Investigation of some commercially available spacer devices for the delivery of glucocorticoid steroids from a pMDI

Spacer devices for inhaled therapy: why use them, and how?

We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.

Real-Life Outcomes for Patients with Asthma Prescribed Spacers for Use with Either Extrafine- or Fine-Particle Inhaled Corticosteroids

BACKGROUND

Spacers are often used with pressurized metered-dose inhalers (pMDIs) to eliminate the need for coordinating inhalation with actuation.

OBJECTIVE

To investigate the real-life effectiveness of spacers prescribed for use with either extrafine- or fine-particle inhaled corticosteroids (ICSs).

METHODS

This historical matched cohort study examined anonymous medical record data over 2 years (1-year baseline, 1-year outcome) for patients with asthma aged 12 to 80 years initiating ICSs by pMDI with or without prescribed spacer. We compared outcomes for spacer versus no-spacer arms, matched for key baseline and asthma-related characteristics, within 2 ICS cohorts: (1) extrafine-particle ICS (beclomethasone) and (2) fine-particle ICS (fluticasone). Effectiveness end points were compared using conditional regression methods.

RESULTS

Matched spacer and no-spacer arms of the extrafine-particle ICS cohort each included 2090 patients (69% females; median age, 46-47 years) and the 2 arms of the fine-particle ICS cohort each included 444 patients (67% females; median age, 45 years). With extrafine-particle ICS, we observed no significant difference between spacer and no-spacer arms in severe exacerbation rate (primary end point): adjusted rate ratio, 1.01 (95% CI, 0.83-1.23). With fine-particle ICS, the severe exacerbation rate ratio with spacers was 0.77 (0.47-1.25). Oropharyngeal candidiasis incidence was low and similar in spacer and no-spacer arms for both ICS cohorts.

CONCLUSIONS

We found no evidence that prescribed spacer devices are associated with improved asthma outcomes for extrafine- or fine-particle ICS administered by pMDI. These findings challenge long-standing assumptions that spacers should improve pMDI effectiveness and indicate the need for pragmatic trials of spacers in clinical practice.

Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT)

Health professionals tasked with advising patients with asthma and chronic obstructive pulmonary disease (COPD) how to use inhaler devices properly and what to do about unwanted effects will be aware of a variety of commonly held precepts. The evidence for many of these is, however, lacking or old and therefore in need of re-examination. Few would disagree that facilitating and encouraging regular and proper use of inhaler devices for the treatment of asthma and COPD is critical for successful outcomes. It seems logical that the abandonment of unnecessary or ill-founded practices forms an integral part of this process: the use of inhalers is bewildering enough, particularly with regular introduction of new drugs, devices and ancillary equipment, without unnecessary and pointless adages. We review the evidence, or lack thereof, underlying ten items of inhaler ‘lore’ commonly passed on by health professionals to each other and thence to patients. The exercise is intended as a pragmatic, evidence-informed review by a group of clinicians with appropriate experience. It is not intended to be an exhaustive review of the literature; rather, we aim to stimulate debate, and to encourage researchers to challenge some of these ideas and to provide new, updated evidence on which to base relevant, meaningful advice in the future. The discussion on each item is followed by a formal, expert opinion by members of the ADMIT Working Group.

In vitro evaluation of nonconventional accessory devices for pressurized metered-dose inhalers

BACKGROUND

The selection of accessory devices for pressurized metered-dose inhalers (pMDIs) by health care professionals is typically cost driven without consideration of how the device modifies clinical outcomes.

OBJECTIVE

To evaluate nonconventional accessory devices and the open-mouth technique with and without ideal coordination of actuation and inhalation to identify and understand the considerations for recommending potential inexpensive devices.

METHODS

In vitro performance parameters of the beclomethasone dipropionate pMDI were evaluated with several devices (AeroChamber, toilet paper roll, paper towel roll, rolled paper, plastic bottle spacer, bottle-holding chamber, and nebulizer reservoir tubing).

RESULTS

Compared with the pMDI alone, all the accessory devices evaluated have significantly lower drug exposure and throat deposition and higher respirable fractions, with the paper towel roll having the greatest effect of the devices evaluated (exposure decreased from a mean [SD] of 76.1 [4.8] μg to 49.2 [2.0] μg, throat deposition decreased from 32.0 [3.2] μg to 0.8 [0.3] μg, and respirable fraction increased from 49.8% [3.2%] to 96.4% [0.4%]). Introduction of a delay between actuation and inhalation resulted in greater variability in performance metrics for the devices evaluated, and the bottle-holding chamber and paper towel roll were most effective in mitigating the effect of the delay. The open-mouth technique was found to decrease throat deposition and respirable mass compared with the pMDI alone.

