New Inhaled Therapy for 2021

If you’re the kind of person who breaks out in a cold sweat every time you hear someone say “have you seen the latest inhaler that’s just come out,” then you may wish to pause a moment, light some scented candles, turn on some soothing music, and take a deep breath.

This time last year we were running out of inhalers,1 and now we seem to be overrun by them. The good thing is that there are no extra devices for you to learn, just some extra combinations to provide another option for your people with Chronic Obstructive Pulmonary Disease (COPD) and asthma.

Atectura Breezhaler is a new inhaled corticosteroid (ICS) and long-acting B2 agonist (LABA) for asthma, marketed by Novartis. It contains the ICS mometasone, and the LABA indacaterol, which are perhaps less well known than others but still effective medicines. Atectura is a fixed-dose combination, meaning that you can’t increase and decrease the dose, as you can with formoterol-based combinations such as Symbicort and Fostair. However, it is available in three different strengths, which provides some flexibility in dosing, often an advantage in a variable condition such as asthma. It also lasts 24 hours so is only taken once a day, which might be an advantage to help with adherence for some. In this respect, you can think of it a little like Relvar, which is also a once-a-day fixed-dose combination. Atectura comes in the Breezhaler, which is a capsule Dry Powder Inhaler (DPI), which involves inserting the capsule in the device, squeezing a button to pierce the capsule, and then inhaling quickly and deeply2. Capsule inhalers may be a little on the old-fashioned side, but the Breezhaler requires a relatively low inspiratory flow rate compared to some DPIs, which may make it easier for some patients to inhale the powder out of the device. Personal feedback from COPD patients I have looked after who have used Ultibro Breezhaler has been very positive.

Novartis are more commonly known for marketing inhaled therapy for COPD. But as well as supplying Atectura, they have launched another asthma therapy in the form of Enerzair Breezhaler. This was publicised as being the first ICS/LABA/LAMA (long-acting muscarinic antagonist) triple therapy for asthma3 and is a much-welcomed addition to the fight to improve asthma control and reduce asthma deaths. Enerzair also comes with a ‘digital companion,’ a sensor that connects to an App, providing real-time data about inhaler use to both the patient and health professional. The idea is that it both reminds the patient to take their meds and provides information about treatment adherence. And no, I don’t know how much this costs, so I’ve dropped Novartis a line to find out more.

We will see an increasing number of digital aids for inhaler devices in the not too distant future. Whether they will improve asthma control and reduce asthma mortality can only be speculated.

The next new development in inhaled therapy comes from Trimbow, marketed by Chiesi, a triple LABA/LAMA/ICS previously for COPD, which has now been licensed for asthma. Two strengths are licensed for asthma; the higher strength licensed only for asthma, and the lower strength licensed for both asthma and COPD. All doses are two puffs twice a day via a Metered Dose Inhaler (MDI), and a spacer can also be used.

LAMA therapy was first licensed for asthma in the form of Spiriva Respimat, which you could add-on to existing ICS/LABA therapies. Now with Enerzair and Trimbow, you can prescribe LAMA with ICS and LABA in one device.

For people with COPD, AstraZeneca have launched their new LABA/LAMA, Bevespi Aerosphere, a combination of formoterol and glycopyrronium. The dose is two puffs twice a day via an MDI, which can be used with a spacer. It’s the first LABA/LAMA combination to come in a traditional MDI. Although Spiolto Respimat could be considered and MDI, the Respimat device looks and feels rather different to a traditional MDI, and the difference in operation is also not insignificant.

AstraZeneca have certainly had their oats over the past twelve months, producing not only a life-saving COVID vaccine, but also the second of two inhaled therapies for COPD. Again coming in an MDI, Trixeo Aerosphere is a LAMA/LABA/ICS combination of glycopyrronium, formoterol and budesonide – sort of Symbicort with a LAMA. The dose is two puffs twice a day via the MDI and a spacer can be used too, and at the moment it is not licensed for asthma. Trixeo is the third triple-therapy for COPD, and joins Trelegy and Trimbow. Which is best remains to be seen, and may come down to safety as much as efficacy, as the evidence for inhaled steroids in COPD is not as comprehensive as that for asthma.

So, there. That’s over. Wasn’t too bad after all, was it? And to help you piece it all together, we’ve updated the Drugs and Devices Table, which you can download from the Training Centre website: go to Resources / Respiratory or click HERE.

Remember to check your local formulary to see which inhalers are recommended in your area and learn these first. You can also visit Rightbreathe.com, and Asthma UK’s ‘How To Use Your Inhaler’ webpage.4

And if that doesn’t help, get yourself some scented candles, a glass of your favourite something, and download some chilled-out George Harrison (from this Spotify playlist devised specially for you), who will advise you to ‘Relax your mind, turn off, and float downstream…”

Respiratory Disease Management Chilled Out Inhalers Playlist

Andrew Booth

1..Supply of Inhalers, 3 April 2020 https://www.primarycaretraining.co.uk/supply-of-inhalers

2. Inhaler Standards and Competency Document, UK Inhaler Group, 2016. https://www.ukinhalergroup.co.uk

3. First 3 in 1 inhaler for asthma launched. MIMS. 2 November 2020. https://www.mims.co.uk/first-3-in-1-inhaler-asthma-launched/respiratory-system/article/1698797

4. How To Use Your Inhaler. Asthma UK https://www.asthma.org.uk/advice/inhaler-videos/

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