A new "co-suspension" triple drug is on the market. How should we choose among the various inhalation preparations?

COPD is one of the most common chronic respiratory diseases in my country. According to incomplete statistics, there are nearly 100 million COPD patients in my country, and the number is still increasing, and the trend is getting younger. One in every seven people aged 40 and above in my country has a COPD patient, and the incidence rate of COPD in people aged 20 and above is 8.6%.

COPD is a "silent killer" with no early symptoms and is often easily ignored. For a long time, it has been a disease with "low awareness, low inspection rate, and insufficient diagnosis." Winter is the season when acute exacerbations of COPD are most common. Acute exacerbations can cause very serious consequences, including irreversible damage to lung function, increased risk of cardiovascular disease, and even a greatly increased risk of death. Therefore, preventing acute exacerbations and standardized treatment of patients during the stable period are very critical links, and this critical link of treatment is mainly guaranteed by inhalation preparations.

On January 11, 2020, Budeglof Inhalation Aerosol, a new triple inhalation drug for COPD, was officially launched in my country, providing a new option for COPD treatment. However, for the majority of patients, there are so many inhalation preparations. Which one is the best? Which one should I choose?

Today, Yaowa will tell you how to choose inhalation preparations. Let us walk into the world of inhalation preparations together~~

Inhaled therapy is the first choice for COPD drug treatment

Inhalation therapy is suitable for the treatment of respiratory diseases, mainly due to the characteristics of lung tissue itself. Inhaled drugs only act on the respiratory tract and directly act on the airways after inhalation, with few systemic adverse reactions. Therefore, inhalation therapy is the first choice for the treatment of lung diseases.

However, not all inhaled preparations can be used for long-term control of COPD. Inhaled preparations are divided into two categories: those for acute attacks and those for stable periods.

Salbutamol is recommended during acute attacks

During the acute attack period, salbutamol aerosol is generally recommended. It is an essential medicine for many 120 emergency rescues. It has a fast onset and good effect during the acute attack of COPD. It can quickly relieve bronchospasm and relieve the clinical symptoms of asthma.

Key point: Salbutamol aerosol cannot be used as a long-term medication during the stable period!!!

After some patients found that salbutamol can relieve asthma symptoms, they prepared the medicine on their own and increased the frequency of drug use. One salbutamol aerosol is often used up in 2 to 3 days. I would like to warn everyone that this medication habit is not advisable! This is not only not conducive to the control of the disease, but also increases the occurrence of adverse drug reactions. Salbutamol must not be used as a treatment drug during the stable period of the disease!

Long-term use of inhaled preparations is required for stable treatment

Drug therapy during the stable period is the core of preventing acute exacerbations of COPD. Long-term use of inhaled preparations can effectively reduce the number of acute exacerbations.

Inhalation preparations used in the stable period generally contain three drug ingredients: long-acting beta-receptor agonists (LABA), such as formoterol and salmeterol; long-acting anticholinergic drugs (LAMA), such as tiotropium; and inhaled corticosteroids (ICS), such as budesonide and fluticasone. These three types of drugs, as commonly used physical and chemical inhalation preparations, are in a "three-legged tripod" state in the basic control of COPD.

Currently, the more common inhalation preparations include single inhalation preparations (such as salbutamol aerosol, tiotropium bromide aerosol, etc.), dual inhalation preparations (such as glycopyrrolate/formoterol inhalation aerosol, salmeterol fluticasone powder inhalation, etc.), and the latest triple preparation, namely the budegone inhalation aerosol mentioned above. It brings together the best of LABA, LAMA and ICS - formoterol, glycopyrrolate, and budesonide, and uses the current cutting-edge "co-suspension technology" to attach the drugs to 3μm phospholipid particles, which are very suitable for inhalation into the small airways ("co-suspension technology" is to use porous phospholipid particles similar to lung surfactant as drug carriers, which can effectively combine multiple drugs with different physical and chemical properties, and most of the drug particles formed are concentrated in the range required for optimal aerodynamics, which is conducive to delivering drugs to the lungs.)

Choose the inhalation preparation that's best for you

Many COPD patients are delighted when they see new high-tech products. Will they be able to use triple-drug preparations to control their disease in the future? Will they be able to rest easy with the latest inhaled preparations?

That is not the case.

COPD patients can be divided into four levels according to the severity of lung function impairment: mild, moderate, severe, and extremely severe. The different levels of COPD, individual differences in patients, and different acceptance of inhaled preparations all determine that different patients are suitable for different treatment drugs. For example, severe COPD patients can choose dual inhalation preparations or triple inhalation preparations, while mild patients can only choose single inhalation preparations.

In addition, current inhalers include aerosol inhalers, aerosol inhalers with spacer, dry powder inhalers and nebulizer inhalers, etc. They all have different characteristics and different operation methods. For example: pressurized metered dose inhalers require propellants, and patients who are intolerant to hydrofluorocarbons (HFA) cannot use them because the propellants contain ingredients such as hydrofluorocarbons (HFA); dry powder inhalers have certain requirements for the patient's lung function, and cannot be used if the inspiratory flow rate does not meet the requirements; nebulizer inhalation has strict requirements on the equipment and high operation requirements.

Therefore, the selection of inhalation preparations requires examination and evaluation, and should be based on one's own specific circumstances and under the guidance of a doctor and pharmacist. It is not necessarily the most suitable one because it is the newest and contains the most therapeutic drugs.

Finally, for the routine management of COPD, you should also pay attention to the following points:

1. Use inhaled medications regularly (including LABA, LAMA, bronchodilators, long-acting bronchodilators combined with ICS, etc.), and take medications regularly as instructed by doctors and pharmacists. Do not change or stop taking medications at will.

2. When taking inhaled preparations, you must pay attention to adverse reactions in the oral area;

3. Recommend non-drug treatments and vaccinations, including influenza vaccination, pulmonary rehabilitation, and personal management;

4. Regular use of oral medications;

5. Quit smoking and limit alcohol consumption. Quitting smoking can reduce the number of acute exacerbations;

6. Strengthen self-management and exercise moderately.

Author: Mao Changqing, Chief Pharmacist, Jinshan Branch, Shanghai Sixth People's Hospital

Review expert: Shen Weihua, deputy director and pharmacist of Jinshan Branch of Shanghai Sixth People's Hospital

Liu Guiyang, Chief Pharmacist of the Pharmacy and Pharmacology Department of the Fourth Medical Center of the PLA General Hospital