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Running on empty
Guest editorial
Running on empty Inhaled medicines are the cornerstone of our therapeutic repertoire for the treatment of asthma. In this month’s issue of the Annals, Sander et al1 reinforce the need for some healthy skepticism regarding asthmatic patients’ use of their inhaled medicines. In their random sample telephone interview of 500 asthmatic families across the United States, several important issues come to the light. As demonstrated in prior publications, the authors note that a significant number of asthmatic patients over-rely on their short-acting -agonists.2,3 Another important issue that is highlighted through this survey (which should come as no surprise) is that most -agonist pressurized metered-dose inhaler (pMDI) users do not keep track of the amount of medication still available in the device. This issue may have significant sequelae, because the authors found that 25% of the 2-agonist pMDI users reported that their inhaler was found to be empty during an asthma exacerbation, with 7 subjects reporting a need to call 911 as a consequence. Also, most (nearly 82%) of the subjects considered their pMDI empty only after noting that nothing further came out of their inhaler. Relying on this technique for determining when an inhaler is empty is flawed, because manufacturers provide 20% to 80% extra doses of propellant after all the medication has been consumed.4 – 6 This report adds to an extensive volume of literature regarding lack of inhaler knowledge among asthmatic patients. Many reports have demonstrated the utility of pMDI for delivering both -agonists and corticosteroids. Studies throughout the world have demonstrated improved morbidity and mortality with regular use of inhaled corticosteroids and the utility of -agonist therapy by pMDI during acute asthma exacerbations.7–12 Balancing this has been a growing literature demonstrating that in the “real world” asthmatic patients demonstrate a frightening lack of knowledge regarding proper use of inhalers and are consistently underusing their inhaled corticosteroid and overusing their rescue -agonist inhalers.13–18 Both these patient practice patterns have been associated with an increase in morbidity and mortality.8,19,20 When considering the issue of compliance, one must separate intentional from nonintentional noncompliance. In the case of inhaler therapy, nonintentional noncompliance may be a result of lack of knowledge regarding inhaler use, specifically when it is empty. Although data derived from electronic dose counters demonstrate that a significant component of inhaler underuse (when examining inhaled corticosteroid use) is intentional noncompliance, one might postulate that at least some of the glaring underuse of inhaled corticosteroids demonstrated by pharmacy refill data may be due to use of an empty inhaler.21–24 As discussed by Sander et
VOLUME 97, JULY, 2006
al, no reliable method beyond counting doses is available for multidose inhaled medicines that are not equipped with dose counters. Although floating pMDIs had been advocated in the past, several recent studies have demonstrated the lack of reliability and potential for valve obstruction as a result of this technique.6,25–27 Thus, the authors’ conclusion that manufacturers of inhaled medicines include dose counters as a standard feature on every multidose inhaler device appears reasonable. Otherwise, our patients are left to question whether their inhaler device is “running on empty.” JOHN OPPENHEIMER, MD University of Medicine and Dentistry of New Jersey Newark, New Jersey REFERENCES 1. Sander N, Fusco-Walker SJ, McElvain JM, Chipps B. Dose counting and the use of pressurized metered-dose inhalers: running on empty. Ann Allergy Asthma Immunol. 2006;97: 34 –38. 2. Campbell D, Luke CG, McLennan G, et al. Near-fatal asthma in South Australia: descriptive features and medication use. Aust N Z J Med. 1996;26:356 –362. 3. Anis AH, Lynd LD, Wang XH, et al. Double trouble: impact of inappropriate use of asthma medication on the use of health care resources. CMAJ. 2001;164:625– 631. 4. Rubin BK, Durotoye L. How do patients determine that their metered-dose inhaler is empty? Chest. 2004;126:1134 –1137. 5. Weinstein AG. When should your asthma patients refill their MDI propelled with chlorofluorocarbons? Del Med J. 1998;70: 293–297. 6. Cain WT, Oppenheimer JJ. The misconception of using floating patterns as an accurate means of measuring the contents of metered-dose inhaler devices. Ann Allergy Asthma Immunol. 2001;87:417– 419. 7. Speizer FE, Doll R, Heaf P, Strang LB. Investigation into use of drugs preceding death from asthma. BMJ. 1968;1:339 –343. 8. Spitzer WO, Suissa S, Ernst P, et al. The use of -agonists and the risk of death and near death from asthma. N Engl J Med. 1992;326:501–506. 9. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk for hospitalization for asthma. JAMA. 1997;277:887– 891. 10. Ernst P, Spitzer WO, Suissa S, et al. Risk of fatal and near-fatal asthma in relation to inhaled corticosteroid use. JAMA. 1992; 268:3462–3464. 11. Suissa S, Ernst P, Benayoun S, et al. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000;343:332–336. 12. Raimondi AC, Schottlender J, Lombardi D, Molfino NA. Treatment of acute severe asthma with inhaled albuterol delivered via
1
13. 14.
15.
16.
17. 18.
19.
