New Drug Update 2011-2012
Deborah Sturpe, PharmD, BCPS
Associate Professor
The speaker has NO actual or potential conflicts of interest in
relation to this educational activity or presentation.
Objectives
• Identify pertinent package insert information
for each drug presented
• Define place in therapy for each drug
presented
• Review significant new dosage forms
Today’s Drugs of Focus
Body System
Brand (generic)
Cardiovascular
 Brilinta (ticagrelor)
 Edarbi (azilsartan)
 Xarelto (rivaroxaban)
CNS
 Horizant (gabapentin enacarbil)
 Viibryd (vilazodone)
Endocrine
 Tradjenta (linagliptin)
HEENT
 Zioptan (tafluprost)
Infectious Disease
 Natroba (spinosad)
 Sklice (ivermectin lotion)
Pulmonary
 Arcapta (indacaterol)
 Daliresp (roflumilast)
Other Drugs Approved Jan 2011-April 2012
Brand (generic)
Indication(s)
Caprelsa (vandetanib)
Thyroid cancer
Dificid (fidaxomicin)
C. diff infection
Edurant (rilpivirine)
HIV
Evivedge (vismodegib)
Basal cell carcinoma
Ferriprox (deferiprone)
Iron chelation
Incivek (telaprevir)
Hepatitis C
Inlyta (axitinib)
Renal cell carcinoma
Jakafi (ruxolitinib)
Myelofibrosis
Kalydeco (ivacaftor)
Cystic fibrosis
Omontys (peginesatide)
Anemia in dialysis
Onfi (clobazam)
Lennox-Gastaut syndrome
Picato (ingenol mebutate)
Actinic keratosis
Potiga (ezogabine)
Partial-onset seizures
Victrelis (boceprevir)
Hepatitis C
Xalkori (crizotinib)
Lung cancer
Zelboraf (vemurafenib)
Melanoma
Zytiga (abiraterone)
Prostate cancer
New Dosage Forms of Interest
Brand (generic)
What’s New?
Combivent Respimat (ipratropium/albuterol)
Non-CFC MDI formulation
Duexis (ibuprofen/famotidine) 800 /26.6 mg
Combination agent
Forfivo XL (bupropion) 450 mg
New strength
Gralise (gabapentin) 300 mg, 600 mg
Once daily formulation
Intermezzo (zolpidem) 1.75 mg, 3.5 mg
Sublingual tablet
Janumet XR (sitagliptin/metformin) 50/500 mg, 50/1000 mg, 100/1000 mg
Extended release
Jentadueto (linagliptin/metformin) 2.5/500 mg, 2.5/850 mg, 2.5/1000 mg
Combination agent
Juvisync (sitagliptin/simvastatin) 100/10 mg, 100/20 mg, 100/40 mg
Combination agent
Oxecta (oxycodone) 5 mg, 7.5 mg
Does not crush/dissolve
Qnasl (beclomethasone)
Nasal dry powder formulation
Rezira (hydrocodone/pseudoephedrine) 5/60 mg
Combination agent
Zetonna (ciclesonide)
New strength
Zutripro (hydrocodone/chlorpheniramine/pseudoephedrine) 5/4/60 mg
Combination agent
Zyclara (imiquimod) 3.75%
New strength
New First Time Generics
Now Available
Anticipated by End 2012
Avapro
Avalide
Boniva
Avandamet
Caduet
Avandaryl
Femcon Fe
Provigil
Geodon
Plavix
Levaquin
Lescol XL
Lexapro
Lunesta
Lipitor
Clarinex
Ritalin LA
Tricor
Seroquel
Actos
Teveten
Alocril
Xyzal
Singulair
Zyprexa
Diovan and Diovan HCT
Exforge
Foxalin XR
Atacand
Brilinta (ticagrelor)
•
•
•
•
•
Indication(s) – reduction in thrombotic CV events s/p ACS
Mechanism of Action – reversible P2Y12 platelet inhibitor
Dosing – 180 mg load, followed by 90 mg BID
Contraindication – moderate to severe hepatic disease
Significant Drug Interaction(s)
– ASA doses > 100 mg/day reduce effectiveness of ticagrelor
– Avoid concurrent strong CYP3A4 inducers and inhibitors
• Competing Agent(s)
– clopidogrel
– prasugrel
Ticagelor Efficacy - PLATO
% Ticagrelor