CONCLUSION

In addition to cost, the amount of drug that deposits in the throat and the lungs and the effect of asynchronous actuation and inhalation can vary with the selection of an accessory device, which may affect the therapeutic benefits of the pMDI selected.

From inhaler to lung: clinical implications of the formulations of ciclesonide and other inhaled corticosteroids

Asthma continues to be a global health problem and currently available treatments such as corticosteroids can cause unwanted side effects. Inhaled corticosteroids (ICS) are recommended as first-line therapy for reducing airway inflammation and have a distinct advantage over oral preparations as they provide a direct route of delivery to the lungs. However, local deposition of ICS in the oropharynx can lead to oral candidiasis, dysphonia, and pharyngitis. The pharmaceutical quality is a primary concern of any ICS asthma treatment, with a higher quality product resulting in improved efficacy and safety profiles. The particle size distribution and the spray force velocity of an ICS may directly influence lung deposition, and the spray duration of a device is another important factor when coordinating inhalation. Recent advances in ICS device and formulation technology have resulted in significant improvements in the efficacy of available asthma treatments. In particular, hydrofluoroalkane (HFA) solution technology and the development of smaller particle sizes have resulted in the production of new ICS formulations that have the ability to directly target drug delivery to the site of airway inflammation. Both the ICS formulation and the pressurized metered-dose inhaler device used to administer ciclesonide (CIC) HFA have been developed to treat the underlying chronic inflammation associated with asthma. CIC is administered as a prodrug which is activated in the lungs, leading to minimal oropharyngeal deposition. The small particle size of CIC results in the delivery of a high fraction of respirable particles to the small airways of the lungs, resulting in high lung deposition and continual dose consistency. This review summarizes how CIC administered as an HFA formulation is an effective treatment for asthma.

Aerosol drug delivery: developments in device design and clinical use

Aerosolised drugs are prescribed for use in a range of inhaler devices and systems. Delivering drugs by inhalation requires a formulation that can be successfully aerosolised and a delivery system that produces a useful aerosol of the drug; the particles or droplets need to be of sufficient size and mass to be carried to the distal lung or deposited on proximal airways to give rise to a therapeutic effect. Patients and caregivers must use and maintain these aerosol drug delivery devices correctly. In recent years, several technical innovations have led to aerosol drug delivery devices with efficient drug delivery and with novel features that take into account factors such as dose tracking, portability, materials of manufacture, breath actuation, the interface with the patient, combination therapies, and systemic delivery. These changes have improved performance in all four categories of devices: metered dose inhalers, spacers and holding chambers, dry powder inhalers, and nebulisers. Additionally, several therapies usually given by injection are now prescribed as aerosols for use in a range of drug delivery devices. In this Review, we discuss recent developments in the design and clinical use of aerosol devices over the past 10-15 years with an emphasis on the treatment of respiratory disorders.

Determining degree of saturation after application of transiently supersaturated metered dose aerosols for topical delivery of corticosteroids

A transiently supersaturated drug delivery system has the potential to enhance topical drug delivery via heightened thermodynamic activity. The aim of this work was to quantify the degree of saturation (DS) for transiently supersaturated formulations using three traditional and one novel in vitro assessment methods. Metered dose aerosols (MDA) were formulated containing saturated levels of beclomethasone dipropionate monohydrate (BDP) or betamethasone 17-valerate (BMV) within a pressurised canister, and included ethanol (EtOH), hydrofluoroalkane 134a propellant and poly(vinyl pyrrolidone). Attempts to determine the DS via the measurement of drug flux through synthetic membranes did not correlate and was shown to be dependent on the EtOH concentration. The inability of these methods to accurately assess the drug DS may be due to the transient nature of the formulation and the volatile solvents dehydrating the membrane. A mathematical equation that used the evaporation rate of the formulation was derived to determine the theoretical DS at various time points after MDA actuation. It was shown that the MDAs became supersaturated with a high DS, this enhanced drug release from the formulation and therefore these preparations have the potential to increase the amount of drug delivered into the skin.

