Relievers, controllers, and inhaler technique: A physician-patient challenge

P hysicians and patients often have different views and perspectives of what constitutes well-controlled asthma. Although patients are routinely informed about the use of inhalers for treatment of their asthma, physicians sometimes overestimate the pa-tient's competence and knowledge of optimal inhaler usage. True to the publication of diverse issues that comprise and challenge the field of allergy and immu-nology, the allergist/immunologist and the patients we serve, this issue of the Proceedings features a spectrum of articles that addresses this challenge. We hope this issue will provide greater insight that will lead to improved management of the patient with asthma. The unmet need attributable to the management of uncontrolled asthma is well established. Although inhaled controller therapy can be very effective, not all patients respond. One of the most common reasons for therapeutic failure is suboptimal inhaler technique. Asku et al. 1 set out to determine the rate of incorrect inhaler technique among patients with pulmonary diseases and the efficacy of delivering physician-provided inhaler training to patients. The study involved 108 patients, and 158 different inhalation techniques were assessed. Despite finding a high prevalence (41%) of inappropriate inhaler use, the authors reported an 80% success rate when physicians provided practical training. Because of the high prevalence of suboptimal inhaler technique, alternate delivery systems have evolved to include multidose dry powder inhalers (MDPI). Within this issue are three articles that report the safety, efficacy , and pharmacologic characteristics of MDPI treatment. Qaqundah et al. 2 demonstrated the comparability of albuterol MDPI and albuterol hydrofluoroalkane in children with asthma. Ratnayake et al. 3 compared the pharmacokinetics, pharmacodynamics, and tolera-bility of albuterol MDPI and hydrofluoroalkane after a single inhaled dose in children with asthma. In a phase III, 12-week study, Amar et al. 4 evaluated the safety and efficacy of beclomethasone dipropionate hydro-fluoroalkane, BAI, and metered-dose inhaler (MDI) versus placebo in patients who previously used a mid-to high-dose inhaled corticosteroid (ICS) or ICS–long-acting ␤ agonist (LABA) for persistent asthma. 4 In the setting of adequate inhaler technique in moderate to severe persistent asthma, when asthma control is not achieved on ICS alone, current guidelines recommend a step-up regimen of combination therapy with an ICS and an LABA. These two agents are thought to enhance the pharmacologic action of each other by a synergistic effect. With the goal of testing this hypothesis, Shimoda et al. 5 compared a group of patients who used ICS monotherapy …