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Policies designed to blanket switch inhalers may cause some patients harm

Published: June 21, 2022

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic respiratory diseases, and inhaled therapies are key to their successful treatment. Many current treatment guidelines for asthma and COPD recommend that the selection of the most appropriate inhaler device should be a shared decision between the patient and their healthcare professional (HCP). While several guidelines further advocate that patients who are stabilised on their inhaler should not be switched to an alternative regimen (at least not without sufficient involvement and training of the patient), inhaler regimen substitution may nevertheless be implemented on a large scale to reduce costs or achieve environmental targets, often without the patient’s knowledge. However, it is largely unclear what the real-world outcomes of such switches may be – both to the patient and the healthcare system providing their treatment – especially if they are not done with the patient’s consent.

Usmani et al. took a broad and systematic look at the real-world evidence describing the impact of switching inhaler regimens for any reason apart from clinical need in patients with asthma or COPD. The team analyzed a broad range of switch types, including changes in device (containing the same drug), changes in drugs (maintaining the same device) or changes in both the drug and the device. The ultimate goal of the study was to assess how switching inhaler regimens could impact both the patient and the healthcare system. This included clinical outcomes (such as how well the patient controlled their disease), costs of care, the use of healthcare facilities (such as visits to the hospital) and the relationship the patient had with their HCP. This systematic review was published in the June 2022 issue of The Journal of Allergy and Clinical Immunology: In Practice.

Usmani et al included 21 real-world studies in their analysis. Most studies reported a variety of non-clinical reasons for switching patients, including reducing costs, aligning with new hospital policies or changing insurance coverage. The team found that inhaler regimen switches that happened without patient consent generally led to worsened outcomes in terms of symptom control, rescue medication use, adherence and consultation rates. Several studies reported that inhaler regimen switches could be detrimental to the patient-HCP relationship, especially when the switches were non-consented. Based on their findings, Usmani et al. suggested several best practices that could be considered when switching patients for reasons other than clinical need. The team also highlighted an urgent need to develop a robust framework to guide the personalised switching of inhalers and the subsequent evaluation of outcomes and reinforced the critical need for HCPs to undertake consent during any type of inhaler regimen switching to support the innate principles of the doctor-patient relationship. Looking to the future, the team noted that additional large, high-quality, standardised studies are needed to provide important evidence to inform policies and best practices around the conditions under which patient inhaler regimen switching should be considered and implemented effectively to avoid patient harm.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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