Announcer:
You’re listening to Deep Breaths: Updates from CHEST on ReachMD. This series is produced in partnership with the American College of CHEST Physicians and is sponsored by Viatris Inc. Here’s your host, Dr. Megan Conroy, Assistant Professor of Medicine in the Division of Pulmonary, Critical Care, and Sleep Medicine at the Ohio State University.
Dr. Conroy:
Despite more recent availability of nebulized long-acting muscarinic antagonists, or LAMAs, for short, patients with moderate-to-severe COPD may still be using their inhalers incorrectly.
This is ReachMD and I’m Dr. Megan Conroy. Joining me today to take a look at the ins and outs of LAMAs for patients with COPD is Dr. Farrukh Abbas, an Assistant Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the Virginia Commonwealth University Health System. Dr. Abbas, welcome to the program.
Dr. Abbas:
Thank you, Dr. Conroy. Happy to be here.
Dr. Conroy:
So, let’s start generally, Dr. Abbas. What can you tell us about nebulizer therapy versus inhaler therapy for patients with COPD?
Dr. Abbas:
I would say there are a few points pertaining to nebulized versus inhaler therapy in COPD. First, regardless of the class of medication, I cannot overemphasize the need for regular assessment of inhaler technique, adherence, and appropriateness. Second, the Global Initiative for COPD, GOLD, indicates that on average, more than two-thirds of patients make at least one error in using an inhaler device. And last but not least, while poor inhaler technique can affect drug delivery, it’s also important to note that patients with COPD who have low peak inspiratory flow show greater efficacy with nebulizer therapy than with DPIs, which are dry powder inhalers.
Dr. Conroy:
Absolutely, those are great points. I know most patients on inhalers, regardless of the disease condition may have difficulty taking that inhaler correctly. But a specific consideration for patients with COPD and more severe COPD is the amount of inspiratory flow that they’re able to generate. You mentioned the Global Initiative for Chronic Obstructive Lung Disease, or the GOLD treatment guidelines. What do those guidelines recommend regarding the use of LAMAs for patients with COPD?
Dr. Abbas:
Dr. Conroy, this is an important question. Per 2020 GOLD recommendations, use of a LAMA is acceptable controller agent for classes B, C, and D COPD. Additionally, there can be confusion about nebulizers being considered first line treatment per GOLD recommendations. Though GOLD recommendation for initiation of therapy recommends a class of agents and not a device type and they specifically recommend re-assessment of therapy.
Dr. Conroy:
That’s a really great point. I think our minds often assume inhalers as the first line but in fact, these recommendations are class-based, not device or delivery system-based. So, what are some of the most common side effects for nebulized LAMAs?
Dr. Abbas:
For the most part, these medications have limited systemic absorption, so their side effects are minimal, and they were comparable to those of placebo, or tiotropium in the randomized control trial. It should be relevant for me to mention here that the patient should be aware that nebulized LAMAs with the face mask can precipitate acute glaucoma, probably because of direct contact of solution with the eye.
Dr. Conroy:
Oh, that’s a great point. So, we definitely need to ensure a really good ophthalmologic history when considering prescribing nebulized LAMAs for our patients.
For those just tuning in, you’re listening to ReachMD. I’m Dr. Megan Conroy and today I’m speaking with Dr. Farrukh Abbas about nebulized LAMAs. Now that we’ve considered guideline recommendations and side effects, let’s switch our focus to barriers to use. What are some common concerns patients have when it comes to switching to a nebulized LAMA? And what are some ways that we can help to reduce patient hesitancy regarding nebulized LAMAs?
Dr. Abbas:
That’s a really good question. Patient and provider may be unaware that more classes of inhaled medications are now available in nebulized form. LAMAs are the most recent class to include a nebulized form with two medications: glycopyrrolate and revefenacin, approved by FDA as recently as 2017 and then 2018. Both these medications can improve lung function and can reduce hospitalization in patients with COPD. These medications are particularly helpful to severe COPD patients with low peak inspiratory flow and for these patients, the aerosolized medication is the most appropriate to ensure the optimal drug delivery. In my personal experience, many of my severe COPD patients experience a significant benefit with reduction in hospitalization and better symptom control when I switch them from inhaled to nebulized therapy. For many of these patients, use of aerosolized medications can also help reduce the need to use multiple types of devices, which many of my patients actually like.
Dr. Conroy:
Can we briefly turn our attention to inhaler technique, how does the use of nebulized LAMAs reduce the risks that come with poor inhaler technique? That’s, kind of, in those patients, even for those who are not those end-stagers with very low inspiratory flow.
Dr. Abbas:
I believe higher cost of nebulized LAMAs could be a concern. Though the price of nebulized LAMA is actually twice than that of inhaled LAMAs. But we also know that the uncontrolled COPD is associated with significant economic burden with exacerbation accounting for the greatest portion of the total burden of our healthcare system. So, nebulized LAMAs when used for appropriate patient population can probably lower the overall cost.
Dr. Conroy:
That’s a great point. So, improved outcomes by being able to improve delivery of the drugs with a nebulizer. Before we close, Dr. Abbas, do you have any takeaways that you’d like to share with our listeners?
Dr. Abbas:
To summarize, I would say about two-thirds of patients make an error when using an inhaler device. GOLD recommendations include a class of therapy rather than type of device. LAMA nebulizers can help reduce hospitalizations, improve lung function, and ultimately improve patient outcomes when used in appropriate patient population, particularly in patients with low peak inspiratory flow and patients who are unable to use inhalers with correct technique.
Dr. Conroy:
Great information on the use of nebulized LAMAs for patients with moderate-to-severe COPD. And with those considerations in mind, I’d like to thank my guest, Dr. Farrukh Abbas, for helping us to better understand the use of nebulized LAMAs for COPD. Dr. Abbas, it was great speaking with you today.
Dr. Abbas:
Thank you for letting me talk about this important topic.
Dr. Conroy:
I’m Dr. Megan Conroy, thank you for listening.
Announcer:
This episode of Deep Breaths: Updates from CHEST was produced in partnership with the American College of Chest Physicians. To access other episodes of this series, visit ReachMD.com/CHEST, where you can Be Part of the Knowledge.
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