Update on Pulmicort : From Turbuhaler to Flexhaler

Hi Dan,

I agree with you. The wording in the patient information (PI) section of the package insert should be more clear. With both the old and new forms of Pulmicort (Turbuhaler and Flexhaler) two turns are required for loading the medication. A click should be heard on one of the turns.

I orient my patients by demonstrating the loading process on a placebo Pulmicort inhaler (provided by the company, AstraZeneca). When the Flexhaler is used for the first time two cycles of two turns are required for priming. This is only done one time (re-priming is not necessary no matter how frequent the use). Thereafter, two turns are required to load each dose for inhalation. Again, one of the turns should generate a click (it does not matter on which turn the click occurs, according to the PI).

I hope this clears up the confusion. I mentioned your point regarding the confusing rhetoric to a pharmaceutical rep. earlier this week.

Thank You,

J. Thompson, MD

Dan,

I didn't address your comment about confirming a Pulmicort dose has been inhaled. The assumption is that if the required steps for loading and inhaling are correctly followed, the intended dose should be inhaled. The new Flexhaler has a dose counter which should give some assurance that the medication is being taken. Many people are not able to taste the dry powder. Practice with the placebo Pulmicort inhaler should be encouraged.

Good Luck,

J. Thompson, MD.

Hi,

Before answering, I will disclose that I am a speaker / consultant for AstraZenaca, the maker of Pulmicort Turbuhaler and the new Pulmicort Flexhalers. I am also a speaker/consultant for GSK, Sanofi-Aventis, Merck and other producers of asthma medications.

I am not aware of the motivating factors involved in AstraZenaca's reformulation of Pulmicort inhaler but the change allowed for greater separation of pediatric vs. adult doses. Pulmicort Turbuhaler was only available in the 200mcg/puff inhaler. The Flexhaler has a 90mcg/puff and 180mcg/puff inhaler. Small children require and are recommended to have lower doses of inhaled steroid for maintenance of asthma if possible.

The other changes are more minor but significant in my opinion. Changing from a dose indicator to an actual counter helps patients keep track of remaining doses. The grooved mouthpiece allows for better positioning of the inhaler between the lips, which may improve upon inhalation technique (one of my major concerns in asthma care).

Thanks for your comments,

J. Thompson, MD

Hi PSL,

I have not come across any complaints about the Flexhaler not working, but I wouldn't be surprised if there were some people that have experienced this. The upper section that represents the mouthpiece should not be twisted. I think there may be a problem if the upper part is twisted, instead of the base. The base should be twisted two half turns, as the middle shaft (just above the base) is held steady. If you forcibly twist the upper third (mouthpiece) while holding the middle shaft, you may damage the Flexhaler. Other than this scenario I am not aware of structural or functional problems.

Any device or inhaler may be faulty. In such a situation you should return it to the pharmacy for inspection (call the pharmacy first just in case they don't agree with my advice). Another alternative is to contact the company, which in this case is AstraZenaca.

Good Luck!

J. Thompson, MD

Hi Ms. Keys,

I am not aware of any discontinuation of Pulmicort Flexhaler. I went online before posting this reply to see if there was any bulletin regarding this issue on their website: http://www.pulmicortflexhaler.com/Flexhaler/adult/asthma-signs-symptoms.aspx?l=a), and there wasn't. Check with other pharmacies in your area. Perhaps some pharmacies decide not to continue ordering certain medications.

I have prescribed several Flexhalers over the course of this month without any call-backs about availability. For some reason certain regions of a particular state run out of some medications. It takes a while for pharmacist to re-stock from distributors (just speculating).

Bottom Line:

Pulmicort Flexhaler should still be available for your pharmacist to order.

Good Luck!

J. Thompson, MD