Dispensing Inhaled Medications

Full update December 2022

Inhalation is a great way to get medications directly into the lungs. Inhaled medications delivered via inhalers and nebulizers are usually used to treat conditions associated with breathing problems. In fact, a puff or two from the right inhaler can mean the difference between life and death in extreme situations. However, inhaled meds can be tricky to get right. It’s because things can go wrong in relation to use, storage, etc. Help patients get the most out of their inhaled medications by learning more about these products.

 Advair Diskus 250/50 prescription

A 33-year-old male patient with a history of asthma comes to get a new Rx for Advair Diskus (fluticasone/salmeterol), 1 inhalation every 12 hours. He’s been using an albuterol inhaler as needed plus a steroid inhaler Flovent (fluticasone) for quite some time. He won’t be getting the fluticasone inhaler refilled, but he will need to keep getting his albuterol inhaler (Ventolin HFA) in addition to the Advair Diskus.

What are the most common conditions treated with inhaled meds?

Asthma and chronic obstructive pulmonary disease (COPD) are the most common conditions treated with inhaled meds. Both involve inflammation in the lungs and narrowing of the airways. Asthma tends to be more acute, with onset at a young age. Asthma symptoms are typically caused by reactions to triggers such as pollen, pet dander, or dust. COPD tends to involve chronically worsening symptoms and usually affects people over 60 years of age, especially those with long-term exposure to substances that damage the lungs such as cigarette smoke. Asthma and COPD are treated with many of the same inhaled medications.

What types of medications come in inhaled dosage forms?

Meds that come in inhaled forms usually help open the airways so patients with breathing problems can breathe more normally. These meds include:

  • steroids that reduce swelling in the airways such as fluticasone and mometasone.
  • beta-agonists that open airways such as:
    • short-acting beta-agonists (SABAs) including albuterol (called salbutamol in Canada) and levalbuterol (US).
    • long-acting beta-agonists (LABAs) including formoterol and salmeterol.
  • anticholinergics that relax airways and reduce secretions such as:
    • short-acting anticholinergics including ipratropium.
    • long-acting anticholinergics (also called long-acting muscarinic antagonists, LAMAs) including tiotropium and umeclidinium.

Tobramycin (TOBI, etc), an antibiotic, is another example of a med that comes in an inhaled form. It can be used to treat serious lung infections such as pneumonia in patients with cystic fibrosis. In the US, insulin is available as an inhalation (Afrezza). Afrezza is a fast-acting insulin ideal for patients who are needle-phobic. However, since it can cause airway irritation, it isn’t recommended in patients who also have asthma or COPD.

What are the different types of inhalers?

Different inhaler types include MDIs (metered-dose inhalers), DPIs (dry-powder inhalers), and SMIs (soft-mist inhalers). They have nuances such as requirements to twist a base, move a lever, pierce a capsule, etc.

MDIs are usually L-shaped. They may also be called HFAs in reference to the chemical propellant (hydrofluoroalkanes).MDIs used to have chlorofluorocarbons (CFCs) as propellants. Those have been phased out because CFCs can harm the environment. Some available MDIs include albuterol, called salbutamol in Canada (Proventil HFA [US], Ventolin HFA, etc), beclomethasone (QVAR Redihaler), ciclesonide (Alvesco, etc), fluticasone/salmeterol (Advair HFA), ipratropium (Atrovent HFA), and levalbuterol (Xopenex HFA [US], etc). The HFA chemical propellant in MDIs helps spray the medication out of the canister and into the patient’s airways when inhaled.

Proper use of an MDI requires coordination on the patient’s part. At the same time the device is compressed to release a dose the patient must inhale the medicine through the mouth and into the airways. MDIs typically require a long, slow breath upon inhalation.

Spacer devices or valved holding chambers (essentially a plastic tube with a one-way valve) can be attached to MDIs to make them easier to use. These devices allow some flexibility when a patient is trying to coordinate deploying the inhaler with their inhalation. This can be tough for some people such as children and the elderly. The device is attached to the inhaler as an extension of the mouthpiece that holds the medication that’s sprayed out of the MDI until the patient inhales it.

DPIs are usually disk- or tube-shaped. Some available DPIs include tiotropium (Spiriva HandiHaler),fluticasone/salmeterol (Advair Diskus, etc),fluticasone (Flovent Diskus, etc), albuterol (ProAir RespiClick [US], etc),salmeterol (Serevent Diskus), and budesonide (Pulmicort Flexhaler [US], Pulmicort Turbuhaler [Canada]). DPIs don’t have a propellant. DPIs have powder in the inhaler device that’s propelled into the lungs by the force of the patient’s inhalation. Some DPIs such as indacaterol (Arcapta Neohaler [US], Onbrez Breezhaler [Canada]) and Spiriva HandiHaler have the powder in separate capsules, which the patient must place in the device before use. DPIs should be used with a short, fast, and forceful inhalation.

