Metered-dose to dry-powder inhaler switch not often reversed in veterans
Key takeaways:
- A metered-dose inhaler was switched to a dry-powder inhaler in July 2021 in Veterans Affairs facilities.
- The transition went into action for nearly 75% of this study population.
A small proportion of veterans who went from a metered-dose inhaler to a dry-powder inhaler had to revert to the metered-dose inhaler, according to a research letter published in JAMA Network Open.
“Many health care systems are discussing a transition to dry-powder inhalers that have a lower carbon footprint than metered-dose inhalers,” Alexander S. Rabin, MD, of the pulmonary section at VA Ann Arbor Healthcare System and clinical associate professor in the division of pulmonary and critical care medicine at University of Michigan, told Healio. “Here we show a proof of concept — in America’s largest integrated health system — that such a transition can occur with a relatively low ‘failure’ rate (ie, requiring a transition back to a metered-dose inhaler).”
Rabin and colleagues evaluated 347,486 veterans (mean age, 65.8 years; 91.9% men) in VA facilities with a prescription for a combination inhaler to see how many patients stuck with the July 2021 VA national formulary switch from a metered-dose inhaler (budesonide-formoterol, Symbicort; AstraZeneca) to a dry-powder inhaler (fluticasone-salmeterol, Wixela Inhub; Viatris).
All included patients had a combination inhaler prescription prior to the dry-powder inhaler switch, as well as following the switch, according to the study.
The transition occurred in nearly 75% of this study population, and researchers found that a prescription for a non-fluticasone-salmeterol dry-powder inhaler in this group was reported in 14.2% of patients.
“We were surprised that among patients who were changed from the metered-dose inhaler to the dry-powder inhaler, only a fraction (1 in 6) was switched back to the old inhaler or another controller inhaler, suggesting that most patients tolerated the device substitution,” Rabin told Healio.
To gain a fuller picture on those who did not stick with the switch, researchers investigated 23,350 VA nonformulary consultations.
Compared with budesonide-formoterol inhaler requests, the number of requests for other combination inhalers was higher (12,869 vs. 10,481). Additionally, a greater proportion of the other combination inhaler requests received approval vs. the budesonide-formoterol requests (98.1% vs. 83.1%).
Researchers found several reasons for an approved request, with therapeutic failure of the dry-powder inhaler noted most frequently in both budesonide-formoterol requests (71.6%) and other combination inhaler requests (74.7%).
When analyzing the disapproved requests, “preferred alternatives were not exhausted” was the explanation frequently behind this action in both request types (budesonide-formoterol request, 83.8%; other combination inhaler request, 61.3%).
“The VA inhaler formulary change was carried out at the VA to save money given similar clinical efficacy data for Symbicort and Wixela Inhub, but we’re very interested to know the impact that this device switch had on short- and long-term health outcomes among patients with asthma and COPD in the real world,” Rabin told Healio.
“We’d also like to see an analysis of the effect of switching from metered-dose inhalers to dry-powder inhalers on net carbon emissions in the U.S. health care system,” Rabin added. “We’re hoping to answer both questions in our current and future work.”
For more information:
Alexander S. Rabin, MD, can be reached at alexander.rabin@va.gov.
Perspective
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It is ironic that the delivery of health care may actually cause health harms. However, systems are increasingly aware that greenhouse gas (GHG) generated as part of providing health care has tangible harms on the very people it is aimed to help.
One particularly stark example is the fact that commonly used inhaled medications known as metered dose inhalers (MDI) contain propellants that have outsized global warming potential that contributes to climate change and resultant health harms. Efforts to move away from MDIs to other inhaled medication delivery devices such as dry powder inhalers (DPIs) are underway globally, but evaluations of how this might impact care on a system-wide level have been lacking.
In an interesting study by Dr. Rabin and colleagues, they leverage prescription patterns as part of a VA national formulary change from a commonly used MDI, budesonide-formoterol (Symbicort, AstraZeneca) to a similar DPI-delivered version, fluticasone-salmeterol (Wixela, Viatris). This change was part of VA competitive bid processes to minimize cost for medications from equivalent classes. However, because DPIs have a fraction of the GHG contributions of MDI, this represents a significant decrease in the manufacture, purchase and use of harmful propellants. The study evaluated how the change was received by the health care system, measuring the number of requests to switch back to the MDI version or to another inhaled medication. It was interesting to see that despite a large number of conversions to DPI, there was a relatively small amount of requests to change back.
I witnessed this formulary change as a primary care provider in this system and discussed this change with patients experiencing it firsthand. Although many had issues with learning a new and different inhalation technique, most readily adapted to it and expressed satisfaction when I followed up with them. For some patients with asthma, the replacement inhaler was not in keeping with more recent treatment guidelines, as the long-acting beta agonist salmeterol component has not been demonstrated to be as effective as formoterol. It is likely this drove some of the successful requests to switch back from the DPI version.Overall, this study demonstrates that if concerted efforts to replace high GHG-containing medications are made in a large health care system, the uptake can be rapid and sustained. This can lead to cost savings, as well as improved environmental impacts. More work is needed in this area to quantify GHG savings and to understand the safest and most effective way to facilitate these transitions. Hopefully, health care systems will understand the co-benefits on a global level that such efforts can provide.
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