A Review of Inhaler Products

Jillian Dougherty
University of Rhode Island

PharmD Candidate 2014
 I have no financial obligations to disclose.
 To identify common inhaler products
 To describe available combination products
 To reproduce appropriate inhaler techniques
 To name important counseling points regarding inhaler

therapy
 Part One: Categories of inhaler products
 Common inhaler products
 Side effects
 Dosing
 Counseling points
 Part Two: Inhaler administration & techniques

 Signs of improper technique
 Inhalers by delivery system
 Administration technique
 Short Acting β2 Agonists (SAβ2A)
 Long Acting β2 Agonists (LAβ2A)
 Anticholinergics (ICA)
 Inhaled Corticosteroids (ICS)
 Combination
 ICS + LAβ2A
 ICA + SAβ2A
Micromedex® Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
Accessed December 20, 2013.
Albuterol HFA Albuterol Inhalation Solution
Levalbuterol HFA Levalbuterol Inhalation Solution
Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2013. URL: http://cp.gsm.com. Updated February 2013.
 Albuterol
 50:50 racemic mixture of R-albuterol (levalbuterol) and S-
albuterol
 Levalbuterol developed based on rationale that
levalbuterol would have:
 Less tachycardia
 Better tolerability
 Similar or greater efficacy
 Levalbuterol is associated with lower mean heart rate
 Little difference vs. albuterol
 Levalbuterol associated with higher cost
Ameredes BT, Calhoun WJ. Levalbuterol versus albuterol. Curr Allergy Asthma Rep. 2009;9:401-409.
• Anxiety
• Racing Heart/Palpitations
• Headache
• Restlessness
• Insomnia
• Nervousness & Tremors
• Chest Pain
• Throat irritation
• Rhinitis
Brand Generic Indication Dosage
Acute Exacerbation
• 4-8 inh q 20 mins up to 4 hours,
then q1-4h PRN
Proair HFA,
albuterol Asthma; Bronchospasm
Proventil HFA,
sulfate EIA PPx • 2 inh q4-6 (or 1 inh q4 PRN)
Ventolin HFA
EIA
• 2 inh 15 to 30 mins prior to
exercise
Acute Exacerbation
• 4-8 inh every 20 min up to 4
levalbuterol hours, then every 1 to 4 hr prn
Xopenex HFA Asthma
tartrate Bronchospasm
• 2 inh q4-6 PRN (may only need 1
q4 PRN)
“Rescue Inhaler” – use for Instruct patient to prime
ACUTE attacks inhaler when:
• First time
• Inhaler has not been used
for > 3 days
Instruct patient to report Wash & dry mouthpiece once
increased use a week
Concomitant ALL asthma/COPD patients

caffeine/stimulants may should have a SAβ2A
increase SEs
Serevent Diskus Foradil Aerolizer
 Increased HR
 Nervousness
 Headache
 Sleeplessness
 Palpitations
 Tremor, shaking feeling
 Nausea & Vomiting
 Hoarseness
 Coughing
Asthma;
Serevent salmeterol One inhalation (50mcg) by
EIA PPx;
Diskus xinafoate mouth twice daily
COPD
Asthma;
Foradil formoterol One capsule every 12 hours
COPD;
Aerolizer fumarate via oral inhalation
EIA PPx
NOT for acute attacks Avoid other LAβ2A
Instruct patient to report Formoterol only:

increased asthma • Warn patient that the
exacerbations drug capsules must not
be swallowed
Patient should not exceed

recommended dose
Flovent HFA Pulmicort Flexhaler
Pulmicort Respules Asmanex Twisthaler
 Common:  Severe:
 Cough  Creamy white patches in
 Nose Bleeds mouth
 Hoarseness  Fast/pounding heartbeat
 Throat Irritation  Puffy Face
 Headache  Skin Rash
 Dry Mouth  Wheezing
 Other Systemic Effects
 Weight gain, fatigue, muscle
weakness
 Cataracts
 Reduced bone mineral
density
Flovent HFA Starting dose dependent on

