COPD: An Individualized Approach to Medication and Delivery - Episode 8
Peter Salgo, MD: The poor primary care physician hears about all of these different devices. We’ve got the metered-dose inhaler (MDI), dry powder, soft mist. And then, we’ve got these devices versus nebulizers. So, parse this out for me.
James F. Donohue, MD: We have the different devices, and a very well-quoted meta-analysis (from many years ago), by Myrna Dolovich, that says they’re all pretty much the same. However, now, in an era of personalized medicine and phenotyping patients with studies, that’s not exactly true. Coming back to Barbara and my favorite topic, women have been really ignored in this dilemma. A lot of women of short stature cannot generate an adequate inspiratory flow to disperse the dry powder drug. They’re not getting it. So, we have to take patient factors into account—the severity, the social, economic, and what have you. For most people, who are reasonably healthy, it’s a toss-up between a dry powder, [an] MDI with a spacer, a Respimat, and you don’t need to go on. But, for those maybe cognitively impaired people, or people who are home bound with severe disease, you would consider the nebulizer. The nebulizer, with its multiple drugs, is paid for by Medicare, for that population. That’s an extra dimension that impacts it. So, you must use the right device.
The In-Check device hasn’t really come in to family medicine too much. The In-Check measures the peak inspiratory flow that the patient can deliver. Usually, you need about 60 liters to get the drug—a dry powder, like an Advair, Breo Ellipta, or Trilogy kind of device. It turns out that many, after an exacerbation, can’t do it. That’s one of the reasons for relapse. We’ve studied that in a number of centers. They are too weak. And the only reason I mentioned women is because of the height, again. They’re often the ones who have more difficulty and more severe conditions. So, we try to titrate or select the right device for the individual patient.
Peter Salgo, MD: There are different kinds of nebulizers, right?
James F. Donohue, MD: Correct.
Antonio Anzueto, MD: Before we talk about the nebulizers, I hate to spoil the party, we’ve got wonderful devices. We have reasons for adherence, with that. I don’t decide what device I give to my patient. It’s the payer. So, my patients who are on medication A get a letter. It says, “You’re switched to medication B.” Well, guess what? Medication B is a completely different delivery system.
James F. Donohue, MD: That’s right.
Antonio Anzueto, MD: Then, the patient comes back and says, “Listen, I hate this. I cannot breathe with this.” For me to get it back to medication A, it takes 2, 3 hours on the phone. Normally, I do that when I write my notes. But, it’s payers who are switching patients back and forth.
Byron Thomashow, MD: I can’t tell you how often that happens. And what’s really disturbing is that, often times, we’ll get a letter from the insurance saying, “That drug is not covered. Here is a list of compatible drugs.” A number of them are completely different classes of drugs. They’re not even the same drug. So, it’s not generic versus brand.
Peter Salgo, MD: Who’s drawing up the list? That raises an interesting question. Who says that they’re equivalent? Who’s drawing the list up?
Byron Thomashow, MD: It’s the formularies for the insurance companies. It’s increasingly an insurance company issue. I think we all agree that these medicines work. Everything that Jim said is absolutely correct. If you don’t know how to use your device, it’s worthless. And if they’re completely changing the device in between your visits, and they don’t know how to use it, it’s worthless.
Antonio Anzueto, MD: And, they get it in the mail. Many years ago, I had access to the Respimat delivery and I brought it to my group. They were smart pulmonology guys. They believed that they were very smart. I put it in the middle of the table and I said, “How does this work?” Nobody could figure it out.
So, my patients would get it in the mail. It’s a different delivery. Then, they would call. They would ask, “What am I supposed to do with this?” “I need to chew the pills?” “I need to do this?” This is the big challenge that we have today. There are no equivalent devices, so we have to emphasize education. “You’re going to get this medication, with this device, and this is what you have to do.”
Barbara P. Yawn, MD, MSc, FAAFP: With that particular device, you have to put it together and, “Do this.” The little trick that I was taught is to put on the prescription “AAP”—assemble, activate, and prime. The pharmacist is supposed to do that, because putting it together is not easy. We’ve all broken some of those devices by putting them together incorrectly. Our patient is not going to figure it out.
Peter Salgo, MD: I must tell you that my kids’ pediatrician, many years ago, said, “You’re going to use a nebulizer,” for reasons which we need not go into here. But, she sat down with me, knowing that I was a physician, anyway, and showed me how to set it up, assemble it, and prime it. It made a world of difference.
Barbara P. Yawn, MD, MSc, FAAFP: Oh, it makes a huge difference. In primary care, even for the ones that are not that complicated, teaching patients how to do inhaler technique is not part of many visits. And the other problem is, once you teach a patient, even if they’re lucky enough to get the same device for 3 or 4 months in a row, their technique will fall off. So, you have to review technique.
Transcript edited for clarity.