Compatibility in Aerosolized Medications

Maher M. AlQuaimi MsRC, AEA, RRT

Lecturer @ Dammam university

Board member in SSRC education group

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• “The more I learn, the more I realize how much I don't know.”

• ― Albert Einstein

Objectives

• Introduction about aerosol

• Types of aerosolized medications

• Types of aerosol devices

• Why mixing ?

• Compatibility

• Compatibility charts

• Conclusion

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• Aerosol: a suspension of liquid and solid particles produced by an aerosol generator

A guide to aerosol delivery devices for respiratory therapist, 3rd edition ( AARC , 2013)4Gulf Thoracic Congress, 2015

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A guide to aerosol delivery devices for respiratory therapist, 3rd edition ( AARC , 2013)

Inhalation route

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A guide to aerosol delivery devices for respiratory therapist, 3rd edition ( AARC , 2013)

Types of aerosolized medications

• Bronchodilators

• Antibiotics

• Antiviral

• Corticosteroids

• Others

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Availability?

nebulized Solution

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Availability?

nebulized Solution

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Nebulized solution

• Continues treatment

• Less coordination required

• No PIF is required

• May be better aerosol output

• More availability

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Why mixing?

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Why mixing?

• Save time

• Multiple patient ?!

• Save Resources

• synergistic effect ( 1+1 = 3)

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Advantages of mixing

Long-acting inhaled therapy (beta-agonists, anticholinergics and steroids) for COPD: a network meta-analysis

Kayleigh M Kew1,*, Sofia Dias2, Christopher J Cates1 (2014)

“This network meta-analysis compares four different classes of long-acting inhalers for

people with COPD who need more than short-acting bronchodilators. Quality of life and lung function were improved most on combination inhalers (LABA and ICS) and least on ICS alone at 6 and at 12 months. Overall LAMA and LABA

inhalers had similar effects, particularly at 12 months. The network has demonstrated the benefit of ICS when added to LABA for these outcomes in participants who largely had an FEV1 that was less than 50% predicted, but the additional expense of combination inhalers and any potential for increased adverse events (which has been established by other reviews) require consideration. Our findings are in keeping with current National Institute for Health and Care Excellence (NICE) guidelines”

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Advantages

The results of the indirect comparison support the hypothesis that budesonide/formoterol is associated with fewer pneumonia events than salmeterol/fluticasone in chronic obstructive pulmonary disease. The limitations of the analysis are that the results from a single study, TORCH, have a large bearing on the overall findings of the analysis, and that there is heterogeneity in the length and the dosing of the included studies, although it does not appear that heterogeneity affected the reported results. Another important limitation is the lack of predefined diagnostic standards for pneumonia in these studies.

Budesonide/formoterol vs. salmeterol/fluticasone in COPD: a systematic review and adjusted indirect comparison of pneumonia in randomised controlled trialsD. M. G. Halpin1, J. Gray2, S. J. Edwards2, J. Morais3 andD. Singh4 ( respirology, 2013)14Gulf Thoracic Congress, 2015

Why mixing?

• Save time• Save Resources • Synergic effect• Multiple patient ?!• Better outcome

“Only if we mix the right medication”

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The ideal compatible mixture

• Proven to be physically compatible

• Proven to be chemically compatible

• Proven to have no change in aerosol output

• Proven to be clinically safe

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incompatibility Chemical

incompatibility Physical incompatibility

• Change in color or odor• Change in pH • Haze or precipitation

• Change in the chemical characteristics• Agar diffusion assay• High performance liquid

chromatography (HPLC)• Ultraviolet spectroscopy

Lack of physical changes don’t rule out chemical changes

W. Kamin et al. / Journal of Cystic Fibrosis 13 (2014) 243–250 17Gulf Thoracic Congress, 2015

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C

C

X

NI

CD

There is evidence in the form of clinical studies

There is evidence from manufacturers’

No enough data

There are conflicting data

Is not compatible

Burchett, D., Darko, W., Zahra, J., Noviasky, J., Probst, L., & Smith, A. (2010). Mixing and compatibility guide for commonly used

aerosolized medications. American Journal Of Health-System Pharmacy: AJHP: Official Journal Of The American Society Of

Health-System Pharmacists, 67(3), 227-230. Retrieved from MEDLINE with Full Text database.

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W. Kamin et al. / Journal of Cystic Fibrosis 13 (2014) 243–250

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“Super safe”

W. Kamin et al. / Journal of Cystic Fibrosis 13 (2014) 243–250

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Hypertonic

W. Kamin et al. / Journal of Cystic Fibrosis 13 (2014) 243–250

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Donasealfa

W. Kamin et al. / Journal of Cystic Fibrosis 13 (2014) 243–250

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Mix safely, or don’t mix

• Refer to published research and data

• Refer to company recommendations

• Contact your hospital pharmacist

• Collaborate and study more medication and publish them

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Thank you

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