fluticasone
(44/110/220 Asthma prior therapy with:
propionate
mcg) bronchodilators, ICS, oral CS
Pulmicort
budesonide Asthma 2 inhalations BID
Flexhaler
Asmanex Starting dose dependent on

mometasone Asthma;
(30/60/120 prior therapy with:
furoate Allergic rhinitis
doses/unit) bronchodilators, ICS, oral CS
beclomethasone Asthma;
Qvar 40 to 160 mcg BID
dipropionate Rhinitis
NOT for acute attacks Diabetic patients should
report any difficulties with
glycemic control
Avoid exposure to Do NOT discontinue

chickenpox & measles without speaking with
healthcare professional
Report any signs of

infection
Ipratropium
Spiriva Handihaler
 May increase wheezing for some patients
 Hypersensitivity reactions
 Dry mouth
 Blurred vision
 Sinusitis
ipratropium
Atrovent HFA COPD 2 inhalations QID
bromide
Spiriva tiotropium 1 capsule (18 mcg) via 2 oral

COPD
Handihaler bromide inhalations once daily
NOT for acute attacks Increase water intake
Avoid activities requiring If paradoxical

balance/visual acuity bronchospasm occurs,
until drug effects are stop drug & contact
realized healthcare professional
Use saline eye lubricants

as needed
Combination Medications Agents
fluticasone propionate/
Advair Diskus
salmeterol xinafoate
ICS
budesonide/
+ Symbicort
formoterol fumarate
LABA
mometasone
Dulera
furoate/formoterol fumarate
Combivent ipratropium bromide/

Anticholinergic Respimat albuterol sulfate
+
SABA ipratropium bromide/
Duonebs
albuterol sulfate
 Increased use/refills of rescue inhalers
 +/- use of daily long term controller
 Lack of symptom improvement
 Increased frequency of attacks/exacerbations
 Possible language/literacy barriers

 Different patient definitions of “long term controller” vs.
“rescue medication”
 Improper technique demonstrated by patient

Al-Jahdali H, Ahmed A, Al-Harbi A, et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department
visits. Allergy Asthma Clin Immunol. 2013 Mar 6;9(1):8.
 Language/Literacy Barriers
 Age
 Dexterity
 Inspiratory capacity/rate
 Hand-Lung Coordination
1. Al-Jahdali H, Ahmed A, Al-Harbi A, et al. Improper inhaler technique is associated with poor asthma control and frequent emergency
department visits. Allergy Asthma Clin Immunol. 2013 Mar 6;9(1):8.
2. “How to Use Inhalers.” Saralsoft LLC. Accessed December 22, 2013. Available at: http://use-inhalers.com.
 Metered Dose Inhalers (MDIs)
 Dry Powder Inhalers (DPIs)
 Twisthaler
 Flexhaler
 Handihaler
 Diskus Inhalers
 Respimat Soft Mist Inhaler
 Nebules
• Pressurized canister that fits into mouthpiece
• Medication is usually released by pushing down canister
• Some, but not all, count down the number of puffs, so

patient knows when empty
• Can be used with a spacer – makes it easier for patient to

inhale
“How to Use Inhalers.” Saralsoft LLC. Accessed December 22, 2013. Available at: http://use-inhalers.com.
 Benefits:  Cleaning Your Spacer
 Hollow tube that attaches  Take the spacer apart.
to inhaler  Move parts in warm water
 Slows delivery of using a mild soap.
medication  Do not use high-pressure
 Less medication deposited or boiling hot water,
in mouth/throat rubbing alcohol or
disinfectant.
 More medication reaches  Rinse the parts well in
the lungs clean water.
 Easier to coordinate  Do not dry inside of the
breathing in and spacer with a towel.
activating the MDI
 Instead, let the parts air
dry.
 Put the spacer back
together.
“How to use an inhaler – with spacer” National Library of Medicine – Medline Plus. Accessed December 22, 2013. Available at:
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000042.htm.
 Important points to remember:
 Only use spacer with MDI NOT with DPIs
 Breathe in as soon as the patient sprays a puff into
spacer
 RX is required for spacer
 Keep the spacer away from heat
 If there is any damage to spacer – do NOT use
 Whistling sound = too fast
 Only use 1 puff at a time
“How to use an inhaler – with spacer” National Library of Medicine – Medline Plus. Accessed December 22, 2013. Available at:
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000042.htm.
 Important to Remember:
 Requires patients to actively breathe in the medication, rather
than canister propulsion
Spiriva HandiHaler package insert. Pfizer and Boehringer Ingelheim Pharmaceuticals. 2013.
• NEVER swallow capsules
• Capsules must be stored in blister packs until