(n=9333)
% Clopidogrel
(n=9291)
NNT
9.8
11.7
53
Planned invasive treatment
8.9
10.6
59
Day 1-30
4.8
5.4
167
Day 31-360
5.3
6.6
77
Stent thrombosis
1.3
1.9
167
Vascular death, MI, and CVA




PLATO included patients hospitalized with STEMI and non-STEMI, with symptom onset in past 24 hours
Major exclusion criteria only high risk of bradycardia and concurrent strong CYP3A4 drugs
Treatment groups:
 Ticagrelor 180 mg load, then 90 mg BID + low-dose aspirin
 Clopidogrel 300 mg load, then 75 mg daily + low-dose aspirin
Key demographics
 72% men
 91% Caucasian
 85% age < 75
Wallentin L, et al. NEJM 2009; 361:1045-57
Ticagelor Safety - PLATO
% Ticagrelor
(n=9333)
% Clopidogrel
(n=9291)
NNH
Major bleeding
11.6
11.2
NS
Life-threatening/fatal bleeding
5.8
5.8
NS
Nonintracranial fatal
0.1
0.3
500
Intracranial fatal
0.1
0.01
1111
Non-CABG related major bleeding
4.5
3.8
143
Major or minor bleeding
16.1
14.6
99
Dyspnea
13.8
7.8
17
Overall conclusion from PLATO: In ACS patients, ticagrelor reduces cardiovascular
endpoints with this benefit offset by non-procedure-related bleeding.
Wallentin L, et al. NEJM 2009; 361:1045-57
Ticagrelor Place in Therapy
• Clopidogrel issue – nonresponders
• Prasugrel issue – higher bleeding than clopidogrel
Per 9th edition American College of Chest Physician
Antithrombotic Therapy Guidelines:
Ticagrelor + ASA is preferred regimen post ACS
Drugstore.com pricing
• Brilinta [$276 is AWP]
• Effient $215
• Plavix
$205
BUT...
 Plavix goes generic this year
 ASA or Plavix remain drug of choice
for established CAD
 Plavix remains drug of choice for LV
thrombus in combination with ASA
and warfarin
Vandvik PO, et al. CHEST 2012; 141:637s-668s
Edarbi (azilsartan)
• Indication(s) - HTN
• Mechanism of Action - ARB
• Dosing – 80 mg daily
– Consider 40 mg if taking high dose diuretics
• Pregnancy Category D
• Significant Drug Interaction(s)
– Concurrent NSAIDs  renal dysfunction
• Competing Agent(s)
− candesartan − eprosartan
− irbesartan
− olmesartan
− valsartan
− telmisartan
− losartan
Azilsartan Efficacy & Safety – Package Insert
Study 1 (n=1285)
Study 2 (n=989)
BP Δ from baseline
(158/93)
BP Δ from baseline
(159/92)
Azilsartan 40 mg
-15/-6
-12/-7
Azilsartain 80 mg
-15/-5
-16/-9
Olmesartan 40 mg
-11/-5
-13/-7
Valsartan 320 mg
-10/-4
NA
 No report of side effects compared to active control.
 Compared to placebo, only diarrhea noted (2% vs. 0.5%)
Although azilsartan may be touted for it’s additional BP lowering with good
tolerability, no studies have examined cardiovascular outcomes!
Edarbi PI. Takeda Pharmaceuticals. Nov 2011.
Azilsartan Place in Therapy
Drugstore.com pricing
• Edarbi
$90
• Diovan
$135
• Benicar
$135
• losartan
$90
• irbesartan
$96
• Edarbyclor (azilsartan/chlorthalidone)
“Me-too” drug – avoid in favor of ARBs with outcomes data
unless dual chlorthalidone desired.
Vandvik PO, et al. CHEST 2012; 141:637s-668s
Xarelto (rivaroxaban)
• Indication(s) – AFib; VTE prevention post knee/hip surgery
• Mechanism of Action – Factor Xa inhibitor
• Dosing
– 20 mg po with evening meal (AFib) – reduce to 15 mg if CrCl 15-50 mL/min. Do
not use CrCl < 15.
– 10 mg once daily (VTE prevention). Do not use if CrCl < 30 mL/min.
