COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 11
The pros and cons to using a dry powder inhaler as treatment for chronic obstructive pulmonary disease.
Neil Minkoff, MD: Dr Drummond, we’ve talked a little bit about the differences. You brought some of these things up originally between the metered-dose inhaler, the dry powder inhaler, the soft mist inhaler, and so on. It seems to me that, at one point, the dry powder inhaler was almost considered a can’t-miss therapy for a lot of patients, especially presented to us in the emergency [department] or in primary care. But it seems they might be trickier than that, especially for certain subpopulations. Could you talk a little bit about that and how you use PIF [peak inspiratory flow] and other tools to try to decide who ends up in that therapeutic class and who goes elsewhere?
M. Bradley Drummond, MD, MHS: There are several factors that go into this decision-making process. And as Dr Mahler said, it does also involve the patient preference. Unfortunately, we do have to consider cost. If an individual has different preferred plans or they don’t have insurance access, that may impact what our options are. But then exactly as Dr Mahler outlined, when I start thinking about whether we should move toward a dry powder inhaler delivery system, it’s mostly about cognitive function, manual dexterity, and peak inspiratory flow. Patients will appreciate these differences. The metered-dose inhaler is portable. There are combination molecules involved there. It does require a spacer or a holding chamber for best delivery, and it also requires some coordination of the actuation and the inhalation. So I’m really trying to get an assessment from the patient. Can that patient do those things effectively?
The dry powder inhalers have a lot of appeals. There are many of them that are once-daily dosing, which patients really appreciate. It certainly helps with adherence. They’re portable. As we’ve mentioned, there are combination molecules that could be included. The challenge is that the dry powder inhalers are flow-dependent, so understanding that the patient may not be able to generate sufficient inspiratory flow and therefore not actually get that medication, is an issue. The other thing to remember is that the dry powder inhalers can sometimes be impacted by humidity, so if they’re being stored in the bathroom, that can impact how well the powder is being disaggregated.
The soft mist inhalers are convenient because they are flow-independent, so we don’t have to worry about that peak inspiratory flow reduction issue. There is once-daily dosing. They are also available in a combination delivery system. There are a lot of appeals there. There are some challenges about loading and priming the device. These are perhaps a little bit foreign to patients, and so oftentimes we’ll ask them to ask their pharmacist to assist with getting the device set up, so that does require a little bit of training.
The nebulized therapies require the minimal amount of coordination and effort, but they’re the longest administration time. There are portability issues. As Dr Mahler mentioned, if somebody has cognitive impairments, they may need to have a caregiver help them in that regard. I think we really have to consider all of these multiple domains as we’re trying to decide how we’re going to assign a particular molecule and device for a patient.
Michael Hess, MPH, RRT, RPFT: One thing I think we’ve got to reinforce: you mentioned that these dry powder inhalers were supposed to be a can’t-miss thing. I don’t think any of these devices are inherently superior to any of the others, and I don’t think we’re ever going to have a device that is inherently superior to any of the others. It’s absolutely essential that we all work together on the clinical side, the patient/caregiver side, and the payer side to match the molecule and the device with the situation and have that precision medicine so we optimize those outcomes.
Maria Lopes, MD, MS: I think that’s a critical point, along with the appreciation for how time-consuming this is. We may not know if we got it right the first or the second time around. It goes back to how we can collect patient-reported outcomes data and using a consistent approach to some of the key metrics that matter in terms of that care coordination effort. Patients may not have just COPD [chronic obstructive pulmonary disease] as well, so I really appreciate everything Dr Mahler, Dr Drummond, and Mr Hess said in terms of how you get to the right fit to optimize the outcomes.
This activity is supported by an educational grant from Boehringer Ingelheim.