DPIs are considered easier to use than MDIs. In fact, DPIs were introduced to overcome the problems of poor technique associated with MDIs. However, one in three patients still uses their DPI incorrectly. One problem is when patients swallow the capsules meant for use with a DPI, instead of placing the capsule in the inhaler. When these capsules are taken orally, they don’t open the airways as they would if the contents were inhaled.

DPIs should not be used with spacers. The force of the patient’s inhalation sucks the drug into the airways, as opposed to MDIs, where it’s both the activation of the inhaler device and the patient’s inhalation.

SMIs are a newer inhaler type. SMIs mechanically aerosolize medicine and don’t contain a chemical propellant. Examples of SMIs include albuterol/ipratropium (Combivent Respimat), olodaterol (Striverdi Respimat [US]), tiotropium (Spiriva Respimat), and tiotropium/olodaterol (Stiolto Respimat [US], Inspiolto Respimat [Canada]). SMIs are similar to MDIs and used in much the same way. SMIs look like a short tube. Instead of a propellant, a spring mechanism inside the device aerosolizes the medicine. As with MDIs, patients should breathe in slowly and deeply.

What is a nebulizer?

A nebulizer is a machine, sometimes called a “breathing machine,” that changes liquid medication into mist. Nebulizers can be used for hospital inpatients, or they can be used at home for outpatients. Nebulizers can be good for small children or for elderly patients who have trouble using inhalers. Meds given via nebulizer might be referred to as “breathing treatments.”

Nebulizers come in different sizes and require either a battery or plugging in to an electrical outlet. Some are compact and others are larger. They typically have a mouthpiece or mask, an air compressor, a cup where the medication is placed, and tubing that connects the cup and compressor.

Inhaled meds such as albuterol (salbutamol [Canada]), ipratropium, and levalbuterol come in formulations made especially for nebulizers. They’re typically packaged as individual doses, in plastic vials (also called nebules or nebs). Patients may need to mix these solutions with each other, such as albuterol and ipratropium. Or they may need to dilute the medication with 0.9% saline, such as concentrated albuterol 0.5%. Some inhaled meds must be used with a specific type of nebulizer. This info can be found in the med’s package insert or product monograph.

When you’re talking with the patient about the new Rx for Advair Diskus, he mentions that his other inhalers haven’t been working well enough. He guesses the Advair is going to replace his Flovent inhaler. You check with the pharmacist who confirms that the Flovent is being replaced with the Advair Diskus since it contains the ingredient in Flovent. You mark the Flovent Rx as discontinued to avoid confusion in the future.

What should I watch for when inputting prescriptions for inhalers?

Choose the right med. If a patient asks for a refill of his or her “breathing med,” ask which one; patients often use multiple inhalers. It’s typical for a patient to use a scheduled “controller” such as an inhaled steroid and a PRN “reliever” such as albuterol. A controller med is used every day like a blood pressure or diabetes med and helps keep the airways open. A reliever med is used when a patient has trouble breathing, to open the airways quickly and as needed. Keep an eye out for frequent refills of reliever meds. This could indicate an uncontrolled breathing condition, which the pharmacist should intervene on. Also alert the pharmacist if a patient gets multiple types of devices (i.e., MDI, DPI, SMI). Sticking to one type can help limit confusion.

Watch for inhalers that come in multiple strengths such as Flovent and Symbicort (budesonide/ formoterol). Be sure to choose the right strength. Watch for inhalers that come as both a DPI and MDI version such as Advair and Flovent. Be sure to choose the right type of inhaler. Be aware that some medications that come in inhalers such as fluticasone and ipratropium also come as nasal sprays with similar names. Avoid mix-ups by checking with the pharmacist if there’s confusion about which dose or product should be dispensed.

Ensure sigs are correct and complete. Inhaled steroids are usually used on a scheduled basis such as once daily or BID. Short-acting beta-agonists (SABAs) such as albuterol (or salbutamol in Canada) are often used on a PRN basis. But certain long-acting beta-agonists (LABAs) such as indacaterol (Arcapta [US], Onbrez Breezhaler [Canada]) andsalmeterol (Serevent Diskus, etc) should not be used on a PRN basis. Albuterol’s action is quick and short; long-acting beta-agonists’ actions may be slower and longer. It’s a similar situation with short-acting anticholinergics such as ipratropium and long-acting anticholinergics (also called long-acting muscarinic antagonists, LAMAs) such as tiotropium (Spiriva) and umeclidinium (Incruse Ellipta). Alert the pharmacist if you see these long-acting drugs prescribed PRN; they might need to contact the prescriber for clarification.

Enter the correct days’ supply. Be sure to enter the correct days’ supply for inhalers. Check how many “puffs” (usually referred to as “actuations”) are in one inhaler. This can usually be found on the box or outer wrapping of the inhaler. If not, check the package insert or product monograph.

Example: A patient brings in a prescription for an albuterol inhaler with the directions, “2 puffs four times daily PRN.” You figure this is up to 8 puffs per day. The inhaler has 200 actuations. What is the days’ supply?

200 puffs/inhaler x 1 day/8 puffs = x days/inhaler

x = 25 days/inhaler

You calculate the days’ supply of Advair Diskus. There are 60 inhalations per DPI. The patient will use two inhalations each day, so one DPI is a 30-day supply. You also check with the patient to see if he needs a refill of his albuterol inhaler. He thanks you and says “no,” because he has an adequate supply.

Is there any special labeling for inhalers?

If you apply a label directly to an inhaler, which may be done in the hospital, don’t cover up the dose counter (if there is one) or any other important information. Also avoid putting the label in a place where it could interfere with use of the device. While most retail pharmacies will put the Rx label directly on the inhaler’s box, some pharmacies apply a second label directly to the inhaler because the box usually gets thrown away by the patient.

Use-by dates. Many inhalers have a “use-by” date that applies after removal from the outer wrapping. This means the manufacturer’s expiration date (stamped on the box, canister, or other packaging) is void if it extends past the amount of time allowed after the outer wrapping is removed. For example, Symbicort must be used within three months after removal from the foil pouch. This information is in the product’s package insert or product monograph. Sometimes use-by times will vary between different sizes or strengths of the same brand of inhaler (in the US, this is seen with Flovent Diskus). Patients shouldn’t use their inhaler past the use-by date because the inhaler may not work as well. This can lead to inadequate control and treatment of their breathing condition. See our chart, Correct Use of Inhalers, for the use-by dates for different inhalers (US subscribers; Canadian subscribers).

Include an auxiliary label indicating the use-by date on these products or mark the use-by date as recommended by the manufacturer’s instructions. Also, remember that the manufacturer’s expiration date should be used if it’s shorter than the use-by date after removing the protective packaging.

Shake well. MDIs that are suspensions, such as Flovent HFA, Proventil HFA, Symbicort, and Xopenex HFA should get a “shake well” label. Shaking these inhalers before use helps mix the drug and propellant to ensure the patient gets a uniform dose each time. Do not put this label on all inhalers. It isn’t necessary for SMIs, and shaking could cause med to be released before it should be from DPIs.

Storage. Moisture in a DPI can create problems like caking of the dry powder medicine, so it’s important for patients to keep their DPIs dry. DPIs should be stored in a dry place, not in a bathroom cabinet or near a sink. Place an auxiliary label indicating this on the packaging if you have such a label available.

MedGuides. In the US, dispense a MedGuide with certain long-acting beta-agonist inhalers, including Arcapta, Brovana, Perforomist, Serevent Diskus, and Striverdi Respimat. As mentioned, using these meds incorrectly can be dangerous; they are NOT for PRN use as rescue inhalers because they take longer to act.

Other. When DPIs have the powder in separate capsules, the capsules should be labeled as “not for oral use” when they’re dispensed. Patients should be instructed to keep the capsules in their original packaging prior to use, not in any other kind of storage container such as a pill box where they keep oral meds.

Besides special labeling, the pharmacist may wish to speak with patients who are new to inhalers or to those who have questions about using their inhalers. It’s important that these patients understand how to properly use their inhalers. Patients should know how to administer the medication, clean the device, prime the device (make the inhaler ready for use), etc. The instructions can vary between the different types of inhalers as well as the different brands of inhalers that are the same type.

Since your pharmacy dispenses a lot of Advair Diskus, you know that once removed from its foil pouch, the inhaler must be used within a month. You place an auxiliary label with the use-by date on the outer packaging of the Advair Diskus, along with instructions to store it in a dry place since it’s a DPI. 

What should I watch for when inputting prescriptions for nebulizer solutions?

As for inhalers, make sure you calculate the days’ supply correctly with nebulizer solutions. Use the number of vials (nebules) per box, NOT mL of medication per box. Each vial is single use, so excess medication from an open vial must be discarded, not saved for later use. However, when entering the quantity of nebulizer solutions, use the total number of mL per box, not the number of vials. This is the number most computer systems will require.

For example, if an Rx is for levalbuterol (Xopenex) 0.31 mg/3 mL nebulized three times daily x 1 box, and the box contains 24 vials, the days’ supply would be 8 days (24 vials/box x 1 day/3 vials = 8 days/box. If the patient is getting one box, enter a quantity of 72 mL into the computer, not 24 vials or 1 box. Calculate the quantity by multiplying the number of vials per box by the volume of each vial: 24 vials/box x 3 mL/vial = 72 mL/box.

