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A Comparison of Inhaler Devices & The Use of Inhalers in the Hospice Setting

Jennifer Chen, PharmD

A variety of new medications and combination treatments along with novel delivery devices are in development to help patients with COPD achieve improved symptom control and a better quality of life. This article will discuss different inhalation delivery devices currently available in the market (pMDI, DPI and Soft Mist Inhaler) and their limitations for hospice patients.

Types of inhalers

pMDI (pressurized metered dose inhaler) is the most commonly used device. The drug is dissolved in the propellant called hydrofluoroalkanes (HFAs) under pressure. The system releases a metered volume of propellant containing the medication. It requires a high degree of hand-breath coordination for effective treatment, which is the major disadvantage of pMDI. These devices deliver the medication at a high velocity which may result in some of the dose being deposited at the back of throat and swallowed instead of actually being inhaled, especially if the inhalation is not timed well with the actuation of the device.  Although a spacer or holding chamber may be used in conjunction with the inhaler to improve drug delivery in patients with poor coordination, this transforms the inhaler into a bulkier device that makes it less portable and more difficult to transport. Some examples of pMDI currently available in the market are Ventolin HFA, Xopenex HFA, Atrovent HFA, QVar, Flovent HFA, Advair HFA and Dulera.

DPI (dry powder inhaler) were developed to help overcome the problems of hand-breath coordination associated with pMDIs. The powdered drug is dispersed into particles by the patient’s own inspiratory effort. The issue of hand-breath coordination is resolved, but the patient must generate adequate inspiratory force to ensure that the medication from a DPI is being delivered to the lungs. This may result in erratic dosage and compromise the consistency in disease control for patients who have inadequate positive inhalation force.  Some examples of DPI currently available in the market are Foradil Aerolizer, Serevent Diskus, Adviar Diskus, Asmanex Twisthaler, and Breo Ellipta.

SMI (Soft Mist Inhaler) generates a soft mist that last longer and delivers higher fine particle fraction than the aerosol cloud, which should lead to improved lung and reduced oropharyngeal deposition versus other types of inhaler. Although the Soft Mist inhaler is not dependent on inspiratory flow rate and has simplified coordination of inhalation and actuation, the device still requires positive inhalation force and some degree of hand-breath synchronization.1 Currently Combivent Respimat, Striverdi Respimat, Spiriva Respimat and Stiolto Respimat are on the market.  

Inhaler technique

Poor inhaler technique is often a main cause of sub-optimal COPD management. In a recent study of 1664 adult patients (mean age 62 years old), critical errors were observed in 12% of patients using a pMDI and 35% of patients using a DPI.2 According to the study, the most common critical errors with MDIs and DPIs are no or short breath-holding after inhalation and failure to achieve a forceful inspiratory flow, respectively. The correct inhalation technique of soft mist inhalers resembles that used with a MDI although the study did not assess the mishandling of SMI.

Use of inhalers in the hospice setting

In general, the use of inhaler devices may be limited in the hospice setting because most end-stage COPD patients do not have effective positive force to inhale medication contents from the device nor able to synchronize actuation with inhalation. Unlike the inhalers, no special inhalation techniques are needed for optimum delivery with conventional nebulizers, which is usually the most effective way to deliver inhaled medications in hospice patients. An inhaler should only be prescribed with the absolute certainty that the patient can use it correctly. Continued and repeated education for both healthcare professionals and patients in correct inhalation technique is essential to ensure optimal COPD management.

Clinical resources

The Clinical Resources section of the Outcome Resources Member's website contains some additional information that may be helpful.  The Clinical Resources section is available to all Outcome Resources hospice clients through the “Member Login”.


  • Inhaled Respiratory Medication Chart:   This chart lists all of the currently available inhaled respiratory medication products grouped according to pharmacologic type & duration of action.   It is an excellent resource to help identify unnecessary therapeutic duplications in the drug regimen.  This chart also contains comparative cost information and common dosages.


  • Inhaler Information & Instructions for use:  This section contains specific detailed instructions for the use of many of the inhaled respiratory metered-dose devices


  1. Dalby R, Spallek M, Voshaar T. A review of the development of Respimat Soft Mist Inhaler. Int J Pharm 2004, 283:1-9.
  2. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105(6):930-8.

Photo Credit


Management of Adverse Events of Antipsychotic Medications in Hospice Patients

Jennifer Chen, PharmD

Antipsychotic medications cause four main extrapyramidal symptoms: pseudo-parkinsonism, akathisia, acute dystonia and tardive dyskinesia. (Tardive dyskinesia, tardive dystonia and neuroleptic malignant syndrome associated with prolonged treatment of antipsychotic medications are not typically seen in hospice patients and will not be included in this discussion.)

Acute dystonia involves with spastic contractions of the muscles, most commonly, in the head and neck. It can occur after a single dose of the antipsychotic agent or days after initiating treatment. Acute dystonic reactions can be life threatening if left untreated. Signs and symptoms are often resolved within 10 minutes of using IM or IV benztropine or diphenhydramine.

Akathisia is commonly described as “anxiety” or “agitation” due to the patient’s presentation of inner motor restlessness. Therefore, it can be difficult to differentiate akathisia from psychiatric anxiety and agitation. Although it is more likely with older generation (traditional) agents, it can also be seen with second-generation antipsychotics. Treatment options include: dose reduction, addition of a low-dose beta blocker (propranolol 20-40mg/d) or a low-dose benzodiazepine (lorazepam 0.5mg q12h).

Pseudo-parkinsonism is a reversible syndrome that include extra-pyramidal symptoms (EPS) such as: stiff posture, shuffling gait, masked facial expression and slow pill-rolling finger tremors. It is often dose-related, therefore it is frequently managed by dose reduction. Most patients recover within two months, and often recover within hours or days of reducing the dose. Anticholinergic drugs are best avoided in older patients because they may cause confusion as well as worsening tardive dyskinesia. Anti-parkinsonism medications such as amantadine may be used to treat drug-induced Parkinsonism. However, it is more suitable for younger patients with drug-induced Parkinsonism as they may also cause confusion and sometimes psychosis in older people. Prophylactic anticholinergics (eg. benztropine and trihexyphenidyl) and anti-parkinsonism medications for hospice patients with prior history of EPS and for those treated with relative high doses of antipsychotic drugs are not recommended due to unfavorable risk profile in older patients.

First generation antipsychotics (FGA) such as haloperidol have been thought to cause more EPS than second-generation antipsychotics (SGA). In fact, recent clinical trial has found there was no statistically significant difference between the treatment groups (FGA vs. SGA) in terms of EPS profile.(1) A systematic review and meta-analysis also compared the new generation antipsychotics versus low-potency conventional antipsychotics and have shown that optimum doses of low-potency conventional antipsychotics might not induce more EPS than new generation drugs.(2) EPS is a potential risk for all antipsychotics so early detection and effective management are important to reduce complications. The use of first generation antipsychotics should not be disregarded due to its risk of EPS and in fact, the older class of drugs are usually associated with better outcomes and lower costs.


  1. Peluso MJ, Lewis SW, Barnes TR, Jones PB. Extrapyramidal motor side-effects of first-and second-generation antipsychotic drugs. Br J Psychiatry. 2012 May;200(5):387-92.
  2. Leucht S, Wahlbeck K, Hamann J, Kissling W. New generation antipsychotics versus low-potency conventional antipsychotics: a systematic review and meta-analysis. Lancet. 2003;361(9369):1581–1589.


Haloperidol Use for Hospice Patients in the Nursing Facility

Jim Joyner, PharmD, CGP

Haloperidol (Haldol) is one of the most useful medications in the hospice setting. It is classified as an antipsychotic drug and is widely used to help manage psychotic symptoms and agitated states resulting from a variety of conditions during end-of-life care in hospice patients. In addition to the psychotropic activity, it is very effective for controlling nausea and vomiting, especially nausea-vomiting that is induced by opioids. Haloperidol is available in a variety of dosage forms including crushable oral tablets, oral concentrated solution (2mg/ml) which may be given sublingual, and a sterile solution for IM or IV injection. These various dosage forms are very advantageous for compromised hospice patients who can no longer take traditional oral tablets due to lack of adequate swallowing ability or severe nausea. 

Unfortunately, many hospices have experienced resistance from administrators and directors when they attempt to use Haloperidol during end-of-life care for their patients who reside in skilled nursing facilities (SNFs). In some cases, this resistance has risen to the level of threatening to completely derail the relationship between the hospice and the SNF. Reasons for the resistance often do not have anything to do with quality of patient care, but are driven primarily by fear of deficiency reports and related fines which might be levied upon the SNF by State and Federal licensing agencies citing the inappropriate use of this drug.   

Haloperidol is an antipsychotic drug. The Centers for Medicare and Medicaid (CMS) have developed very strict standards governing the use of all antipsychotic drugs in patients who reside in the skilled nursing facilities.  These standards are backed with the force of regulation and licensing survey teams may assess deficiency notices and fines with regard to perceived inappropriate use of these antipsychotic medications in the SNF.(1)  The regulatory measures were developed in response to past history of abusive practices at some SNFs where antipsychotics were used inappropriately to “chemically restrain” patients and not as a part of coordinated clinically acceptable intervention to manage their condition.  Current regulations have been drafted with the intent to ensure that antipsychotic drugs are used to treat a specific documented condition for which the medication helps to maintain the patient’s highest practicable mental, physical, and psychosocial well-being in collaboration with the attending physician and facility staff. This includes the administration of the lowest effective dosage, for a duration that is clinically indicated to treat the patient’s specific condition, and appropriate non-pharmacological interventions are considered as a part of therapy along with the antipsychotic drug. Periodic tapering of doses and trials of discontinuation are also recommended as a part of the detailed regulatory guidance for this class of drugs. Close monitoring of patient behaviors and possible adverse effects is required along with detailed documentation of all observations related to the monitoring.   

SNF compliance with these regulations can be daunting considering the level of documentation required as well as the highly subjective way in which many of the licensing survey teams interpret the regulations and apply them to individual patients. This is why many SNF administrators and directors of nursing may view antipsychotic medications, and Haloperidol specifically, as high risk to their organization. For this reason, most SNFs will attempt to limit antipsychotic utilization as much as possible.  

These regulations were created with the intent to guide antipsychotic utilization in the SNF patient suffering from one of the various forms of dementia or otherwise unspecified agitation. For this reason, specific exceptions were written into the surveyor guidance regarding intent of the regulation. The exceptions preclude requirements normally imposed on the use of these medications in the SNF. One of these exceptions is the use of antipsychotic drugs for “adjunctive therapy at end of life,” and another exception is for “nausea and vomiting associated with cancer or cancer chemotherapy”. This is exactly the case when Haloperidol (or other antipsychotics) are used for a hospice patient in the SNF. Unfortunately, many practitioners as well as some licensing surveyors are not well versed on the distinction between these exceptions for hospice patients and other non-hospice SNF patients.  Hospice directors and administrators can take a lead role by being pro-active and discussing this issue with their counter parts at the SNFs to help correct the misconceptions.  

Haloperidol is sometimes singled out as the major offender of this regulatory scenario since it is one of the older classes of antipsychotic drugs commonly referred to as “traditional” antipsychotics.  The newer generation of antipsychotic drugs such as Quetiapine (Seroquel) or Risperidone (Risperdal) are commonly referred to as “atypical” antipsychotic drugs since they tend to be more effective for certain types of atypical psychoses associated with catatonia. The older, traditional antipsychotic drugs may have a greater risk for inducing involuntary movement disorders (parkinsonism, tardive dyskinesia, etc.) than the newer atypicals in general. For this reason Haloperidol is sometimes perceived to be a greater risk to SNF patients than the newer generation antipsychotic drugs. This may be true at high doses, however, at daily doses of 5mg or less (commonly used), haloperidol is tolerated just as well as the newer generation antipsychotic drugs. (2,3) In addition, much of the involuntary movement disorder risk is associated with longer durations of therapy of 3 to 6 months, or more. Such long durations of therapy are unusual for hospice patients.  

It was never the intent of the SNF regulations to restrict the use of antipsychotic drugs, including Haloperidol, for use in managing end-of-life symptoms in hospice patients.  Unfortunately, the distinction between end-of-life care and care for other nursing home residents has become blurred in many instances resulting in the denial of an extremely useful medication for dying patients.  


1. Federal regulation (Centers for Medicare & Medicaid Services – Skilled Nursing Facilities)

F-329; 483.25(l) Unnecessary Drugs, subsection 2. Antipsychotic Drugs

2. Parellada,et al. Risperidone in the Treatment of Patients with Delirium

J. ClinPsychiatry2004;65:348-53. 16

3. Han, et al. A Double Blind Trial of Risperidone and Haloperidol for the

Treatment of Delirium.

Psychosomatics2004:45(4): 297-301


Atropine Sulfate Ophthalmic Solution Shortage and its Implications to Hospice Practice

Esther Liu, PharmD, MSIA, CGP

As of April 20th, 2015, the American Society of Health-System Pharmacist (ASHP) has officially announced that there is a shortage of atropine ophthalmic solution.

Atropine was one of the U.S. Food and Drug Administration (FDA) grandfathered medications originally marketed before 1938 which was prior to current requirement of filing a New Drug Application with the FDA.   Many manufacturers could legally produce generic atropine products without filing New Drug Application (NDA) or Abbreviated New Drug Application (ANDA), which made atropine ophthalmic solution a very cost-effective medication in the past. 

Since July 2014, Akorn, one of the many generic atropine ophthalmic solution manufacturers, filed an original NDA for atropine ophthalmic solution and obtained FDA approval. This act removed atropine ophthalmic solution from the FDA’s grandfather list. This requires any manufacturers, who wish to continue producing atropine ophthalmic solution to file for an ANDA and obtain FDA approval. This shift in FDA approval status on atropine ophthalmic solution has discouraged the rest of the generic manufacturers from continuing to produce the product and Akorn has become the only atropine ophthalmic solution manufacturer since January 2015. Due to this sudden drop in availability from multiple manufacturers, there has been a shortage of atropine ophthalmic solutions from Akorn, as well as a significant price hike on this medication.

Moving forward, we will expect to see only the Akorn atropine ophthalmic solution products in the market until more generic manufacturers have successfully obtained FDA approval on their ANDA. There is no estimated date on when this will happen.

Here is the current price and shortage status for the Atropine Sulfate 1% Ophthalmic Solution, Akorn

2ml Bottle, NDC 17478-0215-02 ---- AWP $30.74 (~ 1week supply if used 1 gtt QID)

5ml Bottle, NDC 17478-0215-05 ---- AWP $58.35 (~ 2 weeks supply if used 1 gtt QID) à shortage

15ml Bottle, NDC 17478-0215-15 ---- AWP $95.25 (~ 4 – 6 weeks supply) à back ordered

In a hospice setting, atropine ophthalmic solution was recommended in many hospice formularies and their comfort kits for the use of managing excessive secretions when used orally. Atropine injectable solution was sometimes used orally as well as a substitution when the ophthalmic solution was not available, but there is currently also a shortage of this formulation since February 2015.  Here are some comparable cost-effective alternatives for managing excessive secretions while atropine ophthalmic solution is in shortage (price quoted on 15 day-supply):

Hyoscyamine (Levsin) 0.125mg Sublingual tab (0.125mg QID) --- AWP $52

Glycopyrrolate (Robinul) 1mg tab (1mg TID) --- AWP $59

Atropine Eye Drop 5ml Bottle (1gtt QID) ---- AWP $58 à in shortage

With the current increase in price of atropine ophthalmic solution, the cost of managing excessive secretions routinely is roughly the same amongst atropine ophthalmic solution, hyoscyamine and glycopyrrolate (see above price comparison for 15 days).  However, atropine ophthalmic solution is a less cost-effective option for hospice comfort kits now due to its smallest non-breakable package size being a 2ml bottle (cost $30 per bottle) in comparison to Levsin or Robinul, which can be dispensed in smaller quantity such as 6 tablets ($5 - $8). It is highly recommended for hospices using atropine ophthalmic solution to evaluate the need to substitute atropine with hyoscyamine on their formulary, as well as their comfort kits due to the significant accessibility issues and cost-effective reasons. 



ASHP Drug Shortage Updates:


FDA Drug Shortage Database:




Medications for Managing Hiccups

Dr. Jim Joyner, PharmD, CGP

A hiccup is an involuntary reflex involving the respiratory muscles of the chest and diaphragm, mediated by the phrenic and vagus nerves and a central (brainstem) reflex center. A single episode can last for a few seconds to as long as several days. Persistent hiccups can last for months. There are a wide range of possible causes for hiccups including; stress or excitement, esophageal or gastric distension, liver disease, CNS lesions, or cancer. Irritation of the vagus nerve or the diaphragm is a common mechanism.  

Many drug and non-drug treatments have been used, but there is little evidence of any one superior approach to management; virtually all current data are anecdotal. When choosing a drug treatment strategy for hiccups, consider the suspected etiology, patient’s drug-allergy history, potential drug-disease state contraindications, and potential adverse effects from any proposed drug therapy.

Chlorpromazine (Thorazine) is the only drug with an FDA approved indication for treatment of hiccups. Haloperidol (Haldol) is a useful alternative. Chlorpromazine and Haloperidol should not be used in patients with Parkinson’s disease because they may exacerbate involuntary movements. Metoclopramide (Reglan) increases GI motility and may be especially useful if hiccups are related to esophageal or gastric distention. The muscle relaxant, Baclofen (Lioresal), is thought to have a direct relaxation effect upon the diaphragm and may be most useful in patients where an irritation of the diaphragm is suspected. Dexamethasone (Decadron) may be appropriate as an adjunct to one of the previously mentioned drugs if there is hepatomegaly or tumor involvement. All of these drugs are available as relatively low cost generics, so the choice of therapy should be based upon the suspected etiology behind the hiccups, the patient’s drug allergy history, and other health conditions that may predispose the patient to adverse drug effects. In difficult cases it may be necessary to combine two to three of the drugs listed below in order to achieve adequate results (haloperidol and chlorpromazine should not be combined because they exert a similar mechanism of action that would represent at therapeutic duplication).  

Common Doses for Hiccups: 

Chlorpromazine (Thorazine)  25-50mg Q6h po,pr

Haloperidol (Haldol) 1– 2mg Q6h po, sl

Metoclopramide (Reglan) 10-15mg Q6h po

Baclofen (Lioresal) 5 –10mg Q6h  po

Dexamethasone (Decadron) 2-6mg daily po



Nebulized Inhaled Opioids for Dyspnea

Dr. Jim Joyner, PharmD, CGP

Opioids are the mainstay of treatment for management of severe dyspnea in late stage CHF and COPD.  The use of opioids in dyspnea is supported by extensive experience as well as clinical studies with the use of both oral and parenteral opioids, specifically morphine. The mechanism of action is unclear and it is interesting that opioids can alleviate dyspnea in many patients without changing the respiratory rate or producing any measurable changes in blood gas parameters.  Speculation as to the actual mechanism of action has centered around the probability that opioids decrease brainstem responsiveness to carbon dioxide and diminish reflex vasoconstriction caused by increased PCO2 levels, decreasing the perception of dyspnea.   There is also the opioid induced effect of decreased anxiety which often accompanies dyspnea.      

Morphine and other opioids are often administered in small doses orally, sublingually, or by injection (SC & IV) for dyspnea management.   Nebulized inhaled opioids are also used for this purpose, but to a much lesser extent.   The use of the inhaled route of administration is favored by some in the palliative care community because of the possibility of a more rapid onset than oral or sublingual routes and possibly less side-effects than systemically administered opioids.

There are no controlled trials to confirm the perception that nebulized opioids have any clear benefits over the other more conventional routes including oral, sublingual, subcutaneous, and intravenous.   One extensive review of 18 randomized, double-blind, controlled trials of opioids for management of dyspnea in terminally ill patients concluded that there was adequate evidence to support the use of oral or IV opioids for dyspnea, but not the use of nebulized opioids. (1)    An earlier published report evaluated blood levels after nebulized morphine and orally administered morphine which demonstrated rapid absorption by the inhaled route compared with oral morphine, but significantly more variability. (2)

Disadvantages of administering opioids via nebulizer would include to the following:
• Increased cost over other routes (nebulizer & preservative-free drug solutions)
• More complex method of administration
• Lack of portability (nebulizer)

If opioids are to be used via nebulizer, the “preservative-free”, sterile solutions for injection are preferred in order to avoid respiratory irritation.   The drug solution is diluted in 2 to 3ml of “preservative-free” normal saline prior to administration.  Doses used fall within these ranges:

Morphine 2.5 – 10mg
Hydromorphone 0.25 – 1mg
Fentanyl  25- 50mcg

The majority of hospice patients with dyspnea will benefit from non-inhaled opioids and tolerate them well.   The nebulized opioid alternative may be appropriate for those few patients who may refuse oral or injectable opioids or those who have exhibited certain adverse effects to systemic therapy.  

(1) Jennings, Davies, Higgins et al.  Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev. 2001; 4CD002066
(2) Masood, Thomas. Systemic absorption of nebulized morphine compared with oral morphine in healthy subjects. Br J Clin Pharmcol. 1996; 41:250-2


New Long-Acting Beta-2 Agonist Bronchodilator in the Respimat Formulation for COPD

Dr. Stephanie Cheng, PharmD, MPH

Striverdi Respimat was given FDA approval on July 31, 2014 and is indicated for use as a long-term, once-daily maintenance bronchodilator treatment of COPD, including chronic bronchitis and/or emphysema. The active ingredient, olodaterol, is a long-acting beta2-adrenergic agonist (LABA) bronchodilator that is formulated as a liquid spray for use via the latest type of inhalation device called a Respimat.  The recommended dose is 2 inhalations once daily.  Each actuation of the device delivers 2mcg of olodaterol.

Warnings/Side Effects

Thus far, Striverdi Respimat has only been indicated for use in COPD and has not been studied in patients with asthma.  As with all LABA, it is not for use for the relief of acute symptoms and is contraindicated in patients with asthma without use of a long-term asthma control medication.  Striverdi Respimat should not be initiated in patients with acutely deteriorating COPD and should be used with caution in patients with cardiovascular or convulsive disorders, thyrotoxicosis or sensitivity to sympathomimetic drugs. A life-threatening paradoxical bronchospasm can occur and Striverdi Respimat should be discontinued immediately.  The most common adverse reactions include: nasopharyngitis, upper respiratory tract infection, bronchitis, urinary tract infection, cough, dizziness, rash, diarrhea, back pain and arthralgia.

Safety and Efficacy

Compared to other LABA bronchodilators (formoterol, indacaterol, salmeterol, and arformoterol), olodaterol has demonstrated similar safety and efficacy. 

Comparison Chart

Advantages of Striverdi Respimat

Striverdi Respimat is being promoted with two advantages over the current LABA on the market.  The first advantage is Striverdi Respimat is dosed as once daily.  All of the other LABA, aside from Arcapta Neohaler (indacaterol), are dosed BID. 

The second promoted advantage of Striverdi Respimat is the drug delivery system.  The Respimat Inhaler system is a multi-dose, propellant-free, hand-held liquid inhaler.  The device delivers a pre-measured amount of medication in a slow-moving mist, which the patient inhales through a mouthpiece. This method of medication delivery allows more of the drug to enter the lungs instead of the esophagus compared to devices with a propellant, such as a Metered Dose Inhaler (MDI).  Compared to the LABAs that come as a Dry-Powder Inhaler (DPI) (formoterol, indacaterol and salmeterol), a patient requires less force to inhale the medication. There have also been studies done which show that patients preferred the Respimat device over the other types of inhaled drug delivery devices, particularly if the patient has vision problems or arthritis.

These advantages are hoped to improve patient compliance with the medication.

Disadvantages of Striverdi Respimat

One of the main disadvantages of Striverdi Respimat is that in patients with COPD, positive inhalation pressure becomes a problem as the disease progresses. Most patients with severe or end-stage COPD are unable to inhale deep enough for inhalers to be effective and are generally switched to the nebulized form of LABAs (Brovana or Perforomist). 

Another disadvantage of Striverdi Respimat is that it requires more training and education for a patient to use it correctly.  One clinical trial comparing a patient’s proper technique in using the Respimat or a MDI for the first time demonstrated that the proportion of patients demonstrating good technique was higher for the MDI (80%) versus the Respimat (48%).  By the final attempt, 98% of patients demonstrated satisfactory inhaler technique with the MDI compared to 96.4% with the Respimat.

Cost is a third disadvantage of Striverdi Respimat.  Similar to other long-acting beta agonist bronchodilators currently available (Arcapta, Foradil, Serevent),  Striverdi Respimat is also relatively expensive.  Cost for these products may range between $6 - $8 per day based upon average wholesale price (AWP).

Place in Hospice Therapy

Although Striverdi Respimat provides another option for patients with COPD that could help with improving patient compliance with the medication, it is largely cost prohibitive in the hospice setting.  Additionally, because of the training required for proper inhaler technique and the inability of most severe or end-stage COPD patients to have enough positive inhalation, this dosage form may not be as efficacious compared to other dosage forms.

1. [Package Insert] Striverdi Respimat (olodaterol) Inhalation Spray. Boehringer Ingelheim Pharmaceuticals, Inc. Aug 2014.
2. Anderson P. Use of Respimat Soft Mist Inhaler in COPD patients. Int J Chron Obstruct Pulmon Dis. Sept 2006;1(3):251-259.
3. Feldman GJ, Bernstein JA, Hamilton A, et.al. The 24-h FEV1 time profile of olodaterol once daily via Respimat and fomoterol twice daily via Aerolizer in patients with GOLD 2-4 COPD: results from two 6-week crossover studies. Springerplus. 2014 Aug 9;3:419.
4. Koch A, Pizzichini E, Hamilton A, et.al. Lung function efficacy and symptomatic benefit of olodaterol once daily delivered via Respimat versus placebo and formoterol twice daily in patients with GOLD 2-4 COPD: results from two replicate 48-week studies. Int J Chron Obstruct Pulmon Dis. 2014 Jul 5;9:697-714.


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New Research: ABH Topical Gel vs Placebo Controlled Clinical Trial for Nausea Treatment

Dr. Jim Joyner, PharmD, CGP

The results of a clinical trial of ABH topical gel vs placebo for the management of nausea in cancer patients were recently published in the Journal of Pain and Symptom Management.(1)  ABH topical gel is a pharmacy-compounded product consisting of Lorazepam (Ativan), Diphenhydramine (Benadryl), and Haloperidol (Haldol) usually prepared in a pluronic lecithin organogel (PLO) base. It has been used frequently in some palliative care settings for management of nausea and vomiting, despite very limited scientific data to support continued use. The product has gained a following due to the ease of use (topical administration) and perceived efficacy.

This recent study was a well designed, randomized, double-blind, placebo controlled, crossover clinical trial to compare the effectiveness of ABH topical gel against a placebo gel. The trial was completed with 20 patients who had an active cancer diagnosis. Nausea in these patients was related to the following: pain, pain medication, bone marrow transplant, or related to their cancer. Results of this trial showed no difference in efficacy between ABH topical gel or the placebo gel for treating nausea or vomiting. The researchers concluded that ABH topical gel should not be used in cancer patients experiencing nausea.

The results of this trial are consistent with earlier research on healthy volunteers who received topical ABH gel and had serial blood samples drawn at various intervals up to 4 hours after application.(2) Blood levels of each of the 3 drugs were evaluated. That small study on 10 volunteers, published in 2012, demonstrated that none of the three medications in the ABH gel formulation were absorbed to any significant degree. The researchers concluded that topical application of this product was ineffective.

The data is conclusive that ABH topical gel is not an efficacious product and cannot be recommended.

(Also see our previous 2011 blog article on ABH Gel.)

1. Fletcher, Coyne, Dodson, et al. A Randomized Trial of the Effectiveness of Topical ABH Gel vs Placebo in Cancer Patients with Nausea. Journal of Pain and Symptom Management. Vol 48;5.
November 2014
2. Smith, Ritter, Poklis, et al. ABH Gel is not Absorbed From the Skin of Normal Volunteers.
Journal of Pain and Symptom Management. Vol 43;5 May 2012


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New Spiriva Formulation Available in January 2015

Jennifer Chen, PharmD

A new formulation of Spiriva will be available on the market in January 2015. Both Spiriva Handihaler and Spiriva Respimat contain the same active ingredients – tiotropium.  Tiotropium is an anticholinergic bronchodilator indicated for the long-term, once-daily, maintenance treatment for COPD. This new formulation turning the inhalation powder of tiotropium into inhalation spray is called Spiriva Respimat. The dry-powder inhalation, Spiriva HandiHaler, will continue to be available on the market. Spiriva Respimat provides a pre-measured amount of medicine in a slow-moving mist that helps patients inhale the medicine and is intended to deliver medication in a way that does not depend upon how fast the dry powder is breathed in from the inhaler. This new formulation may reduce the errors involving the inadvertent oral administration of Spiriva HandiHaler capsules for inhalation. 

The results from clinical trial (TIOSPIR) shows Spiriva Respimat had a safety profile and exacerbation efficacy similar to Spiriva HandiHaler device(1). The most common side effects reported include sore throat, cough, dry mouth and sinus infection. One study assessed the effect of switching from HandiHaler to Respimat in patients with COPD shows similar effects and usability but patients experienced cough for the first 4 weeks of switching before they got used to the new formulation. The other finding was that dry mouth appeared to improve after switching to Respimat. However, this study was done on a small group of COPD patients (about 30 patients) and these patients were followed for 12 weeks after switching(2).

With similar costs and efficacy, the use of Spiriva Respimat may be limited in the hospice setting due to its requirement of active inhalation for effectiveness of drug delivery and training of inhaler technique as most end-stage COPD patients do not have effective positive force to inhale medication contents from the inhalers.

Comparison of Spiriva HandiHaler and Spiriva Respimat and Instructions

1. Wise RA, Anzueto A, Cotton D, et al. Tiotropium Respimat Inhaler and the Risk of Death in COPD. N Engl J Med 2013;369:1491-501.
2. Asakura Y, Nishimura N, Maezawa K, et al. Effect of switching tiotropium HandiHaler to Respimat Soft Mist Inhaler in patients with COPD: the difference of adverse events and usability between inhaler devices. J Aerosol Med Pulm Drug Deliv 2013 Feb;26(1):41-5.

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Hospice Medication Alert: Another Long-Acting Hydrocodone Medication is Approved

Jim Joyner, PharmD, CGP

Hysingla ER,  extended-release hydrocodone, has recently been approved by the FDA on November 20, 2014.   This is the second single-entity, extended release hydrocodone medication to be approved in a little over 1 year.  Last fall, Zohydro ER was approved and detailed on the Outcome Resources blog in March of 2014.   Both of these products are intended for routine management of chronic severe pain.  

Hydrocodone analgesics were previously only available in combination with acetaminophen (as Lortab, Norco, or Vicodin) or in combination with ibuprofen (Vicoprofen).    These new products represent a significant increase in hydrocodone unit strengths.   The older combination products contained hydrocodone in strengths of 5 or 10mg, while the two new extended release products are available in single tablet or capsule strengths as high as 50mg (Zohydro ER capsule) or 120mg (Hysingla ER tablet).   The availability of hydrocodone in these new strengths, which are 5 to 10 times greater than the old combination products, have many clinicians very concerned about the potential for serious dosing errors, mis-use, or abuse of these new high-potency opioid products.   Both of these products are being touted by the manufacturers as being free from the risk of acetaminophen induced liver toxicity that may occur with high doses of the older combination products.   While this is true, the greater risk may actually be associated with the much higher strengths of hydrocodone available in these new products.

Hysingla ER has been formulated to reduce the potential for abuse when the drug is chewed and then taken orally, or crushed and snorted, or injected.  The tablet is difficult to crush, break or dissolve. It also forms a viscous hydrogel (thick gel) and cannot be easily prepared for injection. The FDA has determined that the physical and chemical properties of Hysingla ER are expected to make abuse by these routes difficult.  However, abuse of Hysingla ER by these routes is still possible.    Zohydro ER is not currently available in an abuse deterrent dosage-form, however, the manufacturer has applied to the FDA for approval of a new version of the product that would have similar deterrents built into it.  FDA approved Zohydro ER last year amid significant criticism related to the product’s lack of abuse deterrent attributes.   If approved, the new abuse deterrent version of Zohydro ER would be available in the spring of 2015.  

Hysingla ER is designed to release drug over a 24 hour period.  It should be taken just once a day (every 24 hours) on a routine schedule.  It is not appropriate for “prn” usage for breakthrough pain.   Several strengths will be available:   20, 30, 40, 60, 80, 100 and 120mg.   Tablets must be swallowed whole.

Zyhydro ER is designed to release drug over a 12 hour period.   It should be taken every 12 hours on a routine schedule.   Like Hysingla ER, it is not appropriate for “prn” use either.  Zohydro ER is available in the following strengths:  10, 15, 20, 30, 40, and 50mg.   Capsules must be swallowed whole.   Alcohol must be avoided in patients taking Zohydro.  Consumption of alcoholic beverages or the use prescription or non-prescription products that contain alcohol while taking Zohydro ER may result in increased plasma levels and a potentially fatal overdose of hydrocodone.  

The role of these new long-acting hydrocodone products in hospice patients will be very limited due to factors such as high cost and the availability of other long-acting opioids with established track records of efficacy in severe chronic pain (Methadone tablets and solution, Morphine Extended Release dosage-forms, etc.)  

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