Home' Australian Pharmacist : Australian Pharmacist June 2013 Contents Australian Pharmacist June 2013 I ©Pharmaceutical Society of Australia Ltd. 59
Continuing Professional Development
1. Pull the cap off the device.
2. Hold the base of the inhaler firmly
and tilt the mouthpiece to open
3. Immediately before use, with
dry hands, remove one capsule
from the blister. Insert capsule
by placing it into the capsule
chamber. Never place a capsule
directly into the mouthpiece.
4. Close the inhaler until you hear
5. Hold the inhaler upright with the
mouthpiece pointing up.
6. Pierce the capsule by firmly
pressing together both side
buttons at the same time. Do this
only once. You should hear a 'click'
as the capsule is being pierced.
7. Release the side buttons fully.
8. Before placing the mouthpiece
in your mouth, breathe out fully.
Do not blow into the mouthpiece.
9. Hold the inhaler with the side
buttons facing left and right.
Do not press the side buttons.
Place the mouthpiece in your
mouth and close your lips firmly
around the mouthpiece. Breathe
in rapidly but steadily and as
deeply as you can. As you breathe
in through the inhaler, the capsule
spins around in the chamber and
you should hear a whirring noise.
10. Hold your breath for at least
5--10 seconds or as long as you
comfortably can while taking
the inhaler out of your mouth.
Then breathe out.
11. Open the inhaler to see if any
powder is left in the capsule.
If there is powder left in the
capsule: Close the inhaler.
Repeat steps 8, 9, 10 and 11.
clinical studies (12 weeks to one year)
in patients with moderate to severe
COPD, once-daily indacaterol 150 or
300 mcg improved lung function
(primary endpoint) significantly more
than placebo, and improvements were
significantly greater than twice-daily
formoterol 12 mcg or salmeterol 50 mg,
and non-inferior to once-daily tiotropium
bromide 18 mcg (all agents were
administered via inhalation).8 A recent
systematic review assessed the role of
indacaterol in dyspnoea.9 The marker
used by the review was the transition
dyspnoea index (TDI).
The TDI measures the transition in
scores of a measure called the baseline
dyspnoea index (BDI) pre and post trial
of therapy. The BDI domains measure
baseline dyspnoea severity, and are
rated from 0 (severe) to 4 (unimpaired)
and summed to provide a BDI total
score of 0 to12, with a lower score
indicating more severe dyspnoea.
The TDI domains measure change from
the BDI over time, rated on a scale of
+3 (major improvement) to -3 (major
deterioration).10,11 Overall the systematic
review included six trials and indicated
that patients receiving indacaterol had
clinically significant improvements in
symptoms of dyspnoea compared to
placebo. Incremental benefits in TDI
were observed with increasing doses.8
Indacaterol is not listed for use in asthma,
primarily as the data supporting its use
in dyspnoea relief exist only for COPD
patients.6 Further; it is now strongly
recommended that LABAs should not be
used on their own in asthma for symptom
relief, unless a preventer medication is
being used concomitantly.12
Practice points to consider for
Whilst indacaterol offers several
advantages such as once-daily
administration, having a fast onset of
action and being clinically effective, the
utility can be hampered by suboptimal
device use. In dispensing this relatively
new medication, it is important to
check device technique, especially
when counselling new patients.
When counselling patients on the use
of DPIs, ensure that patients can load
the capsule into the device correctly,
that patients can actuate the capsule so
that it pierces, that patients remember
to exhale out and then inhale reasonably
fast and forcefully, and finally that
patients hold their breath for as long as
possible to allow reasonable deposition.13
As a device, the Breezhaler does not offer
a high device resistance, so it should not
be too hard for people with stable COPD
to have inspiratory flow rates in excess
of 60 L/min, and thus it may be used in a
wide range of COPD severities.14
Research suggests that the instructions
for the inhaler device should be repeated
frequently (once every three months
ideally), and that the best method of
imparting this skill is:
• to get the patient to demonstrate
• for you to demonstrate to the patient,
highlighting the steps that were
incorrect in the way the patient used
• to get the patient to back-demonstrate
until the technique is appropriate.
Keeping a placebo device (Breezhaler)
in the pharmacy may be a good idea to
allow the pharmacist staff members to
counsel and demonstrate appropriately.15
Adverse e ect and side e ect pro le
Mostly the adverse effect profile is the
same as for other LABAs and SABAs.
The incidence and severity of adverse
effects depend on dosage and route of
administration.6 Common listed side
effects include tremor, palpitations and
headache. Infrequent effects include
hyperglycaemia (high dose), tachycardia,
muscle cramps, agitation, hyperactivity in
Table 1. Steps for use of the
Source: Onbrez Product Information leaflet.
Source of image: www.onbrez.co.uk/pages/
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