2
jet nebulizer, metered dose inhaler with spacer, or dry powder. Chest. 1997;112:24 –28. Hilton S. An audit of inhaler technique among asthma patients of 34 general practitioners. Br J Gen Pract. 1990;40:505–506. Pedersen S, Frost L, Arnfred T. Errors in inhalation technique and efficiency in inhaler use in asthmatic children. Allergy. 1986;41:118 –124. Nimmo CJ, Reesor D, Chen NM, et al. Assessment of patient acceptance and inhalation technique of a pressurized aerosol inhaler and two breath-actuated devices. Ann Pharmacother. 1993;27:922–927. Goodman D, Israel E, Rosenberg M, et al. The influence of age, diagnosis, and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med. 1994;150:1256 –1261. Cochrane MG, Bala M, Downs KE, et al. Inhaled corticosteroids for asthma therapy. Chest. 2000;117:542–550. Rabe KF, Adachi M, Lai CW. Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys. J Allergy Clin Immunol. 2004; 114:40 – 47. Goldman M, Rachmiel M, Gendler L, Katz Y, et al. Decrease in asthma mortality rate in Israel from 1991–1995: is it related to
20. 21. 22. 23. 24. 25. 26. 27.
increased use of inhaled corticosteroids? J Allergy Clin Immunol. 2000;105:71–74. Gerdtham U, Hertzman P, Jonsson B, Boman G. Impact of inhaled corticosteroids on acute asthma hospitalization in Sweden: 1978 to 1991. Med Care. 1996;34:1188 –1198. Rand CS, Nides M, Cowles MK, Wise RA, Conet J. Long-term metered-dose inhaler adherence in a clinical trial. Am J Respir Crit Care Med. 1995;152:580 –588. Simmons MS, Nides MA, Rand CS, et al. Unpredictability of deception in compliance with physician-prescribed bronchodilator inhaler: use in a clinical trial. Chest. 2000;118:290 –295. Kelloway JS, Wyatt R, Adlis SA. Comparison of patients’ compliance with prescribed oral and inhaled asthma medications. Arch Intern Med. 1994;154:1349 –1352. Cochrane GM, Horne R, Chanez P. Compliance in asthma. Respir Med. 1999;93:763–769. Wolf BL, Cochran KR. Floating patterns of metered dose inhalers J Asthma. 1997;34:433– 436. Brock TP, Wessell AM, Williams DM, Donohue JF. Accuracy of float testing for metered-dose inhaler canisters. J Am Pharm Assoc. 2002;42:582–586. Williams DJ, Williams AC, Kruckek DG. Problems in assessing the contents of metered-dose inhalers. BMJ. 1993;307:771–772.
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Running on empty Inhaled medicines are the cornerstone of our therapeutic repertoire for the treatment of asthma. In this month’s issue of the Annals, Sander et al1 reinforce the need for some healthy skepticism regarding asthmatic patients’ use of their inhaled medicines. In their random sample telephone interview of 500 asthmatic families across the United States, several important issues come to the light. As demonstrated in prior publications, the authors note that a significant number of asthmatic patients over-rely on their short-acting -agonists.2,3 Another important issue that is highlighted through this survey (which should come as no surprise) is that most -agonist pressurized metered-dose inhaler (pMDI) users do not keep track of the amount of medication still available in the device. This issue may have significant sequelae, because the authors found that 25% of the 2-agonist pMDI users reported that their inhaler was found to be empty during an asthma exacerbation, with 7 subjects reporting a need to call 911 as a consequence. Also, most (nearly 82%) of the subjects considered their pMDI empty only after noting that nothing further came out of their inhaler. Relying on this technique for determining when an inhaler is empty is flawed, because manufacturers provide 20% to 80% extra doses of propellant after all the medication has been consumed.4 – 6 This report adds to an extensive volume of literature regarding lack of inhaler knowledge among asthmatic patients. Many reports have demonstrated the utility of pMDI for delivering both -agonists and corticosteroids. Studies throughout the world have demonstrated improved morbidity and mortality with regular use of inhaled corticosteroids and the utility of -agonist therapy by pMDI during acute asthma exacerbations.7–12 Balancing this has been a growing literature demonstrating that in the “real world” asthmatic patients demonstrate a frightening lack of knowledge regarding proper use of inhalers and are consistently underusing their inhaled corticosteroid and overusing their rescue -agonist inhalers.13–18 Both these patient practice patterns have been associated with an increase in morbidity and mortality.8,19,20 When considering the issue of compliance, one must separate intentional from nonintentional noncompliance. In the case of inhaler therapy, nonintentional noncompliance may be a result of lack of knowledge regarding inhaler use, specifically when it is empty. Although data derived from electronic dose counters demonstrate that a significant component of inhaler underuse (when examining inhaled corticosteroid use) is intentional noncompliance, one might postulate that at least some of the glaring underuse of inhaled corticosteroids demonstrated by pharmacy refill data may be due to use of an empty inhaler.21–24 As discussed by Sander et
