Challenges in Transitioning to Powder Inhalers

The management of conditions such as asthma and chronic obstructive pulmonary disease (COPD) typically requires the long-term use of inhaled medications. A common treatment strategy involves a fixed combination of a beta-2 agonist, which acts as a bronchodilator, and a glucocorticoid, serving as an anti-inflammatory agent. While metered-dose inhalers (MDIs) are known for their ease of use, they fall short in terms of environmental sustainability compared to dry powder inhalers (DPIs).

In an effort to promote eco-friendliness, both Germany, which has established a guideline for 'climate-conscious prescribing of inhaled medications', and international bodies are aiming to transition patients from MDIs to DPIs. A notable shift occurred in July 2021 when the Veterans Health Administration (VHA) in the United States modified its approach. From then on, veterans suffering from asthma or COPD were preferentially provided with a DPI containing fluticasone and salmeterol, replacing the previously standard MDI with budesonide/formoterol.

This change affected thousands of patients, and a recent study led by researchers from the University of Michigan highlights the complications arising from this transition. Published in the journal JAMA Internal Medicine, the study analyzed data from over 260,000 VHA beneficiaries who switched from an MDI to a DPI.

Following this switch, researchers observed significant increases in indicators suggesting a decline in respiratory condition management. Notably, the use of rescue inhalers containing the fast-acting bronchodilator salbutamol rose by 10%, and prescriptions for prednisone increased by 2%. Additionally, there was a 5% rise in emergency room visits, with hospitalizations rising by 8% overall. Specifically, hospitalizations related to respiratory issues climbed by 10%, and those due to pneumonia saw a staggering increase of 24%.

In a comparative analysis, the researchers evaluated outcomes for the 258,557 patients who did not switch to DPIs, assessing the first 180 days post-transition. While there was no increase in mortality risk among those who switched, slight disadvantages were noted in hospitalization rates. For instance, 16.14% of the switched patients required hospitalization for any cause compared to 15.64% of those who remained on MDIs. Furthermore, 3.15% of the switched group were hospitalized due to respiratory conditions, versus 2.74% in the non-switched group, and pneumonia-related hospitalizations were slightly elevated as well (1.15% vs. 1.03%).

This data underscores the complexities involved in transitioning patients to new medication delivery systems, emphasizing the necessity for thorough patient education and support during such changes.