Choosing the right inhaled medication device for COPD.

As Dr. Lee and colleagues describe in this issue of American Family Physician,1 inhaled therapy is the preferred route of medication delivery in patients with chronic obstructive pulmonary disease (COPD). Data suggest that inhaler devices have similar effectiveness in treating patients with COPD; however, a variety of factors must be considered when selecting the best device for each patient2 (see Table 1 on page 652). Factors such as the patient’s ability to use the device properly, the need for multiple inhaled medications, cost and reimbursement, convenience, and patient preferences must be considered. A patient’s ability to use a device may be affected by cognitive function, strength, and dexterity. The prevalence of COPD increases with age, which increases the likelihood of additional comorbid conditions that further complicate device selection. Patients with declining cognitive function may not be able to attain and recall the technique needed to use inhaler devices appropriately. Additionally, most inhaler devices require some dexterity and strength for appropriate use. Patients with more severe COPD may have difficulty using inhaler devices because some devices are dependent on peak inspiratory flow, which diminishes with advanced COPD. Long-acting bronchodilators are commonly used to treat patients with COPD; however, these patients also require a short-acting bronchodilator for acute shortness of breath. The more devices a patient uses, the greater the chances of using them incorrectly.3 Because Medicare is the primary insurance provider for older patients in the United States and prescription coverage is provided through Medicare Part D, cost and reimbursement should also be considered when selecting inhaler devices. Although newer inhalers may be available through pharmaceutical company samples, a long-term plan must be in place to ensure that the patient can afford the medications prescribed. Convenience and patient preferences have important roles in device selection; patients are more likely to use a device that they prefer and are comfortable with and that does not interfere with daily activities.4,5 Regardless of the inhaler device prescribed, time and resources must be dedicated to patient education, and physicians should have sufficient knowledge and training to provide counseling on proper use. Patient education materials should consider patient health literacy and should serve as a viable tool for information recall once the patient is home. The physician should confirm that the patient understands the instructions and can demonstrate proper inhaler technique during the initial visit when the inhaled medication is prescribed, and also at subsequent visits to ensure that the information is retained. Although inhaled medications for COPD have been shown to reduce symptoms, improve quality of life, and in some cases prevent COPD exacerbations, these medications cannot accomplish this without patient adherence and proper inhaler technique. Appropriate device selection and patient education are crucial to ensuring that expected clinical outcomes are achieved.