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      Preference, satisfaction and critical errors with Genuair and Breezhaler inhalers in patients with COPD: a randomised, cross-over, multicentre study

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          Abstract

          Background:

          The specific attributes of inhaler devices can influence patient use, satisfaction and treatment compliance, and may ultimately impact on clinical outcomes in patients with chronic obstructive pulmonary disease (COPD).

          Aims:

          To assess patient preference, satisfaction and critical inhaler technique errors with Genuair (a multidose inhaler) and Breezhaler (a single-dose inhaler) after 2 weeks of daily use.

          Methods:

          Patients with COPD and moderate to severe airflow obstruction were randomised in a cross-over, open-label, multicentre study to consecutive once-daily inhalations of placebo via Genuair and Breezhaler, in addition to current COPD medication. The primary end point was the proportion of patients who preferred Genuair versus Breezhaler after 2 weeks (Patient Satisfaction and Preference Questionnaire). Other end points included overall satisfaction and correct use of the inhalers after 2 weeks, and willingness to continue with each device.

          Results:

          Of the 128 patients enrolled, 127 were included in the safety population (male n=91; mean age 67.6 years). Of the 110 of the 123 patients in the intent-to-treat population who indicated an inhaler preference, statistically significantly more patients preferred Genuair than Breezhaler (72.7 vs. 27.3%; P<0.001). Mean overall satisfaction scores were also greater for Genuair than for Breezhaler (5.9 vs. 5.3, respectively; P<0.001). After 2 weeks, there was no statistically significant difference in the number of patients who made ⩾1 critical inhaler technique error with Breezhaler than with Genuair (7.3 vs. 3.3%, respectively).

          Conclusions:

          Patient overall preference and satisfaction was significantly higher with Genuair compared with Breezhaler. The proportion of patients making critical inhaler technique errors was low with Genuair and Breezhaler.

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          Most cited references23

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          What the pulmonary specialist should know about the new inhalation therapies.

          A collaboration of multidisciplinary experts on the delivery of pharmaceutical aerosols was facilitated by the European Respiratory Society (ERS) and the International Society for Aerosols in Medicine (ISAM), in order to draw up a consensus statement with clear, up-to-date recommendations that enable the pulmonary physician to choose the type of aerosol delivery device that is most suitable for their patient. The focus of the consensus statement is the patient-use aspect of the aerosol delivery devices that are currently available. The subject was divided into different topics, which were in turn assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. To achieve consensus, draft reports and recommendations were reviewed and voted on by the entire panel. Specific recommendations for use of the devices can be found throughout the statement. Healthcare providers should ensure that their patients can and will use these devices correctly. This requires that the clinician: is aware of the devices that are currently available to deliver the prescribed drugs; knows the various techniques that are appropriate for each device; is able to evaluate the patient's inhalation technique to be sure they are using the devices properly; and ensures that the inhalation method is appropriate for each patient.
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            Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD.

            Incorrect usage of inhaler devices might have a major influence on the clinical effectiveness of the delivered drug. This issue is poorly addressed in management guidelines. This article presents the results of a systematic literature review of studies evaluating incorrect use of established dry powder inhalers (DPIs) by patients with asthma or chronic obstructive pulmonary disease (COPD). Overall, we found that between 4% and 94% of patients, depending on the type of inhaler and method of assessment, do not use their inhalers correctly. The most common errors made included failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Inefficient DPI technique may lead to insufficient drug delivery and hence to insufficient lung deposition. As many as 25% of patients have never received verbal inhaler technique instruction, and for those that do, the quality and duration of instruction is not adequate and not reinforced by follow-up checks. This review demonstrates that incorrect DPI technique with established DPIs is common among patients with asthma and COPD, and suggests that poor inhalation technique has detrimental consequences for clinical efficacy. Regular assessment and reinforcement of correct inhalation technique are considered by health professionals and caregivers to be an essential component of successful asthma management. Improvement of asthma and COPD management could be achieved by new DPIs that are easy to use correctly and are forgiving of poor inhalation technique, thus ensuring more successful drug delivery.
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              Inhaler mishandling remains common in real life and is associated with reduced disease control.