• Significant Drug Interaction(s)
– Avoid strong CYP3A4 and P-gp inhibitors/inducers
– Phenytoin, CBZ, and rifampin increase elimination – increase VTE ppx dose to
20 mg
• Competing Agent(s)
– warfarin
− enoxaparin
– dabigatran
− fondaparinux
Rivaroxaban Efficacy & Safety for AFib
1
ROCKET HF
% rivaroxaban
(n=6958)
% warfarin
(n=7004)
NNT/NNH
Stroke or systemic embolism
2.1
2.4
NS
Major and nonmajor bleeding
14.9
14.5
NS
Fatal bleed
0.2
0.5
333
GI bleed
3.2
2.2
100
Intracranial hemorrhage
0.4
0.8
250
Additional notes:
 Time in the therapeutic range for warfarin only 55% (most in clinical trials achieve 64-68%)
 Third AFib option – Pradaxa (dabigatran) had similar bleeding rates compared to warfarin, but
superior efficacy (especially in those with poor INR control)2
1. Patel MR, et al. NEJM 2011; 365:883-91.
2. Connolly SJet al. NEJM 2010; 361:1139-51.
Rivaroxaban Efficacy Post THR/ TKR
VTE Incidence
NNT ~ 62
Turun S, et al. Thrombosis Research 2011; 127:525-34.
Rivaroxaban Safety Post THR/ TKR
Major Bleeding
Turun S, et al. Thrombosis Research 2011; 127:525-34.
Rivaroxaban Place in Therapy
CHEST guidelines
– Recommended post THR/TKR, but enoxaparin preferred
– No comment for AFib or VTE
Drugstore.com pricing
• Xarelto [AWP is $262]
• Pradaxa $245
•
•
warfarin
$14
enoxaparin $808
THOUGHTS – not a huge player…yet:
 Dabigatran is preferred non-warfarin alternative (over rivaroxaban) for AFib
 Future potential for rivaroxaban as treatment for acute VTE (EINSTEIN and
EINSTEIN-PE)
 Will insurance coverage drive post THR/TKR to rivaroxaban despite CHEST
guidelines?
CHEST 2012; 141 supplement
Horizant (gabapentin enacarbil)
• Indication(s) – restless leg syndrome
• Mechanism of Action – gabapentin prodrug
• Dosing – 600 mg with dinner.
– Avoid CrCl < 30 mL/min.
– Dosing NOT equivalent between this and plain gabapentin
• Competing Agent(s)
– gabapentin
Gabapentin enacarbil Efficacy & Safety
600 mg
(n=115)
1200 mg
(n=113)
Placebo
(n=97)
-13.8
-13
-9.8
73
77
45
Dizziness (%)
10.4
24.3
5.2
Somnolence
21.7
18
2.1
Δ EES score (daytime sleepiness)
-2.8
-2.9
-2.4
Headache
14.8
13.5
8.3
Δ IRLS score*
Proportion of responders per CGI-I* (%)
*statistically significant
 No evidence of better efficacy or tolerability compared to gabapentin
 No direct comparisons to other RLS agents, but IRLS score reduction similar
Lee DO, et al. Journal of Clinical Sleep Medicine 2011; 7:282-92.
Gabapentin enacarbil Place in Therapy
• Dopamine agents generally first line for RLS
• Potential uses of gabapentin in RLS
– Intolerance to dopamine agents
– Concurrent pain symptoms
Drugstore.com pricing
• ropinirole
$26
• pramipexole $84
• gabapentin $16
• Horizant
[AWP $118]
THOUGHTS – reasonable to try
Horizant for patients needing
gabapentin product who have
wearing off effects in middle of night
with generic immediate release
formulation (or consider Gralise)
Viibryd (vilazodone)
• Indication(s) – major depression
• Mechanism of Action – SSRI plus partial agonist at 5-HT1A receptor
• Dosing – 40 mg once daily with food
– Starting titration: 10 mg x 7 days; 20 mg x 7 days; then 40 mg
– Reduce dose to 20 mg with strong CYP3A4 inhibitors
• Significant Drug Interaction(s)
– Monoamine oxidase inhibitors
– Other serotonergic agents
• Competing Agent(s)
– SSRIs (es/citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)
– SNRIs (desvenlafaxine, duloxetine, venlafaxine)
Vilazodone Efficacy & Safety
8 week follow-up
Khan et al.
Rickels et al.
Vilazodone
Placebo
Vilazodone
Placebo
Mean Change in Montgomery-Asberg
Depression Rating Scale*
-13.3
-10.8
-12.9
-9.6
Mean Change in Hamilton Depression
Rating Scale
-10.7
-10.1
-10.4
-8.6
Diarrhea %
30.6
10.7
Nausea %
26
5.6
Headache %
12.8
10.3
Dry mouth %
8.9
3.9
Dizziness %
8.9
3.9
Insomnia %
7.2
3
*statistically significant
 As with other antidepressants, risk of suicide increased and highest age < 18
Khan A, et al. J Clin Psychiatry 2011;72:441-47.
