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Individualizing Medication Therapy in Patients with COPD: Considerations with Inhalers


Selecting appropriate inhalers based on individual characteristics and shared decision-making is crucial for optimizing care for patients with COPD.

Jeffrey D. Dunn, PharmD, MBA: Coming back to what Mike touched on, let’s dig into this a little….Can you comment on the different formulations and the pros and cons? MDIs [metered-dose inhalers], DPIs [dry powder inhalers], soft mist, nebulized. This is a broad question, but do you mind maybe taking a stab at that?

Mike Hess, MPH, RRT, RPFT: I’ll [qualify] this by saying that I wouldn’t view any one of these as inherently superior to any other. It’s nice to have all of these different tools in the tool chest because they all have different pros and cons and they’re all going to be good for different sets of [patients]. We’ll start with the MDIs. These are the [most] familiar ones that we have: your traditional handheld puffer. They’re very portable. You don’t need any power for them, but you need to have pretty good hand and breath coordination to get it into the lungs where it needs to go, even if you have a valve holding chamber, which is the standard of practice for these kinds of devices.

Dry powder inhaler, similarly, is very portable, small, with lots of different formulations. You don’t need as much coordination because they’re patient-actuated devices. The patient puts it into their mouth, and they take a deep breath in. The caveat to these is you have to be able to generate sufficient peak inspiratory flow in order to disaggregate the medication from the carrier and get it into the lungs where it’s supposed to go. There are certain [patients], especially those with more advanced disease or older [patients], who aren’t able to generate that kind of flow, who aren’t going to be able to get their optimal dosage.

The soft mist inhaler is in between. It isn’t patient-actuated, but it doesn’t require quite as much coordination. But it can be a little more complicated to assemble. It can be hard to put together sometimes, and there aren’t as many medications available with it. Off the top of my head, there aren’t any inhaled corticosteroids that you can get in that device, so if you’re on triple therapy—to our previous points—you’re automatically going into at least 2 different devices there.

Then, of course, our good friend, the old nebulizer. It’s in some respects the best because it doesn’t require any special technique or anything like that. But on the flip side, they take the longest to run a medication dose in. We often forget to teach [patients] how to clean them…or [patients] forget to clean them, forget to change the filters….Cost can be a factor on some of these things. You asked about the pros and cons. They all have great pros. They all have great cons. The most important thing is to match the device with the [patient] and the goals of therapy, their individual characteristics, and what they want to get out of it.

Jeffrey D. Dunn, PharmD, MBA: How much of a role does the patient have in that? Or are you trying to make that decision for them?

Mike Hess, MPH, RRT, RPFT: I try not to make any decisions for anybody. How much of a role we have on that often depends on the payer, for better or for worse. We’ve touched on the formulary a couple of times. That’s often the main driver. Guidelines are the main driver of care in the ideal world, but the formularies are the main driver in the real world.

Jeffrey D. Dunn, PharmD, MBA: It’s that engagement, but it’s helping them understand the pros and cons, and then finding what works for them.

Mike Hess, MPH, RRT, RPFT: Eventually, we can get there, even if it isn’t necessarily the first thing on the formulary. We have the step therapy where we’ve tried this device, it didn’t work, they weren’t able to use it, so now we have a justification to try something else.

Jeffrey D. Dunn, PharmD, MBA: I want to mention a study: the INTREPID study [NCT0346742]. It evaluated single vs multiple inhaler triple therapy for COPD. Do you have any comments there? Can you summarize that for us? What did the results of that study show?

Courtney Crim, MD: The INTREPID study basically compared using multiple inhalers vs a single inhaler that contains triple therapy. That’s what they looked at in more of a real-world setting, using a device that had all 3 medications—the ICS [inhaled corticosteroid], the long-acting β-agonist, and a long-acting muscarinic antagonist—in a single device vs allowing patients in their usual care practice with their personal physician of receiving triple therapy but in multiple devices. Oftentimes it’ll be 2 devices, but in multiple devices. They wanted to see if there would be a difference in the impact on health status as measured by the COPD Assessment Test, as well as lung function in terms of FEV1 [forced expiratory volume in 1 second], and then likewise from the standpoint of critical errors in terms of using their devices. There were written steps in terms of how to properly use these devices.

This particular study assessed over a 6-month period that if you could deliver all 3 medications in a single device compared with multiple devices, more [patients] had a positive response in terms of having a clinically meaningful improvement in their health status as measured by the COPD Assessment Test. The improvement in FEV1 measured by spirometry was also greater in those who received the 3 drugs in a single inhaler vs multiple inhalers, but there was no difference in the critical errors. Therefore, intuitively, it comes back to what we’ve been discussing all day. If you can simplify their regimen in terms of being able to deliver the medication in a single inhaler as opposed to multiple inhalers, in which you can be assured of the deposition of all components, you’re more likely to have a clinical response than if you have different inhalers that they may use differently, and things of that nature. That’s what this study showed. Intuitively, that’s what you would’ve thought would happen, and that’s what the study demonstrated.

Jeffrey D. Dunn, PharmD, MBA: It confirms what we should know.

Transcript edited for clarity.

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