              Proper inhaler technique is crucial for effective management of asthma and COPD. This multicentre, cross-sectional, observational study investigates the prevalence of inhaler mishandling in a large population of experienced patients referring to chest clinics; to analyze the variables associated with misuse and the relationship between inhaler handling and health-care resources use and disease control. We enrolled 1664 adult subjects (mean age 62 years) affected mostly by COPD (52%) and asthma (42%). Respectively, 843 and 1113 patients were using MDIs and DPIs at home; of the latter, the users of Aerolizer®, Diskus®, HandiHaler® and Turbuhaler® were 82, 467, 505 and 361. We have a total of 2288 records of inhaler technique. Critical mistakes were widely distributed among users of all the inhalers, ranging from 12% for MDIs, 35% for Diskus® and HandiHaler® and 44% for Turbuhaler®. Independently of the inhaler, we found the strongest association between inhaler misuse and older age (p = 0.008), lower schooling (p = 0.001) and lack of instruction received for inhaler technique by health caregivers (p < 0.001). Inhaler misuse was associated with increased risk of hospitalization (p = 0.001), emergency room visits (p < 0.001), courses of oral steroids (p < 0.001) and antimicrobials (p < 0.001) and poor disease control evaluated as an ACT score for the asthmatics (p < 0.0001) and the whole population (p < 0.0001). We conclude that inhaler mishandling continues to be common in experienced outpatients referring to chest clinics and associated with increased unscheduled health-care resource use and poor clinical control. Instruction by health caregivers is the only modifiable factor useful for reducing inhaler mishandling. Copyright © 2011 Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                NPJ Prim Care Respir Med
                NPJ Prim Care Respir Med
                NPJ Primary Care Respiratory Medicine
                Nature Publishing Group
                2055-1010
                30 April 2015
                2015
                : 25
                : 15018
                Affiliations
                [1 ] Hospital del Mar-IMIM, CIBERES , Barcelona, Spain
                [2 ] Pneumologie Odeonsplatz , Munich, Germany
                [3 ] Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne, UK
                [4 ] Department of Respiratory Medicine, Freeman Hospital , Newcastle upon Tyne, UK
                [5 ] Servicio de Neumología, Hospital Universitari Son Espases , Palma de Mallorca, Spain
                [6 ] Institut d’Investigació Sanitària de Palma (IdISPa) , Palma de Mallorca, Spain
                [7 ] CIBERES, Instituto Carlos III , Madrid, Spain
                [8 ] Institute of Applied Health Sciences, University of Aberdeen , Aberdeen, UK
                [9 ] Medical Affairs , Almirall, Barcelona, Spain
                [10 ] R&D Centre , AstraZeneca, Barcelona, Spain
                [11 ] Formerly of Almirall S.A. , Barcelona, Spain
                [12 ] Forest Research Institute, a subsidiary of Actavis PLC , Jersey City, NJ, USA
                [13 ] Department of Pharmacy, University of Huddersfield , Huddersfield, UK
                Author notes
                []

                SP, JF, ADS and JSR were responsible for conducting the study, contributed to writing the article and reviewed it for intellectual content. JH was involved in the study design, conducting the study, contributed to writing the article and reviewed it for intellectual content. LP was responsible for coordinating the study, carrying out data analysis, contributed to writing the article and reviewed it for intellectual content. BS and LR were responsible for the statistical analysis plan and the statistical analysis, contributed to writing the article and reviewed it for intellectual content. AR had overall responsibility for the study, carried out data analysis, contributed to writing the article and reviewed it for intellectual content. HC was the chief investigator and was involved with the study design, data analysis, contributed to writing the article and reviewed it for intellectual content. HC takes responsibility as guarantor of the article. All authors approved the final version of the manuscript.

                Article
                npjpcrm201518
                10.1038/npjpcrm.2015.18
                4415437
                25927321
                7bf6a160-1e22-46d4-944a-ae7f34347d7d
                Copyright © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited

                This work is licensed under a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

                History
                : 23 September 2014
                : 22 December 2014
                : 03 February 2015
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