Opportunities for inhaler device selection in elderly patients with asthma or COPD

Figures & data

Figure 1 Algorithm for inhaler selection in elderly patients with asthma/COPD.

Abbreviations: pMDI, pressurized metered dose inhaler; DPI, dry powder inhaler; HCP, health care provider.

Table 1 Inhaled medication and corresponding devices for asthma and COPD in the USA 2015

Medication category	Generic name	Brand name	Device availability
Beta agonist			pMDI	DPI	Nebulizer SMI
Short acting	Albuterol	ProAir HFA®, Proventil HFA®,	✓
		ventolin HFA®	✓
		ProAir® RespiClick		^✓M
	Albuterol	Accuneb			✓
	Levalbuterol	Xopenex®	✓		✓
Long acting	Salmeterol	Serevent Diskus®		^✓M
	Salmeterol xinafoate	Serevent®	✓
	Formoterol fumarate	Foradil Aerolizer®		^✓L
	Formoterol fumarate	Perforomist Inhalation Solution®			✓
	Arformoterol	Brovana Inhalation Solution			✓
	Olodaterol	Striverdi Respimat				✓
	Indacaterol	Arcapta Neohaler			✓
Anticholinergics
Short acting	Ipratropium bromide	Atrovent®	✓		✓
Long acting	Tiotropium	Spiriva Handihaler®		^✓H	✓
		Spiriva Respimat®				✓
	Aclidinium	Tudorza® Pressair		^✓M
	Umeclidinium	Incruse Ellipta		^✓M
Inhaled corticosteroids	Budesonide	Pulmicort Respules®			✓
		Pulmicort Flexhaler		✓
	Beclomethasone dipropionate	QvAR Inhalation Aerosol®	✓
	Beclomethasone	vanceril Inhalation Aerosol®	✓
	Fluticasone propionate	Flovent HFA Inhalation Aerosol®	✓
		Flovent Diskus		^✓H
		Arnuity ellipta		^✓M
	Mometasone	Asmanex® Twisthaler®		^✓H
	Ciclesonide	Alvesco®	✓
	Flunisolide	Aerobid-m®, Aerobid®,	✓
		Aerospan	✓
Combination therapy	Fluticasone + salmeterol	Advair®		^✓M
	Budesonide + formoterol	Symbicort®	✓
	Albuterol + ipratropium	Combivent® Respimat®				✓
	Albuterol + ipratropium	DuoNeb Inhalation Solution®			✓
	Mometasone + formoterol	Dulera®	✓
	Umeclidinium + vilanterol	Anoro ellipta®		^✓M

Notes: Dry powder inhaler resistance to airflow: H = high resistance (<50 L/min PIF): Spiriva Handihaler^®, Asmanex Twisthaler^®, Pulmicort Flexhaler^®. M = medium resistance (50–90 L/min PIF): Anoro Ellipta^®, Advair Diskus^®, Arnuity Ellipta^®, Tudorza^® Pressair^®, Incruse Ellipta^®. L = low resistance (>90 L/min PIF): Foradil Aerolizer^®.

Abbreviations: PIF, peak inspiratory flow; DPI, dry powder inhaler; SMI, soft mist inhaler; pMDI, pressurized metered dose inhaler; HFA, hydrofluoroalkane.

Table 2 Inhaler conveniences and cost

	Number of steps^	Dosing counter	Dosing prompt**	Cost***
Dry powder inhaler
Albuterol (ProAir® RespiClick®)	1	Yes	Yes	$$
Salmeterol (Serevent® Diskus®)	2	Yes	No	$$$
Formoterol (Foradil Aerolizer®)*	7	No	Yes	$$
Tiotropium (Spiriva® Handihaler®)*	7	No	Yes	$$$$
Aclidinium (Tudorza® Pressair®)	2	Yes	Yes	$$$
Umeclidinium (Incruse® Ellipta®)	1	Yes	No	$$
Budesonide (Pulmicort Flexhaler®)	3	Yes	No	$$$
Fluticasone (Flovent® Diskus®)	2	Yes	No	$$$
Fluticasone (Arnuity® ellipta®)	1	Yes	No	$$
Mometasone (Asmanex® Twisthaler®)	2	Yes	No	$$$$
Fluticasone + Salmeterol (Advair® Diskus®)	2	Yes	No	$$$
Umeclidinium + Vilanterol (Anoro® ellipta®)	1	Yes	No	$$
Pressurized metered dose inhalers	Number of steps**
Albuterol (ProAir® HFA ventolin HFA®)	4	Yes	No	$
Levalbuterol (Xopenex®)	4	No	No	$$
Ipratropium (Atrovent®)	3	Yes	No	$$$$
Beclomethasone (QVAR®) (Vanceril®)	3	Yes	No	$$
Fluticasone (Flovent HFA®)	4	Yes	No	$$$$
Ciclesonide (Alvesco®)	3	Yes	No	$$$$
Flunisolide (Aerospan®)	4	No	No	$$$
Budesonide + Formoterol (Symbicort®)	4	Yes	No	$$$$
Mometasone + Formoterol (Dulera®)	4	Yes	No	$$$$
Soft mist inhalers	Number of steps
Albuterol + Ipratropium (Combivent Respimat®)	3	Yes	No	$$$$
Tiotropium (Spiriva® Respimat®)	3	Yes	No	$$$$
Olodaterol (Striverdi® Respimat®)	3	Yes	No	$$

Notes: *Single dose DPI; **dosing prompt: visual or audible indicator of dosing completion; ^number of steps for preparation of DPI device: 1) open device (expose mouthpiece – most devices); 2) expose mouthpiece (separate from device – as seen on Handihaler); 3) push capsule through foil (single dose device); 4) place capsule into capsule chamber (single dose device); 5) close mouthpiece (single dose device); 6) puncture capsule (single dose device) or blister pack (multiple dose device); 7) actuate device; ^^number of steps for preparation of pMDI device (without spacer): 1) shake device; 2) remove mouthpiece cover; 3) prime device (must determine need – device specific); 4) actuate device; ^^^cost for single inhaler (average wholesale price): $: <$50; $$: $50 to $100; $$$: $100 to $200; $$$$: >$200. For ≥2 medication strengths: average wholesale price was calculated among all formulations. Cost is in US$.

Abbreviations: DPI, dry powder inhaler; pMDI, pressurized metered dose inhaler; HFA, hydrofluoroalkane.