COPD: An Individualized Approach to Medication and Delivery - Episode 9
Peter Salgo, MD: Nebulizers versus various other hand-held devices—is there a distinction? Do patients do better with one? Do they do better with the other?
Byron Thomashow, MD: Many patients like nebulizers. They’re very simple to use. You don’t have to go through the hand dexterity issues. Until literally a couple of months ago, there was no nebulized LAMA [long-acting muscarinic antagonist] available. At this point in time, LAMAs are the mainstay of therapy, They are generally combined, but are certainly the mainstay of therapy. The problem, even now that we have a nebulized LAMA, is that, as you’ve heard, chronic obstructive pulmonary disease management is more than 1 thing. We don’t still know whether you can mix that LAMA with a LABA [long-acting beta-agonist]. We don’t know whether we can mix the LAMA, and the LABA, and the steroid in the same nebulizer. Until we’ve defined those issues, nebulizer therapy for COPD will still not be the primary mode of therapy, because we can’t deliver the group of medicines that we want.
Antonio Anzueto, MD: It’s limited for patients who have reasons—mentally, physically. They’re the ones who are primarily getting nebulizers.
Peter Salgo, MD: It also occurs to me that it’s harder to get on an airplane, carry these things around, and plug them in. Yes?
James F. Donohue, MD: Well, we can take oxygen on the airplane. We have the POC—portable oxygen concentrator. That was a big effort that was led by the pulmonary community, a few years back. So, yes, you can use them. The small ones have not been approved, until now. We have a LAMA with an eFlow, which is a low-volume type of device.
Peter Salgo, MD: Does it make a difference, in terms of patient adherence—a nebulizer versus another delivery system? Do patients like one versus another?
Barbara P. Yawn, MD, MSc, FAAFP: Well, I think a lot of patients will tell you they really like a nebulizer. They want a nebulizer. But, if they’re using one of the older nebulizers, that’s 10 to 15 minutes per drug. Suppose they have 3 different drugs. That’s 30 to 60 minutes to take your medicine. Can you take them with you? Well, maybe you can, on the airplane. But, how about for rescue therapy? If you need a quick reliever, it’s not so easy, at the grocery store, to pull out a nebulizer and use it. So many people are going to need to have both, including an MDI [metered-dose inhaler], because that’s what most of the rescuers, short-acting, are. And if they need a nebulizer, this is fine at home. But, it also takes some effort to put the medication into the nebulizer. So, someone that’s got cognitive impairment is going to need support, whether they need a nebulizer or another device.
Peter Salgo, MD: Do the insurance companies like nebulizers, or do they like the other devices?
James F. Donohue, MD: Nebulizers, because of Medicare, under Part B and D. They’re paid for by Medicare. We call that, at times, Medicare Advair, for example. That would be a long-acting eformoterol plus budesonide, which is compounded. Or, you could use the pediatric .25. So, we do a lot of that. We didn’t have the LAMA. As Byron just mentioned, we’re going to have 2 of those coming. One will be in a new nebulizer—one of the ultra-efficient ones. But, we don’t know how that will work out. So, the main reason that I use those nebulized drugs is based on economic reasons. Now, the severe is all the of the things that Barbara mentioned with a caregiver, at times—cognitive impairment. The other thing is that for the nebulizer, all you have to do is tidal volume breathing. To get a dry powder, as I mentioned, you have to have a really big peak inspiratory flow rate. It takes training to use the MDI with a spacer. And the Respimat, once you figure out how to do it, is very easy.
Antonio Anzueto, MD: It’s a great system.
James F. Donohue, MD: It’s highly desired by the patient.
Peter Salgo, MD: Do we have data as to patient outcomes—nebulizers versus other hand-held devices?
James F. Donohue, MD: The meta-analysis is from 2005 and 2007, and they’re all the same. That was the basis of that initial report, from the American College of Chest Physicians, Peter. But, again, we need to individualize the therapies that we’ve been hearing about all the way through, in their own environment. Some people will clearly do well with it. Plus, the cost factor.
Byron Thomashow, MD: I think that’s actually true. My only issue with the nebulizer, first of all, is that everybody is an individual. You need to define therapy for the individual patient. But, the problem, to date, is that we still don’t know about mixing these things together. That leads to Barbara’s concerns about 2 hours of nebulizer use per day, which is not practical. Once we have newer agents and data showing that you can mix them safely, and that they’re effective together, safely, that will change some of these things.
Peter Salgo, MD: So, you make 1 cocktail (one therapy) burst, and then you’re done?
Byron Thomashow, MD: Sort of like the coffee pot system, right? You wake up in the morning and you say, “This is the day that I want the combination.” You put your combination in, unless Jim knows more than me?
James F. Donohue, MD: No. This is funny. When I was in India, I asked them why they invited me. It turns out that I think I was involved in the development of the 7 nebulized therapies that are out there for COPD, going way back. I’m old enough to have been on the original ipratropium. But, Byron is exactly right. A lot of companies try to get by the patent rights by altering the formulation, just a twitch, for drugs like albuterol and formoterol. Exactly as Byron says, we consider the osmolality changes, the tonality changes, and you might have an ineffective product or a harmful product. So, it’s a serious issue. There is no research. Because it takes 30 minutes, if you’re taking 3 drugs, you’re tempted to throw them all in a soup and then give it. But, you don’t know what you’re giving.
Antonio Anzueto, MD: Peter, your original question was, do we have data to determine whether one is better than another. The answer is, no. You cannot compare. These are apples and oranges. Even though you read through the meta-analysis, who are the people who were nebulized, who were mentally impaired, and who were incapable? We need to go back to identify, “Well, these patients will benefit from nebulized therapy. This patient is more active. The patient is more ambulatory.” We can give many of the other devices that we have, today.
Barbara P. Yawn, MD, MSc, FAAFP: Why don’t we just give a quick warning on what to watch out for with a couple of the new nebulizers? They are only indicated for 1 drug. You have to be very careful. Not only would you have to spend 30 minutes, you may have to have 2 or 3 nebulizers, and that’s not practical.
Peter Salgo, MD: I was asking about that before. There are different kinds of nebulizers, right? There’s the ultrasonic, there’s the compressor, and something called a mesh nebulizer. So, not only do you have to deal with the other issues that we’ve discussed, but you’ve got to use the right nebulizer. And now you’re telling me that some of the drugs are incompatible with some of the nebulizers?
Barbara P. Yawn, MD, MSc, FAAFP: Right.
Peter Salgo, MD: Oh, that’s just great.
Barbara P. Yawn, MD, MSc, FAAFP: Yes. I think it’s the reason that primary care frequently asks, “Pulmonologists, would you like to help us? We don’t know what’s going on.”
James F. Donohue, MD: This is so important. Really, to have the ‘keep it simple’ commentary, you’d like to have 1 type of dry powder inhaler for everything. It cuts down on teaching time. However, glycopyrrolate will come with an eFlow. It feels like cystic fibrosis, though. Each new inhaled antibiotic, and other different drugs that have been developed, all come with their own delivery system. It becomes very, very expensive, and extremely difficult. But, the thing that’s interesting is that the field is changing rapidly. There’s a revolution. Antonio has talked greatly about inhaled antibiotics, in the intensive care unit, with ventilator-associated pneumonia. So, the field is going to be very, very wide, with antibiotics, in particular, and other types of inhaled therapies for the field of COPD. And they’ll all have their own devices.
Transcript edited for clarity.