Rickels K, et al. J Clin Psychiatry 2009;70:326-33.
Vilazodone and Sexual Side Effects
Viibryd Package Insert. Forest Laboratories 2011.
Vilazodone Place in Therapy
• True efficacy / safety comparison not yet available – active comparisons
needed
Drugstore.com pricing
• Viibryd 40 mg
• bupropion XL 150 mg
• escitalopram 20 mg
• sertraline 100 mg
• venlafaxine XL 150 mg
$136
$100
$130
$16
$124
THOUGHTS – reasonable to try in patients who fail
established options – especially if next step is addition of
second agent
Tradjenta (linagliptin)
• Indication(s) – Type 2 DM
• Mechanism of Action – DPP-4 inhibitor
• Dosing – 5 mg once daily
• Significant Drug Interaction(s)
– Avoid strong CYP3A4 inducers
• Competing Agent(s)
– saxagliptin
– sitagliptin
Linagliptin Efficacy & Safety – Package Insert
Δ HgbA1c from baseline
Linagliptin
Control
Monotherapy vs. placebo
-0.4
0.1
Add-on to metformin: linagliptin vs. placebo
-0.5
0.15
Add-on to metformin: linagliptin vs. glimepiride
-0.4
-0.6
Initial therapy with pioglitazone: linagliptin vs. placebo
-1.1
-0.6
Add-on to sulfonylurea: linagliptin vs. placebo
-0.5
-0.1
Add-on to sulfonylurea + metformin: linagliptin vs. placebo
-0.7
-0.1
 No direct comparisons to other DPP-4 inhibitors
 Appears A1c lowering capability similar to other drugs in its class
 Little to no side effects as with other DPP-4 inhibitors
Tradjenta PI. Boehringer Ingelheim Pharmaceuticals, 2011.
ADA & EASD Guidelines: Type 2 DM
Inzucchi SE, et al. Diabetologia 2012
Linagliptin Place in Therapy
Drugstore.com pricing
• Tradjenta $241
• Januvia
$235
• Onglyza
$236
No reason not to consider linagliptin as a DPP-4 inhibitor of
choice – with no clear advantage/disadvantage as compared
to its competitors.
Final decision likely driven by insurance coverage.
Zioptan (tafluprost)
• Indication(s) – glaucoma
• Mechanism of Action – prostaglandin analog, preservative
free
• Dosing – 1 drop in affected eye(s) q PM
• Competing Agent(s)
– Bimatoprost (Lumigan)
– Latanoprost (Xalatan)
– Travoprost (Travatan Z)
Tafluprost Efficacy
Uusitalo H, et al. Acta Ophthalmol 2010; 88:12-19
Tafluprost Safety*
*Both agents contained benzalkonium chloride preservative
Patients intolerant to latanoprost switched to preservative-free tafluprost+
• No change in intraocular pressure pre/post switch
• 50% reduction in ocular side effects
Uusitalo H, et al. Acta Ophthalmol 2010; 88:12-19
H, et al. Acta Ophthalmol 2010; 88:329-36
+Uusitalo
Tafluprost Place in Therapy
• American Academy of Ophthalmology has not designated first-line class
• Prostaglandin agents often selected over beta-blockers due to once daily
dosing
Drugstore.com pricing
• Zioptan
[AWP $116]
• latanoprost $23
• Lumigan
$100
• Travatan Z
$95
Only clear reason for selection at this time is rare need for
preservative-free product
Natroba (spinosad) and Sklice (ivermectin lotion)
Natroba (spinosad)
Sklice (topical ivermectin)
• Indication – head lice (age ≥ 4)
• Indication – head lice (age ≥ 6 mo)
• Dosing
• Shake bottle
• Fully cover scalp & dry hair
x 10 minutes
• Repeat after 7 days prn.
• Dosing
• Fully cover scalp & dry hair x
10 minutes.
Competing Agent(s)
•
permethrin
•
Ovide (malathion)
•
Ulesfia (benzyl alcohol)
•
Stromectol (oral ivermectin)
Spinosad Efficacy & Safety
Spinosad
Permethrin
Age range 6 months-68 years (mean ages in late teens)
Study 1
Study 2
Study 1
Study 2
Lice free 14 days after last treatment (%)*
84
88
45
42
Requiring only one treatment (%)*
62
86
37
40
Adherence (%)*
89
90.4
83.1
86.9
Application site erythema (%)*
3.1
6.8
Application site irritation (%)
0.9
1.5
*statistically significant
Tidbits of Interest
• Non-toxic by any other administrative route
• No combing necessary
Stough D, et al. Pediatrics 2009; 124:e389-95.
Ivermectin Lotion Efficacy & Safety
Ivermectin
Age >= six months
Lice free 14 days after last treatment (%)*
Placebo
Study 1
Study 2
Study 1
Study 2
76
71
16
19
Tidbit of Interest
• No other information available, either in package insert or via Medline search
Stough D, et al. Pediatrics 2009; 124:e389-95.
Spinosad and Ivermectin Lotion: Place in Therapy
• American Academy of Pediatrics still recommends permethrin first-line
• Drugstore.com pricing
–
–
–
–
–
–
Natroba
Sklice
Permethrin
Ovide
Ulesfia
Stromectol
[AWP $262]
[N/A]
$18
$185
$63
$111
Based on current data, would consider
spinosad as viable option(not
ivermectin topical) in cases of
permethrin failure and/or concern
that adherence to combing or retreatment will be low.
Arcapta (indacaterol)
• Indication(s) – COPD
• Mechanism of Action – long-acting beta agonist
• Dosing – once daily inhalation (75 mcg)
– Dry powder “NEOHALER” with externally loaded capsule
– Dose finished when all powder inhaled (usually 1-2 inhalations)
• Competing Agent(s)
– formoterol
– salmeterol
Indacaterol Efficacy & Safety
Indacaterol
group
Comparator
group
Indacaterol 150 mcg daily vs. salmeterol 50 mcg BID (6 mo)1
• SGRQ score
• TDI score improvement of >= 1 unit (%)
• Days with no rescue (%)*
• Days able to perform activities (%)*
•
•
•
•
-5.0
60.5
60
43
•
•
•
•
-4.1
53.6
55
38
Indacaterol 150 mcg daily vs. tiotropium 18 mcg daily (12 wk)2
• SGRQ score*
• TDI score*
• Days with no rescue (%)*
•
•
•
-5.1
-2.01
46
•
•
•
-3.0
-1.43
41
Moderate to severe COPD – ICS allowed
* Statistically significant difference
 COPD exacerbations, not yet studied/reported
 No studies use FDA dose of 75 mcg
 Adverse effects as expected
1. Kornmann O, et al. Eur Respir J 2011; 37:273-79.
2. Buhl R, et al. Eur Respir J 2011; 38:797-803.
Indacaterol: Place in Therapy
• Per 2011 GOLD Guidelines, choice of beta-agonist vs. anticholinergic
driven by individual patient response and drug availability
• Drugstore.com pricing
–
–
–
–
Arcapta
Foradil
Serevent
Spiriva
[AWP $195]
$176
$181
$261
Until clinically important outcomes
proven with the FDA approved dose,
stick with Foradil or Serevent unless
once daily dosing critical for
adherence.
Daliresp (roflumilast)
• Indication(s) – severe COPD
• Mechanism of Action – oral PDE-4 inhibitor that reduces lung
inflammation
• Dosing – 500 mcg once daily
• Contraindication(s) – moderate to severe hepatic dysfunction
• Significant Drug Interaction(s)
– Strong CYP3A4 inducers
– Strong CYP3A4 and CYP1A2 inhibitors
• Competing Agent(s)
– No direct competitors
– May be option to inhaled steroids?
Roflumilast Efficacy
Roflumilast
Placebo
SABA
LABA
LAAC
SABA
LABA
LAAC
1.14*
NA
NA
1.37
NA
NA
Mild, moderate or severe exacerbation
(mean per year)
NA
1.9
1.8
NA
2.4
2.2
Median days to first exacerbation
80*
83*
80.5
71
71
74.5
Moderate or severe exacerbation
(mean per year)
*statistically significant
• Calverley study: only short-acting bronchodilators allowed
• Fabbri study: long-acting bronchodilators included
• Neither allowed inhaled corticosteroids
Calverley PMA, et al. Lancet 2009; 374:685-94.
Fabbri LM, et al. Lancet 2009; 374:695-703.
Roflumilast Safety
ADRs Significantly Higher than
Placebo
Decreased appetite
Diarrhea
Headache
Insomnia
Nausea
Weight loss (minor)
Other Rare ADRs of Concern
Depression
Suicide
Cancer
Weight loss (significant)
Calverley PMA, et al. Lancet 2009; 374:685-94.
Fabbri LM, et al. Lancet 2009; 374:695-703.
Pharmacists Letter July 2011. Detail Document 20709.
Roflumilast: Place in Therapy
• Mentioned in 2011 GOLD Guidelines, but noted that no comparative
efficacy to inhaled steroids exists
• Clinical trials not designed to allow evaluation of best long-acting drug
class in combination with roflumilast
• Drugstore.com pricing
– Daliresp
[AWP $207]
Maintain inhaled bronchodilators first
line. Possibly consider if oral therapy
desired over additional inhaled or if
concerned over risk of pneumonia
with inhaled steroids.
New Dosage Forms of Interest
Brand (generic)
What’s New?
Combivent Respimat (ipratropium/albuterol)
Non-CFC MDI formulation
Duexis (ibuprofen/famotidine) 800 /26.6 mg
Combination agent
Forfivo XL (bupropion) 450 mg
New strength
Gralise (gabapentin) 300 mg, 600 mg
Once daily formulation
Intermezzo (zolpidem) 1.75 mg, 3.5 mg
Sublingual tablet
Janumet XR (sitagliptin/metformin) 50/500 mg, 50/1000 mg, 100/1000 mg
Extended release
Jentadueto (linagliptin/metformin) 2.5/500 mg, 2.5/850 mg, 2.5/1000 mg
Combination agent
Juvisync (sitagliptin/simvastatin) 100/10 mg, 100/20 mg, 100/40 mg
Combination agent
Oxecta (oxycodone) 5 mg, 7.5 mg
Does not crush/dissolve
Qnasl (beclomethasone)
Nasal dry powder formulation
Rezira (hydrocodone/pseudoephedrine) 5/60 mg
Combination agent
Sklice (ivermectin)
Topical lotion
Zetonna (ciclesonide)
New strength
Zutripro (hydrocodone/chlorpheniramine/pseudoephedrine) 5/4/60 mg
Combination agent
Zyclara (imiquimod) 3.75%
New strength
Closer Focus
New Dosage Form and Drugstore.com cost
Comparative Options and Drugstore.com cost
Duexis 800 mg /26.6 mg
#90
[AWP = $176]
Ibuprofen 800 mg
Famotidine 20 mg
$13
$20
Generic components save
Forfivo XL 450 mg
#30
Unknown
Bupropion XL 150 mg
#90 = $160
Must await pricing on Forfivo
Gralise 300 mg or 600 mg
#30
[AWP = $81]
Gabapentin 100 mg
Gabapentin 300 mg
#90 = $44
#60 = $16
Only use if once daily really
needed
Intermezzo 1.75 mg, 3.5 mg
#30
[AWP = $232]
Zaleplon 5-10 mg
#30 = $18-35
Using generic Sonata saves
Oxecta 5 mg, 7.5 mg
#100
[AWP = $320]
Oxycodone 5 mg
#100 = $113
Generic oxycodone cheaper
Special Administration Devices
Combivent Respimat
• Dosing only 1 puff QID
• Must discard 3 months after cartridge inserted
• On first use: cartridge inserted, then clear base
attached
• Prime using same general steps as inhalation –
ready when spray appears
• Patient use
• Hold upright and turn clear base on it
clicks
• Flip orange cap open
• Press dose release button as slow
inhalation happens
• Hold breath for 10 seconds
Combivent Respimat PI. Boehringer Ingelheim Pharmaceuticals, 2012.
Arcapta Neohaler
•
•
•
•
•
•
Remove inhaler cover
Tilt back mouthpiece
Open capsule blister
Place capsule into inhaler device
Close mouthpiece
Pierce capsule by squeezing pink tabs
• Exhale away from mouthpiece
• Wrap lips and inhale steady, fast – should hear
whirring noise
• Hold breath x 10 seconds
• Inspect capsule to assure all powder gone – if
not repeat inhalation
Arcapta PI. Novartis, 2011.
Qnasl
• Before first use – prime with four sprays
• Device has dose counter
• Patient use
• NOT sniff and spray as with other nasal
steroids
• Instead, hold breath – then spray into
nostril and continue to hold breath for 5
seconds
• Exhale through mouth
• Repeat as needed to get all doses
Qnasl patient instruction leaflet. Teva Respiratory, 2012.
Thanks for Attending!