A Novel Apparatus for the Determination of Solubility in Pressurized Metered Dose Inhalers

The accurate solubility of salbutamol sulfate, budesonide, and formoterol fumarate dihydrate in hydrofluoroalkane propellant 134a at 25 degrees C for 24 h, are reported. The authors describe a novel reusable in-line pressurized solubility apparatus containing an integral filter holder and a continuous decrimpable valve for the determination of drug/excipients solubility in pressurized metered dose inhalers. The solubility was determined by high-performance liquid chromatography. Solubility of salbutamol sulfate was determined as being below the detection limits while budesonide and formoterol fumarate dihydrate solubility were 23.136 +/- 2.951 microg x g(-1) and 0.776 +/- 1.023 microg x g(-1), respectively (n = 3). This novel solubility apparatus offers an improved ease of use and potential higher analytical throughput.

The influence of sodium hyaluronate, L-leucine and sodium taurocholate on the nebulization of aqueous betamethasone-17-valerate suspensions

The purpose of this research was to evaluate the variables that are suggested to influence the adsorption of the hydrophilic hyaluronic acid (HA) onto the surface of the hydrophobic betamethasone-17-valerate (BV) particles in order to formulate a nebulizable suspension. The adsorption of HA from aqueous solutions (0.04% to 0.16%, w/v) to a fixed BV concentration (0.04%, w/v) under different experimental conditions, was investigated. The method of preparation of HA-BV suspensions involved suspending BV particles either in the hydrated HA solution (method 1) or in water followed by addition of solid HA (method 2). Other variables like the time required for the adsorption to complete and temperature at which adsorption is carried out were studied. The nebulization of the suspensions was tested via an air jet nebulizer connected to a twin stage impinger. In order to improve the nebulization behavior of the optimized suspension, L-leucine or sodium taurocholate was incorporated in increasing concentrations (0.01-0.04%, w/v). The optimized suspension, having a nebulization efficiency of 33.75%, was achieved following the adsorption of HA (0.1%, w/v) onto BV particles adopting method 2 of preparation and extending for three days at 4 degrees C. Incorporation of either l-leucine or sodium taurocholate significantly decreased the aggregate size of the optimized suspension and consequently caused significant increases in the nebulization efficiency to reach 46.87% and 56.25%, respectively.

Novel propellant-driven inhalation formulations: engineering polar drug particles with surface-trapped hydrofluoroalkane-philes

Challenges in reformulating pressurized metered-dose inhalers (pMDIs) with hydrofluoroalkane (HFA) propellants, and the potential of inhalation formulations for the delivery of drugs to and through the lungs have encouraged the development of novel suspension-based pMDI formulations. In this work we propose a new methodology for engineering polar drug particles with enhanced stability and aerosol characteristics in propellant HFAs. The approach consists in 'trapping' HFA-philic moieties at the surface of particles, which are formed using a modified emulsification-diffusion method. The trapped moieties act as stabilizing agents, thus preventing flocculation of the otherwise unstable colloidal drug particles. This approach has advantages compared to surfactant-stabilized colloids in that no free stabilizers remain in solution (reduced toxicity), and the challenges associated with the synthesis of well-balanced amphiphiles are circumvented. The methodology was tested by trapping polyethylene glycol (PEG) at the surface of particles of a model polar drug-salbutamol sulfate. Colloidal probe microscopy is used to quantitatively demonstrate the trapping of the HFA-phile at the surface, and the ability of PEG in screening particle-particle cohesive interactions. Both physical stability and the corresponding aerosol characteristics are significantly improved compared to those of a commercial formulation. The fine particle fraction of PEG-coated salbutamol sulfate was observed to be 42% higher than that of Ventolin HFA. The formation of stable dispersions of terbutaline hemisulfate using the same approach, suggests this to be a generally applicable methodology to polar drugs.

Core-shell particles for the dispersion of small polar drugs and biomolecules in hydrofluoroalkane propellants

PURPOSE

Demonstrate the applicability of a novel particle-based technology for the development of suspensions of small polar drugs and biomolecules in hydrofluoroalkane (HFA) propellants for pressurized metered-dose inhalers (pMDIs).

MATERIALS AND METHODS

Emulsification diffusion was used to prepare core-shell particles. The shell consisted of oligo(lactide) grafts attached onto a short chitosan backbone. The active drug was arrested within the particle core. Colloidal Probe Microscopy (CPM) was used to determine the cohesive forces between particles in a model HFA propellant. The aerosol characteristics of the formulations were determined using an Anderson Cascade Impactor (ACI). Cytotoxicity studies were performed on lung epithelial and alveolar type II cells.

RESULTS

CPM results indicate that particle cohesive forces in liquid HFA are significantly screened in the presence of the polymeric shell and correlate well with the physical stability of suspensions in propellant HFA. The proposed formulation showed little or no cytotoxic effects on both Calu-3 and A549 cells.

CONCLUSIONS

Core-shell particles with a shell containing the lactide moiety as the HFA-phile showed excellent dispersion stability and aerosol characteristics in HFA-based pMDIs. This is a general strategy that can be used for developing novel suspension pMDIs of both small polar drugs and large therapeutic molecules.

Propellant-driven metered-dose inhalers for pulmonary drug delivery

The current market for pulmonary drug delivery is at a bottleneck. The therapeutic advantages of inhalation aerosols, and the potential for the lungs as a route for systemically acting drugs, vaccines and gene therapeutic agents, have resulted in a rapid growth of the industry. Alongside this, the environment of inhaler design and formulation has changed markedly in recent years. Environmental concerns over propellants, the commercial success of dry powder inhalers, and the apparent lack of advancement of propellant-driven metered-dose inhalers (pMDIs) has led to a less clear future for these devices. This review critically assesses these pressures and also potential opportunities for the pMDI. It is proposed that the future role of pMDIs will be determined by several important forces that can be classified under 'technology development' or 'market climate' categories. Technology development forces will be strengthened by the ability of the industry to have a systematic understanding of mechanisms of spray formation, perform subsequent and continued device and formulation advances, and a focus on all patient groups: particularly paediatric and geriatric populations. The ability to succeed in these areas will be largely determined by the willingness to invest in fundamental research of pMDI technologies.

The influence of formulation and spacer device on the in vitro performance of solution chlorofluorocarbon-free propellant-driven metered dose inhalers

The purpose of this study was to evaluate the hypothesis that spacer devices have limited effect on the in vitro fine particle dose emitted from solution metered dose inhalers containing different proportions of HFA134a [1,1,1,2,-tetrafluoroethane] propellant. Two solution formulations (80% and 97.5% wt/wt HFA134a) were tested across the actuator alone, actuator plus Aerochamber, and Ace holding chamber. Particle size distributions were determined using laser diffraction (LD) and cascade impaction (CI). Multimodal particle size distributions were identified using LD. CI analyses were characterized by a major mode located at approximately 0.5 microm. The fine particle dose emitted from the inhaler spacer combinations containing 97.5% HFA134a was independent of the device setup used. Fine particle doses were influenced by spacer setup in 80% HFA134a formulations, indicating different plume dynamics of low vapor pressure formulations. Sampling inlet deposition was approximately 0 when spacer devices were used with either formulation. When spacers were not used, sampling inlet deposition was increased significantly. However, inlet deposition with the 97.5% HFA134a formulation was significantly less than that of the 80% HFA134a formulation (approximately 25% of emitted dose compared with 69%, respectively). Thus, high propellant concentration formulations appear to have more robust in vitro performance. This is particularly important given the preponderance of poor patient compliance that is associated with spacer use. High propellant concentrations had the advantage of fine particle doses that were independent of the device setup and significantly lowered sampling inlet deposition when no spacer was used.

Inhalation delivery of anticancer agents via HFA-based metered dose inhaler using methotrexate as a model drug

In the present study, the feasibility of delivering anticancer drugs via metered dose inhaler (MDI) was demonstrated using methotrexate (MTX) as a model anticancer drug. MDI formulations of MTX were prepared using hydrofluoroalkane-134a containing 0.67% MTX and 10% ethyl alcohol. The particle size of MTX was reduced by cryo milling with or without a surfactant (Pluronic F77) and the milled drug was employed for MDI formulations, which were subsequently evaluated for their medication delivery, mass median aerodynamic diameter (MMAD) and geometric standard deviation (GSD). Further, the efficacy of aerosolized MTX was evaluated by determining the in-vitro cytotoxicity of MTX against HL-60 cells using a six-stage viable impactor and the induction of apoptosis in HL-60 cells by acridine orange staining. Our results indicate that MTX aerosols having an MMAD varying between 2.2 and 3.2 microm (GSD 2.6-3.7) with a respirable fraction varying between 14.2 and 17.1% could be obtained by using MTX, which was cryo milled either alone or in combination with Pluronic F77. Exposure of HL-60 cells plated in third, fourth, fifth, and sixth stages of viable impactor to two actuations of MDI showed a cell kill of greater than 50%. Further, aerosolized MTX was found to induce apoptosis in HL-60 cells, as assessed by the morphological examination of the cells with fluorescent and confocal microscopy. Our results demonstrate that it is possible to deliver cytotoxic concentrations of MTX in an in vitro system simulating the lower respiratory tract (by using a six-stage viable impactor) via MDI and the cytotoxicity of the aerosolized MTX could be further improved by the optimization of the aerodynamic size.