VOLUME 97, JULY, 2006
al, no reliable method beyond counting doses is available for multidose inhaled medicines that are not equipped with dose counters. Although floating pMDIs had been advocated in the past, several recent studies have demonstrated the lack of reliability and potential for valve obstruction as a result of this technique.6,25–27 Thus, the authors’ conclusion that manufacturers of inhaled medicines include dose counters as a standard feature on every multidose inhaler device appears reasonable. Otherwise, our patients are left to question whether their inhaler device is “running on empty.” JOHN OPPENHEIMER, MD University of Medicine and Dentistry of New Jersey Newark, New Jersey REFERENCES 1. Sander N, Fusco-Walker SJ, McElvain JM, Chipps B. Dose counting and the use of pressurized metered-dose inhalers: running on empty. Ann Allergy Asthma Immunol. 2006;97: 34 –38. 2. Campbell D, Luke CG, McLennan G, et al. Near-fatal asthma in South Australia: descriptive features and medication use. Aust N Z J Med. 1996;26:356 –362. 3. Anis AH, Lynd LD, Wang XH, et al. Double trouble: impact of inappropriate use of asthma medication on the use of health care resources. CMAJ. 2001;164:625– 631. 4. Rubin BK, Durotoye L. How do patients determine that their metered-dose inhaler is empty? Chest. 2004;126:1134 –1137. 5. Weinstein AG. When should your asthma patients refill their MDI propelled with chlorofluorocarbons? Del Med J. 1998;70: 293–297. 6. Cain WT, Oppenheimer JJ. The misconception of using floating patterns as an accurate means of measuring the contents of metered-dose inhaler devices. Ann Allergy Asthma Immunol. 2001;87:417– 419. 7. Speizer FE, Doll R, Heaf P, Strang LB. Investigation into use of drugs preceding death from asthma. BMJ. 1968;1:339 –343. 8. Spitzer WO, Suissa S, Ernst P, et al. The use of -agonists and the risk of death and near death from asthma. N Engl J Med. 1992;326:501–506. 9. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk for hospitalization for asthma. JAMA. 1997;277:887– 891. 10. Ernst P, Spitzer WO, Suissa S, et al. Risk of fatal and near-fatal asthma in relation to inhaled corticosteroid use. JAMA. 1992; 268:3462–3464. 11. Suissa S, Ernst P, Benayoun S, et al. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000;343:332–336. 12. Raimondi AC, Schottlender J, Lombardi D, Molfino NA. Treatment of acute severe asthma with inhaled albuterol delivered via
1
13. 14.
15.
16.
17. 18.
19.
2
jet nebulizer, metered dose inhaler with spacer, or dry powder. Chest. 1997;112:24 –28. Hilton S. An audit of inhaler technique among asthma patients of 34 general practitioners. Br J Gen Pract. 1990;40:505–506. Pedersen S, Frost L, Arnfred T. Errors in inhalation technique and efficiency in inhaler use in asthmatic children. Allergy. 1986;41:118 –124. Nimmo CJ, Reesor D, Chen NM, et al. Assessment of patient acceptance and inhalation technique of a pressurized aerosol inhaler and two breath-actuated devices. Ann Pharmacother. 1993;27:922–927. Goodman D, Israel E, Rosenberg M, et al. The influence of age, diagnosis, and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med. 1994;150:1256 –1261. Cochrane MG, Bala M, Downs KE, et al. Inhaled corticosteroids for asthma therapy. Chest. 2000;117:542–550. Rabe KF, Adachi M, Lai CW. Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys. J Allergy Clin Immunol. 2004; 114:40 – 47. Goldman M, Rachmiel M, Gendler L, Katz Y, et al. Decrease in asthma mortality rate in Israel from 1991–1995: is it related to
20. 21. 22. 23. 24. 25. 26. 27.
increased use of inhaled corticosteroids? J Allergy Clin Immunol. 2000;105:71–74. Gerdtham U, Hertzman P, Jonsson B, Boman G. Impact of inhaled corticosteroids on acute asthma hospitalization in Sweden: 1978 to 1991. Med Care. 1996;34:1188 –1198. Rand CS, Nides M, Cowles MK, Wise RA, Conet J. Long-term metered-dose inhaler adherence in a clinical trial. Am J Respir Crit Care Med. 1995;152:580 –588. Simmons MS, Nides MA, Rand CS, et al. Unpredictability of deception in compliance with physician-prescribed bronchodilator inhaler: use in a clinical trial. Chest. 2000;118:290 –295. Kelloway JS, Wyatt R, Adlis SA. Comparison of patients’ compliance with prescribed oral and inhaled asthma medications. Arch Intern Med. 1994;154:1349 –1352. Cochrane GM, Horne R, Chanez P. Compliance in asthma. Respir Med. 1999;93:763–769. Wolf BL, Cochran KR. Floating patterns of metered dose inhalers J Asthma. 1997;34:433– 436. Brock TP, Wessell AM, Williams DM, Donohue JF. Accuracy of float testing for metered-dose inhaler canisters. J Am Pharm Assoc. 2002;42:582–586. Williams DJ, Williams AC, Kruckek DG. Problems in assessing the contents of metered-dose inhalers. BMJ. 1993;307:771–772.
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY