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Improving Medication Adherence in COPD with an Effective Device Orapan Poachanukoon, MD. เนื้ อหา ั ยทีม ปัจจั ่ ผ ี ลตอการตกสะสมของยา ่ อุปกรณพ ดตางๆ ์ นยาชนิ ่ ่ วิธก ี ารเลือกอุปกรณพ เ่ หมาะสมกับผู้ป่วย ์ นยาที ่ Particle deposition in the respiratory tract Relationship between aerodynamic chamber and lung deposition Total Oropharynx Bronchial/ Conducting airways Alveolar Laube et al Eur Respir J 2011; 37: 1308–1331. Factor affecting deposition of aerosols in lung Physical Ventilatory Particle size Particle shape Particle density Humidity Temperature Tidal volume Inspiratory flow Breath-hold time Breathing frequency Nose vs mouth breathing Anatomic Airway diameter Age Disease Rubin BK, Fink JB. Respir Care Clin N Am 2001;7:175-213. Patient-related variables impacting correct device use Pulmonary function and disease stage Smoking status, age, sex, being overweight Comorbidities Manual dexterity Ability to understand and follow instructions Eyesight Psychosocial issues Fink JB et al. COPD 2013;10: 1-13. Patient’s inhaler device preference in COPD Increased patient satisfaction and preference with a device can help optimize patient adherence to treatment1,2. Factors affecting patient preferences: Perceived efficacy of device by patients Ability to use a given inhaler easily Psychological or physical issues o Such as comorbidities (neuromuscular disorders and arthritis) can impact inhaler technique. Inhaler features considered “very important” by COPD patients (Data from Moore and Stone 2004) 1. Anderson et al. ERR 2005 2. Jones et al. PCRJ 2004 Restrepo et al. Int J COPD 2008:3(3) 371-384 Nebulizers Aerosol devices pMDI DPI MDI vs MDI with Spacer Spacer devices E Nebuchamber Aerochamber Valved holding chamber Babyhaler ACE spacer Volumatric DIY Spacer DIY Petty patent of Thailand No. 5479 AWARDS • 2013. Gold Prize in International Exhibition of Inventions of Geneva.Swiss Confederation. 10-14 April 2013 • 2013. Special Award from Taiwan Invention Association. • 2012. Silver Prize in SII: Korea • 2012. Excellence Award “Thai-ASEAN” Thaksin University National Conference. DIY SPACER on THAMMASAT DIY SPACER https://www.youtube.com/watch?v=XeTBTJLnWyg ่ ยพ่นยา TU Asthma Club อุปกรณ์ชว https://www.youtube.com/watch?v=kMbXeOo6S3I www.tuasthmaclub.com Clinical efficacy of spacer therapy with/without electrostatic charge This study showed no negative influence of ESC on plastic spacers in children with asthma. Arch. Dis. Child. 2001;84;178-182. Dry Powder Inhaler (DPI) DPI MDI MDI and DPI: advantages and disadvantages Advantages Disadvantages Portable and compact Coordination of actuation and inhalation needed Short treatment time Most patients inhale too fast No contamination risk Important to prime before first use High reproducibility between doses Often difficult to determine remaining doses Spacers available for some devices Spacers more expensive and less portable No coordination required Forceful inhalation needed to aerosolize particles Not to be used with spacer More expensive than MDIs Portable and compact; multi-dose Only used with drug that is dispensed with the device devices available Single-dose devices with doses kept Must be kept upright or horizontal during inhalation separately in sealed packs Breath actuated Patients not to exhale into device once prepared Short treatment time Single devices require repeat loading Chrystyn & Price. Prim Care Resp J 2009; Laube et al. Eur Respir J 2011 DPI MDI MDI and DPI: advantages and disadvantages Advantages Disadvantages Portable and compact Coordination of actuation and inhalation needed Short treatment time Most patients inhale too fast No contamination risk Important to prime before first use High reproducibility between doses Often difficult to determine remaining doses Spacers available for some devices Spacers more expensive and less portable No coordination required Forceful inhalation needed to aerosolize particles Not to be used with spacer More expensive than MDIs Portable and compact; multi-dose Only used with drug that is