ready to use
• Clean device as needed

• wait 24 hours to dry
Spiriva HandiHaler package insert. Pfizer and Boehringer Ingelheim Pharmaceuticals. 2013.
Pulmicort Flexhaler package insert. Aztra Zeneca; Wilmington, DE. 2010.
• Dose indicator on barrel
• Red mark = 20 doses left

• As soon as you see the red mark, refill your prescription
• When the “0” appears in the dose indicator window, throw

away the Flexhaler and start a new one
• Keep the Flexhaler closed when not in use & store the
Flexhaler in a cool dry, place
• If the mouthpiece gets dirty, wipe it with a cloth
Pulmicort Flexhaler package insert. Aztra Zeneca; Wilmington, DE. 2010.

Asmanex Twisthaler package insert. Merck & Co., Inc.; Whitehouse Station, NJ. January 2013.
• Can only properly load medicine by twisting cap
• Keep the cap on the inhaler when not in use
• “01” in dose indicator = one dose remaining
• When counter reads “00” the pink base will lock
• Throw away inhaler after 45 days or when “00”
• Store the Twisthaler in a cool, dry place. If the

mouthpiece gets dirty, wipe it with a cloth
Asmanex Twisthaler package insert. Merck & Co., Inc.; Whitehouse Station, NJ. January 2013.
1. Advair Diskus package insert. GlaxoSmithKline; Research Triangle Park, NC. January 2011.
2. Serevent Diskus package insert. GlaxoSmithKline; Research Triangle Park, NC. December 2010.
• Doses 5 through zero = Red Zone
• Refill inhaler
• “0” in dose window = discard and start new

Diskus
• Keep the Diskus closed when not in use and

store the Diskus in a cool dry, place
• Keep the Diskus dry. If the mouthpiece gets

dirty, wipe it with a cloth
1. Advair Diskus package insert. GlaxoSmithKline; Research Triangle Park, NC. January 2011.
2. Serevent Diskus package insert. GlaxoSmithKline; Research Triangle Park, NC. December 2010.
Combivent Respimat package insert. Boehringer Ingelheim Pharmaceuticals, Inc.; Ridgefield, CT. August 2012.
• Inhaler requires assembly
• Do not remove cartridge after insertion
• Inhaler should last 30 days
• Pointer dose counter

• “Red zone” = 7 days left
• Write discard date on the label of the inhaler

• 3 months from the date the cartridge is inserted
“Nebulizer Use - Series” National Library of Medicine – Medline Plus. Accessed December 22, 2013. Available at:
http://www.nlm.nih.gov/medlineplus/ency/presentations/100201_1.htm.
 Place mouthpiece in your mouth
 Breathe slowly through your mouth until all the medicine is

