These findings highlight that important differences exist between DPI devices, which could have implications for disease control when selecting a device for a patient.

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Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD

Cited by 521 publications

References 39 publications

Inhaled Corticosteroids and the Occurrence of Oral Candidiasis: A Prescription Sequence Symmetry Analysis

Inhaled Corticosteroids and the Occurrence of Oral Candidiasis: A Prescription Sequence Symmetry Analysis

A Method to Calculate Adherence to Inhaled Therapy that Reflects the Changes in Clinical Features of Asthma

Comparison of correct technique and preference for Spiromax®, Easyhaler® and Turbuhaler®: a single-site, single-visit, crossover study in inhaler-naïve adult volunteers

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