Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting

Abstract

Objective: Correct inhaler technique is central to effective delivery of asthma therapy. The study aim was to identify factors associated with serious inhaler technique errors and their prevalence among primary care patients with asthma using the Diskus dry powder inhaler (DPI). Methods: This was a historical, multinational, cross-sectional study (2011–2013) using the iHARP database, an international initiative that includes patient- and healthcare provider-reported questionnaires from eight countries. Patients with asthma were observed for serious inhaler errors by trained healthcare providers as predefined by the iHARP steering committee. Multivariable logistic regression, stepwise reduced, was used to identify clinical characteristics and asthma-related outcomes associated with ≥1 serious errors. Results: Of 3681 patients with asthma, 623 (17%) were using a Diskus (mean [SD] age, 51 [14]; 61% women). A total of 341 (55%) patients made ≥1 serious errors. The most common errors were the failure to exhale before inhalation, insufficient breath-hold at the end of inhalation, and inhalation that was not forceful from the start. Factors significantly associated with ≥1 serious errors included asthma-related hospitalization the previous year (odds ratio [OR] 2.07; 95% confidence interval [CI], 1.26–3.40); obesity (OR 1.75; 1.17–2.63); poor asthma control the previous 4 weeks (OR 1.57; 1.04–2.36); female sex (OR 1.51; 1.08–2.10); and no inhaler technique review during the previous year (OR 1.45; 1.04–2.02). Conclusions: Patients with evidence of poor asthma control should be targeted for a review of their inhaler technique even when using a device thought to have a low error rate.

• Asthma therapy
• cross-sectional
• Diskus inhaler
• inhalation devices
• multinational

Acknowledgements

The iHARP database was funded by unrestricted grants from Mundipharma International Ltd and Research in Real-Life Ltd; these analyses were funded by an unrestricted grant from Teva Pharmaceuticals. Mundipharma and Teva played no role in study conduct or analysis and did not modify or approve the manuscript. The authors wish to direct a special appreciation to all the participants of the iHARP group who contributed data to this study and to Mundipharma, sponsors of the iHARP group. In addition, we thank Julie von Ziegenweidt for assistance with data extraction and Anna Gilchrist and Valerie L. Ashton, PhD, for editorial assistance. Elizabeth V. Hillyer, DVM, provided editorial and writing support, funded by Research in Real-Life, Ltd.

Declaration of interest

Janine A. M. Westerik declares that she has no conflicts of interest in relation to this article. Victoria Carter, Anne Burden, Samantha L. Thompson and Catherine Hutton were employees of Research in Real-Life (RiRL), which conducted this study and which has conducted paid research in respiratory disease on behalf of the following other organizations in the past 5 years: Aerocrine, AKL Ltd, Almirall, Astra Zeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Meda, Mundipharma, Napp, Novartis, Orion, Sanofi, Takeda and Teva. Henry Chrystyn has no shares in any pharmaceutical companies. He has received sponsorship to carry out studies, together with Board Membership, consultant agreements and honoraria for presentation, from several pharmaceutical companies that market inhaled products. These include Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Innovata Biomed, Meda, Napp Pharmaceuticals, Mundipharma, NorPharma, Novartis, Orion, Sanofi, Teva, Truddell Medical International, UCB and Zentiva. Research sponsorship has also been received from grant awarding bodies (EPSRC and MRC). He owns 50% of Inhalation Consultancy Ltd. Dermot Ryan has provided consultancy to or lectured on behalf of AstraZeneca, GlaxoSmithKline, Novartis, Almirall, Teva, Meda, Uriach, Stallergenes, Chiesi, Boehringer-Ingelheim, Orion. Kevin Gruffydd-Jones has spoken on behalf of and acted as a consultant for AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Mundipharma/NAPP. John Haughney has received reimbursements for attending symposia, fees for speaking, organizing educational events, funds for research or fees for consulting from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Merck Sharp & Dohme, Mundipharma, Novartis and Teva. Nicolas Roche has received over the past 3 years (i) fees for speaking, organizing education, participation in advisory boards or consulting from Aerocrine, Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, MSD-Chibret, Mundipharma, Novartis, Pfizer, Stallergenes, Teva; (ii) research grants from Novartis, Boehringer Ingelheim and Pfizer. Federico Lavorini has received in the past 5 years honoraria for consultancy and presentations from the following pharmaceutical companies that market inhaled products: Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, TEVA and Zentiva. Alberto Papi has received grants, personal fees and non-financial support from AstraZeneca, Chiesi Farmaceutici, GlaxoSmithKline, Boehringer Ingelheim, Merck Sharp & Dohme, Menarini, Novartis, Zambon, TEVA, Pfizer, Takeda and Mundipharma. Antonio Infantino has no conflicts of interest to declare in relation to this article. Miguel Román-Rodríguez has provided consultancy to or lectured on behalf of AstraZeneca, GlaxoSmithKline, Novartis, Almirall, Chiesi, Mundipharma, Boehringer-Ingelheim, Rovi and Teva. Sinthia Bosnic-Anticevich has received reimbursements for attending meetings, fees for speaking or consultancy from Mundipharma and Teva. Karin Lisspers has received payment for advisory board from Meda, Novartis, scientific committee from AstraZeneca, Novartis and for lectures from Meda, AstraZeneca, Novartis, GlaxoSmithKline, Nycomed and Boehringer Ingelheim. Björn Ställberg has received honoraria for educational activities and lectures from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Meda, MSD, Novartis and TEVA, and has served on advisory boards arranged by AstraZeneca, Novartis and Boehringer Ingelheim. Svein Høegh Henrichsen has no conflicts of interest to declare. Thys van der Molen has received grants for research, travel fees, reimbursement for presentations and advisory boards from AstraZeneca, GlaxoSmithKline, Almirall, Mundipharma, Boehringer Ingelheim, Chiesi, Teva and Novartis. David B. Price has Board Membership with Aerocrine, Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis and Teva. Consultancy: Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Meda, Mundipharma, Napp, Novartis, Pfizer, Teva and Zentiva; Grants/Grants Pending with UK National Health Service, British Lung Foundation, Aerocrine, AstraZeneca, Boehringer Ingelheim, Chiesi, Eli Lilly, GlaxoSmithKline, Meda, Merck, Mundipharma, Novartis, Orion, Pfizer, Respiratory Effectiveness Group, Takeda, Teva and Zentiva; Payments for lectures/speaking: Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Meda, Merck, Mundipharma, Novartis, Pfizer, SkyePharma, Takeda and Teva; Payment for manuscript preparation: Mundipharma and Teva; Patents (planned, pending or issued): AKL Ltd.; Payment for the development of educational materials: GlaxoSmithKline, Novartis; Stock/Stock options: Shares in AKL Ltd which produces phytopharmaceuticals and owns 80% of Research in Real Life Ltd and its subsidiary social enterprise Optimum Patient Care; received Payment for travel/accommodations/meeting expenses from Aerocrine, Boehringer Ingelheim, Mundipharma, Napp, Novartis and Teva; Funding for patient enrolment or completion of research: Almirral, Chiesi, Teva and Zentiva; Peer reviewer for grant committees: Medical Research Council (2014), Efficacy and Mechanism Evaluation programme (2012), HTA (2014); and Received unrestricted funding for investigator-initiated studies from Aerocrine, AKL Ltd, Almirall, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, Orion, Takeda, Teva and Zentiva.

Supplementary material available online Supplementary Tables S1–S4