used up (usually 10 to 15 minutes)
 Use nose clip to help mouth breathing
 Small children usually do better with mask
 Wash medicine cup and mouthpiece with water, and air dry
until next treatment
“Nebulizer Use - Series” National Library of Medicine – Medline Plus. Accessed December 22, 2013. Available at:
http://www.nlm.nih.gov/medlineplus/ency/presentations/100201_1.htm.
Metered Dose Dry Powder
MDI with Spacer
Inhaler (MDI) Inhaler (DPI)
Portability Yes Maybe No
Require
No Yes No
deep/fast breath
Exhalation
affecting delivery No Yes No
Throat
Yes Yes No
deposition
Maintenance
No No Yes
required
Dose counter Maybe Yes Maybe
Prime 4X away from face:
Proventil
1. Before first use
HFA 2. If inhaler has not been used for > 2 weeks
Prime against mouthpiece 2X:
Atrovent
1. Before first use
HFA 2. If inhaler has not been used for > 3 days
Prime by actuating toward ground 1x & when cloud visible actuate 3x:
Combivent 1. Before first use
Respimat 2. If Inhaler has not been used for >21 days
*If not used for > 3 days then actuate inhaler once
Prime 4X away from face:
Xopenex
1. Before first use
HFA 2. If inhaler has not been used for > 3 days
Prime 2X:
1. Before first use
Flovent HFA 2. If inhaler has not been used for > 7 days
3. If inhaler has been dropped
Pulmicort
Prime prior to first use ONLY
Flexhaler
 Wait 1 minute between multiple puffs/doses
 If a bronchodilator and maintenance medications are

prescribed
 Use bronchodilator first, wait 5 mins, then use
maintenance inhaler
 Always keep the protective cap on the inhaler when not

in use
 Store your inhaler in a clean plastic bag while
carrying it in your pocket or purse
 Store your inhaler in a cool, dry place

 Never in car
 Make sure your inhalers are not expired

 DO NOT try to float inhaler to see # of doses left
Jillian Dougherty
University of Rhode Island
PharmD Candidate 2014

A Review of Inhaler Products

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

A Review of Inhaler Products

Uploaded by

Copyright:

Available Formats

Jillian Dougherty

University of Rhode Island

 To describe available combination products

 To reproduce appropriate inhaler techniques

 To name important counseling points regarding inhaler

 Part Two: Inhaler administration & techniques

 Long Acting β2 Agonists (LAβ2A)

 Inhaled Corticosteroids (ICS)

Levalbuterol HFA Levalbuterol Inhalation Solution

Concomitant ALL asthma/COPD patients

Instruct patient to report Formoterol only:

Patient should not exceed

Pulmicort Respules Asmanex Twisthaler

Flovent HFA Starting dose dependent on

Asmanex Starting dose dependent on

Avoid exposure to Do NOT discontinue

Report any signs of

Spiriva tiotropium 1 capsule (18 mcg) via 2 oral

Avoid activities requiring If paradoxical

Use saline eye lubricants

Combivent ipratropium bromide/

 Lack of symptom improvement

 Increased frequency of attacks/exacerbations

 Possible language/literacy barriers

 Improper technique demonstrated by patient

• Medication is usually released by pushing down canister

• Some, but not all, count down the number of puffs, so

• Can be used with a spacer – makes it easier for patient to

• Capsules must be stored in blister packs until

• Clean device as needed

• Red mark = 20 doses left

• When the “0” appears in the dose indicator window, throw

• If the mouthpiece gets dirty, wipe it with a cloth

Pulmicort Flexhaler package insert. Aztra Zeneca; Wilmington, DE. 2010.

• “01” in dose indicator = one dose remaining

• When counter reads “00” the pink base will lock

• Throw away inhaler after 45 days or when “00”

• Store the Twisthaler in a cool, dry place. If the

• “0” in dose window = discard and start new

• Keep the Diskus closed when not in use and

• Keep the Diskus dry. If the mouthpiece gets

• Do not remove cartridge after insertion

• Inhaler should last 30 days

• Pointer dose counter

• Write discard date on the label of the inhaler

 Breathe slowly through your mouth until all the medicine is

 Use nose clip to help mouth breathing

 Small children usually do better with mask

 If a bronchodilator and maintenance medications are

 Always keep the protective cap on the inhaler when not

 Store your inhaler in a cool, dry place

 Make sure your inhalers are not expired

You might also like