NAPLEX Question of the Week: It isn't easy being wheezy

This week's question involves a commonly asked question among pharmacists: device technique among inhalers.
NAPLEX Question of the Week: It isn't easy being wheezy
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FB is a 50 year old female who comes into your pharmacy to fill a new prescription for Anoro Ellipta 1 inhalation once daily and Proventil HFA 2 inhalations every 4 to 6 hrs PRN shortness of breath. FB is a regular patient who you know has a past medical history of hypertension, 15 pack year smoking history, GERD, and seasonal allergies. Her current medications are lisinopril 20 mg QD, Wellbutrin 150 mg BID, famotidine 20 mg BID, and Flonase PRN seasonal allergies. FB told you she was recently diagnosed with COPD and she was given a prescription for a new inhaler, but she doesn’t know how to use it.  She tells you years ago she had a prescription for Proventil HFA in the past, and she remembers how to use that, but she isn’t sure if her new inhaler is the same. 

Which of the following would you counsel FB on today regarding the use of her Anoro Ellipta inhaler? Select all that apply:

A. Shake the inhaler before using and then prime the inhaler before your first dose.

B. After placing your lips around the mouthpiece take a long deep breath through your mouth then remove the inhaler and hold your breath for 3-4 seconds.

C. If you open and close the cover without inhaling you will lose a dose.

D. If you inhale again after your first inhalation you will get a double dose of your medicine. 

E. There is a counter on the inhaler that counts down by 1 every time you open the cover. 

Brand/Generics Covered: Proventil HFA(Albuterol), Anoro Ellipta(Umeclidinium/Vilanterol), Zestril(Lisinopril), Wellbutrin(Bupropion),  Pepcid(Famotidine), Flonase(Fluticasone propionate)

Answers with Rationale

As a pharmacist you could be asked to answer a patient’s question about their inhalers and with so many different types of inhalers available, it is important to know how to counsel on each. For patients using inhalers, technique can be crucial for the patient getting the full dose and seeing results with their disease state whether it be asthma or COPD. In this question the patient is picking up a prescription for a LABA + LAMA ellipta inhaler. Most manufacturers including the one that makes Anoro Ellipta provides good summaries of how to properly their inhaler devices. Let's discuss the Anoro Ellipta inhaler. 

There is a counter on the inhaler and it should start with 30 doses. When the counter gets down to 10 doses left it will turn red and it will help remind the patient to refill their prescription. The Anoro Ellipta does not require shaking or cleaning. These are the directions for use:

  1. First slide the counter down to reveal the mouthpiece and hear a click, once this click is heard the dose is ready.

  2. Next breathe out in a direction away from the mouthpiece. 

  3. After the full exhale put the mouthpiece between your lips with good coverage over the mouthpiece. Take one steady long inhale through your mouth, then remove the inhaler from your mouth and hold your breath for 3-4 seconds. In this process be careful not to block the air vent and do not breathe in through your nose. 

  4. After holding your breath for 3-4 seconds, breathe out fully. The dose has been administered even if you can’t feel or taste the medicine.

  5. Now close the inhaler by closing the cover over the mouthpiece fully.

In this situation it would be important for the patient to understand the differences between the Proventil HFA inhaler and the Anoro Ellipta inhaler. With inhalers, it is also important to emphasize how often the patient will take their dose, and it can vary greatly between inhalers. For the Anoro Ellipta, the patient should take one inhalation once daily. The patient should always have a rescue inhaler and the patient should not use Anoro Ellipta to treat sudden symptoms. 

Answer choice A is incorrect, because the Anoro Ellipta inhaler does not require shaking before using or priming. However, the HFA inhaler does require shaking and priming before use. Answer choice B and C are correct, because the Anoro Ellipta loads a dose every time the click is heard and if the mouthpiece is subsequently closed without inhaling then the dose is lost. Answer choice D is incorrect because the patient can’t take two doses without clicking the inhaler between doses. Answer choice E is correct, because the patient will see a counter count down all of their doses. 

Therefore, the correct answers are B, C, and E. 

NAPLEX Core Competencies covered:

2.2 (Brand/generic), 3.5 (Drug route of administration), 5.5 (Instructions or techniques for drug administration), 

Sources: https://www.anoro.com/about-anoro/how-to-use-anoro/

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