Critical Error Frequency and the Impact of Training with Inhalers Commonly used for Maintenance Treatment in Chronic Obstructive Pulmonary Disease

David J Collier, Pascal Wielders, Job van der Palen, Logan Heyes, Dawn Midwinter, Kathryn Collison, Andy Preece, Neil Barnes, Raj Sharma, David J Collier, Pascal Wielders, Job van der Palen, Logan Heyes, Dawn Midwinter, Kathryn Collison, Andy Preece, Neil Barnes, Raj Sharma

Abstract

Introduction: Training in correct inhaler use, ideally in person or by video demonstration, can minimize errors but is rarely provided in clinics. This open-label, low-intervention study evaluated critical error rates with dry-powder inhalers (DPIs), before and after training, in patients with chronic obstructive pulmonary disease.

Methods: Patients prescribed an inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) (ELLIPTA, Turbuhaler, or DISKUS), long-acting muscarinic antagonist (LAMA)/LABA (ELLIPTA or Breezhaler), or LAMA-only DPI (ELLIPTA, HandiHaler, or Breezhaler) were enrolled. Critical errors were assessed before training (Visit 1 [V1]; primary endpoint) and 6 weeks thereafter (Visit 2 [V2]; secondary endpoint). Logistic regression models were used to calculate odds ratios (ORs) for between-group comparisons.

Results: The intent-to-treat population comprised 450 patients. At V1, fewer patients made ≥1 critical error with ELLIPTA (10%) versus other ICS/LABA DPIs (Turbuhaler: 40%, OR 4.66, P=0.005; DISKUS: 26%, OR 2.48, P=0.114) and other LAMA or LAMA/LABA DPIs (HandiHaler: 34%, OR 3.50, P=0.026; Breezhaler: 33%, OR 3.94, P=0.012). Critical error rates with the primary ICS/LABA DPI were not significantly different between ELLIPTA ICS/LABA (10%) and ICS/LABA plus LAMA groups (12-25%). Critical errors with the primary ICS/LABA DPI occurred less frequently with ELLIPTA ICS/LABA with or without LAMA (11%) versus Turbuhaler ICS/LABA with or without LAMA (39%, OR 3.99, P<0.001) and DISKUS ICS/LABA with or without LAMA (26%, OR 2.18, P=0.069). Simulating single-inhaler versus multiple-inhaler triple therapy, critical error rates were lower with ELLIPTA fluticasone furoate/vilanterol (FF/VI; 10%) versus ELLIPTA FF/VI plus LAMA (22%), considering errors with either DPI (OR 2.50, P=0.108). At V2, critical error rates decreased for all DPIs/groups, reaching zero only for ELLIPTA. Between-group comparisons were similar to V1.

Conclusion: Fewer patients made critical errors with ELLIPTA versus other ICS/LABA, and LAMA or LAMA/LABA DPIs. The effect of "verbal" training highlights its importance for reducing critical errors with common DPIs.

Keywords: ELLIPTA; critical errors; inhaled corticosteroid; inhaler technique; long-acting muscarinic antagonist; long-acting β2-agonist.

Conflict of interest statement

David J Collier was supported in part by the NIHR Barts Biomedical Research Centre. Job van der Palen reports personal fees from AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline plc., and grants from Chiesi, outside the submitted work. Logan Heyes was an employee of GlaxoSmithKline plc. at the time of the study, and is currently employed by Pharmaceutical Management Agency (PHARMAC). Dawn Midwinter, Kathryn Collison, Andy Preece, Neil Barnes, and Raj Sharma are employees of, and have shares in, GlaxoSmithKline plc. The authors report no other conflicts of interest in this work.

© 2020 Collier et al.

Figures

Figure 1
Figure 1
Percentage of patients making ≥1 critical error with the primary DPI at V1. LAMA represents ELLIPTA UMEC or HandiHaler TIO. Abbreviations: BUD, budesonide; DPI, dry-powder inhaler; FF, fluticasone furoate; FOR, formoterol; FP, fluticasone propionate; GLY, glycopyrronium; IND, indacaterol; LAMA, long-acting muscarinic antagonist; SAL, salmeterol; TIO, tiotropium; UMEC, umeclidinium; VI, vilanterol; V1, Visit 1.
Figure 2
Figure 2
Percentage of patients making ≥1 critical error with the primary DPI at V2, 6 weeks after training. LAMA represents ELLIPTA UMEC or HandiHaler TIO. Abbreviations: BUD, budesonide; DPI, dry-powder inhaler; FF, fluticasone furoate; FOR, formoterol; FP, fluticasone propionate; GLY, glycopyrronium; IND, indacaterol; LAMA, long-acting muscarinic antagonist; SAL, salmeterol; TIO, tiotropium; UMEC, umeclidinium; VI, vilanterol; V2, Visit 2.

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