Switching Inhalers: A Practical Approach to Keep on UR RADAR

Abstract

The choice of an inhaler device is often as important as the medication put in it to achieve optimal outcomes for our patients with asthma and/or COPD. With a multitude of drug-device combinations available, optimization of respiratory treatment could well be established by switching devices rather than changing or even augmenting pharmacological or non-pharmacological therapies. Importantly, while notable between-device differences in release mechanism, particle size, drug deposition and required inspiratory flow exist, a patient uncomfortable with their device is unlikely to use it regularly and certainly will not use it properly. Switching requires a careful process and should not be done without patient consent. Switching devices entails several steps that need to be considered, which can be guided using the UR-RADAR mnemonic. It starts with (i) UncontRolled asthma/COPD (or UnaffoRdable device), followed by RADAR: (ii) review the patient's condition (e.g. diagnosis, phenotype, co-morbidities) and address reasons for suboptimal control (e.g. triggers, smoking, non-adherence, poor inhaler technique) to be ruled out before switching; (iii) assess patient's skills related to inhalation (e.g. inspiratory force); (iv) discuss inhaler switch options, patient preferences (e.g. size, daily regimen) and treatment goals; (v) allow patients input and use shared decision-making to decide final treatment choice, acknowledging individual patient skills, preferences and goals; and (vi) re-educate to the new device (at minimum, physical demonstration, verbal explanation and patient repetition, both verbally and physically) and prime the patient for the follow-up (i.e. explain the future patient journey, including multidisciplinary work flows with physicians, nurses and pharmacists).

Exploring quality of life and satisfaction with treatment in asthmatic patients receiving dry powder inhalers: a multinational survey

“…However, switching is a delicate process that should involve the patient and follow a number of steps summarized by the UR-RADAR (UncontRolled asthma/UnaffoRdable device-Review, Assess the technique, Discuss options, Allow patient's input, Re-educate) mnemonic. Patient's input, such as device preference and shared decision making with a healthcare professional, is very important in this process (37).…”

Switching to the Dry-Powder Inhaler Easyhaler®: A Narrative Review of the Evidence

“…The common understanding is that switching devices should not be advocated for patients unless they suffer from uncontrolled asthma or COPD, and that this change requires a careful process including patient consent, clinical assessment, patient discussion, device retraining, and follow-up [ 7 ]. However, at a population level, there is evidence that switching to ‘an equivalent’ inhaler in patients with COPD and asthma does not negatively affect patients’ health or healthcare utilization.…”

“…There are, however, inherent difficulties with systematic clinical trials of inhaler switching due to difficulties in blinding, the need for re-education, balancing of arms with regard to inspiratory force, and patients’ personal abilities and preferences [ 7 ]. The various studies summarized in Table 1 identify the Easyhaler as a credible option when a switch of drug-delivery device is mooted, but it has to be acknowledged that this is an area of respiratory medicine in which well-configured randomized trials are lacking and that many of those that have been conducted (e.g., Syk et al [ 53 ]) quantify success in terms of disease symptom control.…”

“…A full treatment of the options is beyond the scope of this short review, which focuses on pressurized metered-dose inhalers (pMDIs) and dry-powder inhalers (DPIs), the latter being specifically exemplified by the Easyhaler (for a concise technical review of the Easyhaler device, the reader is referred to a recent overview [ 13 ]). Kaplan and van Boven [ 7 ] have published a tabulated comparison of other device types, including the breath-actuated metered-dose inhaler and soft-mist inhaler and nebulizer, while complementary comparative data on issues such as fine-particle dose have been reviewed at length by Lavorini et al [ 14 ].…”

“…As recently articulated by Kaplan and van Boven [ 7 ] in the principles of the UR-RADAR concept, the selection and switching of inhalers should be considered within a wider framework of clinical evaluation and patient engagement. Notwithstanding acknowledged differences between different devices with regard to release mechanism, drug particle size and deposition, and required inspiratory flow, the optimal matching of patient and inhaler can exert a powerful influence on the overall clinical success of a treatment strategy in these chronic respiratory diseases [ 8 – 12 ].…”