dispensed with the device devices available Single-dose devices with doses kept Must be kept upright or horizontal during inhalation separately in sealed packs Breath actuated Patients not to exhale into device once prepared Short treatment time Single devices require repeat loading Chrystyn & Price. Prim Care Resp J 2009; Laube et al. Eur Respir J 2011 Why dry powder inhalers? Automatic co-ordination of inhalation and drug release1,2: – reduces patient errors associated with need to co-ordinate inhalation and drug release Dose counting or low warning (multi-dose DPIs) – also a feature of newer pMDIs Lack of propellant is environmentally friendly3 – although plastics content, electronics (with some devices) and fewer doses per device may contribute to a less environmentally friendly profile 1. Ashurst, et al. Pharm Sci Technol Today 2000; 2. Newman, Busse. Respir Med 2002 3. Byron. PATS 2004 Lung deposition of devices Respir Care Clin N Am 2001 How to choose right aerosol delivery device Poor coordination Good coordination Inspiratory flow > 30 L/min Inspiratory flow < 30 L/min Inspiratory flow > 30 L/min Inspiratory flow < 30 L/min pMDI pMDI pMDI+spacer pMDI+spacer DPI Nebulizer DPI Nebulizer Nebulizer Nebulizer Laube et al Eur Respir J 2011; 37: 1308–1331. Evaluating Drug Delivery of DPI Inspiratory Flow Device Resistance Fine Particle Mass Airflow resistance in DPIs 120 Flow rate (L/min) 100 80 60 40 2.2 10-2 kPa1/2 L-1 min 2.7 10-2 kPa1/2 L-1 min 3.4 10-2 kPa1/2 L-1 min 5.1 10-2 kPa1/2 L-1 min Breezhaler Diskus Turbuhaler Handihaler 20 0 0 2 4 6 Inspiratory effort (kPa) 8 10 Singh D et al. ATS 2010 (poster) Peak inspiratory flow rate (PIFR) Breezhaler was not affected by COPD severity • Patients with mild to very severe COPD achieved a flow rate of ≥60 L/min (>18.9 cmH2O pressure drop) using Breezhaler® 140 PIFR (L/min) 120 100 80 60 40 20 0 Mild N=26 COPD patients Moderate Moderate/ severe Severe Very severe COPD severity Peak inspiratory flow rates via the device were determined in patients with COPD using an Inhalation Profile Recorder. Each bar represents one patient Pavkov et al. CMRO 2010; 26 (11): 2527-2533 Particle size & Dose Regional Deposition in Lung • Delivered dose are usually in range of 75%-90% of metered dose. • FPD/FPM are very much dependent from formulation and delivery system but never 100% of delivered dose. Consistent results for fine particle mass Indacaterol 150 µg Indacaterol 300 µg 60 120 42 43 45 47 48 38 40 34 30 100 Fine Particle Mass (μg) Fine Particle Mass (μg) 50 101 27 20 10 85 80 60 90 106 103 93 72 54 40 20 0 0 30 40 50 60 70 80 90 100 Flow Rate (L/min) ** Fine particle mass = drug particles <4.7 μm in diameter 30 40 50 60 70 80 90 100 Flow Rate (L/min) Pavkov et al. CMRO 2010; 26 (11): 2527-2533 Estimated drug deposition in Breezhaler® and HandiHaler® 35 Intrathoracic deposition (% of delivered dose) 30 Patient 25 20 15 10 5 0 1 2 3 4 5 Breezhaler 6 7 Mean ±SD 1 2 3 4 5 Handihaler 6 7 Mean ±SD Particles <5 μm have greatest potential for lung deposition1 FPF (proportion of particles <5 μm) was higher with Breezhaler (27%) vs HandiHaler (10%)2 Mean estimated intrathoracic drug deposition: 31% Breezhaler; 22% HandiHaler2 Mean estimated extrathoracic drug deposition: 57% Breezhaler; 71% HandiHaler2 1. Laube et al. Eur Respir J 2011; 2. Chapman et al. Int J COPD 2011 Breezhaler-new capsule based DPI Low airflow resistance Easy to use, Feedback on correct use Taste, Transparent Reasons for Non-adherence complexity of treatment, S/E Possible avoidance patient education difficult to access cost/reimbursement patients features chronicity Pt/HCW partnership Impact on adherence Technique to improve adherence to aerosol medications Written explanation and demonstration Have patient bring medication to every appointment and check technique at each visit Ask the patient specifically about adherence Follow up on unfilled and refilled Minimized medications, keep it simple Parents need to take responsibility (> 13 years take medicine independently) Respiratory care 2011. ขอบคุณคะ่ Please visit us at www.tuasthmaclub.com