Also keep in mind that nebulizer solutions can be billed under Medicare Part B in the US. When billing Medicare Part B a diagnosis code is required, along with exact directions for use, etc.

What should I watch for when dispensing prescriptions for nebulizer solutions?

Be careful with strengths and volumes of nebulizer solutions. These can be easy to mix up. For example, in the US, albuterol nebulizer solutions come in 0.63, 1.25, and 2.5 mg per 3 mL and 2.5 mg per 0.5 mL vials. Multiple strengths/volumes of salbutamol are also available in Canada. Keep in mind that albuterol and levalbuterol can be easy to mix up as well.

Dispense nebulizer solutions in their original packaging. The vials/nebules of medication are packaged in foil pouches to protect them from light. Tell patients to keep them in their foil pouches prior to use. This includes after opening the pouch if there are multiple vials/nebules per foil pouch.

Keeping vials/nebules in their packaging also helps prevent mix-ups with similar looking vials/nebules when patients use multiple nebulized meds. It can be difficult to read drug names and strengths embossed on the vials/nebules. This is especially important in the hospital setting, where individual doses may be dispensed for inpatients. It may be necessary to attach barcode labels when dispensing individual vials.

In the hospital, be sure vials/nebules are appropriately dated if they’re removed from light protective packaging when dispensed. For example, levalbuterol inhalation solution is only good for one week once removed from its foil pouch. Also label any injectable meds being used for inhalation (e.g., amikacin, amphotericin B, colistimethate) as “for inhalation” to prevent inadvertent IV administration.

Is there any special labeling for nebulizer solutions?

As with capsules that come with DPIs, place a “do not swallow” label on nebulizer solutions to let patients know they’re only to be used with a nebulizer for inhalation. Also, tell patients to fill out the “use-by date” labels that come with some nebulizer solutions. Similar to the Xopenex example in the previous section, Pulmicort Respules (US) expires 14 days after the foil pouch is opened (three months for Canadian Pulmicort Nebuamp) and Brovana (US) expires after 42 days if stored at room temperature. When dispensing nebulizer solutions in the hospital setting, fill out “use-by date” labels or add labels with beyond-use dates according to your pharmacy’s policies.

Cite this document as follows: Technician Tutorial, Dispensing Inhaled Medications. Pharmacist’s Letter/Pharmacy Technician’s Letter. December 2022. [381282]

--Continue to the next section for a “Cheat Sheet” for Dispensing Inhaled Medications--

 

“Cheat Sheet” for Dispensing Inhaled Medications

 

What types of meds come in inhaled dosage forms?

Meds that come in inhaled forms usually help open the airways so patients with breathing problems (e.g., asthma, COPD) can breathe normally.  They include:

  • steroids that reduce swelling in the airways (e.g., fluticasone).
  • beta-agonists that open up airways (e.g., albuterol [called salbutamol in Canada]).
  • anticholinergics that relax airways and reduce secretions (e.g., ipratropium).

What are the different types of inhalers?

  • MDIs (metered-dose inhalers)
  • DPIs (dry-powder inhalers)
  • SMIs (soft-mist inhalers)

What is a nebulizer?

  • A nebulizer is a machine, sometimes called a “breathing machine,” that changes a liquid med into a mist.

What should I watch for when inputting Rxs for inhalers?

  • Choose the right med.
  • Ensure sigs are correct and complete.
  • Enter the correct days’ supply.

Is there any special labeling for inhalers?

  • Many inhalers have a “use-by” date that applies after removal from the outer wrapping.
  • MDIs that are suspensions should get a “shake well” label.
  • Place a label indicating to store in a dry place on DPI packaging if you have such a label available.
  • In the US, dispense a MedGuide with long-acting beta-agonist inhalers.
  • Label DPIs with powder in separate capsules as “not for oral use.”

What should I watch for when inputting Rxs for nebulizer solutions?

  • Calculate the days’ supply correctly with nebulizer solutions.
  • Keep in mind, nebulizer solutions can be billed under Medicare Part B in the US.  

What should I watch for when dispensing Rxs for nebulizer solutions?

  • Be careful with strengths and volumes of nebulizer solutions.  They can be easy to mix up.
  • Dispense nebulizer solutions in their original packaging.

Is there any special labeling for nebulizer solutions?

  • Place a “do not swallow” label on nebulizer solutions.
  • Tell patients to fill out the “use-by date” labels that come with some nebulizer solutions.
  • In the hospital setting, fill out “use-by date” labels or add labels with beyond-use dates.
  • In the hospital setting, label injectable meds being used for inhalation (e.g., amphotericin B, colistimethate) as “for inhalation” to avoid inadvertent IV administration.

[December 2022; 381282]



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