Local side effects
of inhalers in patients with COPD in KHMC
......................................................................................................................................................................
Rakan M. Haddad (1)
Jafar A. Al-Momani (1)
Adnan S. AlSuleihat (1)
Khaled M. Alnadi (1)
Amaal F. Dbase (2)
(1) Department of Internal Medicine, Respiratory
Medicine Division, King Hussein Medical Center(KHMC),
Amman, Jordan
(2) Department of Obstetrics and Gynecology, King
Hussein Medical Center(KHMC), Amman, Jordan
Correspondence:
Dr.R.Haddad
Department of Internal Medicine, Respiratory Medicine
Division,
King Hussein Medical Center(KHMC),
Amman, Jordan
Email: Rakanhaddad@yahoo.com
ABSTRACT
Objective:
To find out the most common local side effects
caused by inhalers in patients with Chronic
Obstructive Pulmonary Disease (COPD), treated
in the pulmonary clinic in King Hussein
Medical Center (KHMC). The effect of regular
mouth rinsing with water after inhaler use
in preventing these side effects was also
evaluated.
Method: Descriptive study of
127 patients diagnosed to have Chronic Obstructive
Pulmonary Disease (COPD) between January
2015 and January 2017 , treated in the pulmonary
clinic in King Hussein Medical Center (KHMC).
The rates of different local side effects
of inhalers used in Chronic Obstructive
Pulmonary Disease (COPD) were assessed in
patients using inhalers regularly for more
than 6 months, during their regular visit
to the pulmonary clinic, using a questionnaire.
The rates of regular mouth rinsing after
inhaler use were evaluated as well.
Results: Of the 127 patients enrolled
in our study, 93 patients (73%) were males.
The mean(±SD) age was 68.0±7.6
years. The ages ranged between (47-79) years.
102 patients (80%) reported at least one
adverse local side effect of inhalers .The
most common local side effect was sore throat,
affecting 29 patients (23%). Other side
effects included dysphonia (18%), mouth
ulcers (2%), oral candidiasis (5%), thirst
(17%) and dry throat (21%). Out of the 102
patients who reported having local side
effects of inhalers, 82 patients (80%) admitted
that they don't rinse their mouth after
inhaler use. Out of the 25 patients who
didn't have adverse local side effects from
the inhalers, only 2 patients (8%) admitted
that they don't rinse their mouth regularly
after inhaler use.
Conclusion:
Local side effects of inhalers are common
among COPD patients treated in KHMC. The
most common side effects are throat and
vocal complaints. Failure to adhere to mouth
rinsing with water after inhaler use plays
a major role in increasing the rates of
these side effects.
Key
words: COPD, Side effects, Inhalers
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Chronic Obstructive Pulmonary
Disease (COPD) is considered one of the most common
diseases worldwide. It is currently the fourth
leading cause of death worldwide.(1) By 2020,
COPD is expected to account for more than 3 million
deaths annually, and to be the third leading cause
of death worldwide.(2)
Inhaler therapy is considered the main mode of
treatment of COPD. Bronchodilators, including
Beta-2 agonists and anticholinergics, as well
as inhaled corticosteroids, are considered to
be the cornerstones in the management of COPD.
(3) Despite the efficacy of inhaler therapy in
managing COPD, adverse local side effects of these
inhalers, especially inhaled corticosteroids,
are common among these patients. (4-8) Those side
effects are usually neglected and underestimated
by both the patients and the physicians .(9,10)
The different adverse local side effects of inhalers
in COPD patients are poorly studied, and the information
regarding the rates of these side effects are
limited.(7) Direct questioning by the treating
physician, as well as spontaneous patient reports
regarding the different adverse side effects of
inhaler therapy in COPD patients, are considered
very important in detecting these side effects,
and managing them properly and effectively. (11)
In our study, our aim was to assess the different
adverse local side effects of inhalers in patients
with COPD, treated in the pulmonary clinic in
King Hussein Medical Center (KHMC). The effect
of regular mouth rinsing after the use of inhalers
in preventing these side effects was evaluated
as well.
In our study, 127 patients who
are diagnosed to have COPD, and who are regularly
followed up and treated in the pulmonary clinic
in KHMC, were enrolled in this study done between
January 2015 and January 2017. Thorough explanation
of the aims of the study was done to all the patients,
after which a consent form was signed by all the
patients prior to enrolling them in the study.
Approval of the ethical committee was obtained
in order to carry out the study. Inclusion criteria
were as follows: age >40 years, current or
former smokers, and an established diagnosis of
COPD for at least 3 years. Exclusion criteria
were as follows: immunocompromised patients, patients
who received oral or parenteral corticosteroids
for more than 2 weeks during the last 6 weeks
, patients who suffered from an exacerbation requiring
hospitalization during the last 6 weeks, patients
who are not receiving inhaled corticosteroids
as a part of their treatment, and patients who
are non compliant to their inhalers.
After being enrolled in the study, all the patients
were evaluated by a pulmonologist in the clinic.
Information regarding the age and the gender of
the enrolled patients were gathered. The type
of inhalers used by the patients was recorded.
Afterwards, the patients were asked to answer
a questionnaire during their regular visit to
the clinic. The questionnaire asked whether or
not the patient suffered from any local side effect
after using the inhalers. The side effects that
were mentioned included the following: change
of voice (dysphonia), oral ulcers, oral candidiasis,
sore throat, thirst and dry throat. The patients
were also informed that they can mention any other
local side effect, and they can choose more than
one side effect if they have experienced them
at any time during their treatment with the inhalers.
The patients were asked to answer whether or not
they are compliant to rinsing their mouth regularly
with water after the use of their steroid inhaler.
The number and percentage of patients who developed
each local side effect was calculated, and the
number and percentage of those who were not compliant
to regular mouth rinsing was assessed as well,
and a comparison between the group of patients
who developed local side effects and those who
did not was done in order to assess the efficacy
of mouth rinsing in preventing the local side
effects of the inhalers.
127 patients
with COPD , who are using regular inhaler therapy
were enrolled in this study. 93 patients (73%)
were males. The mean (±SD) age was 68.0±7.6
years. The ages ranged between (47-79) years.
Overall, 102 patients (80%) reported at least
one adverse local side effect. The most common
side effect was sore throat, which was mentioned
by 29 patients (23%). Dry throat, dysphonia and
thirst were the next most common local side effects,
mentioned by 21%, 18% and 17% respectively.
Chart 1 shows the number of patients who developed
different local side effects of inhalers in this
study.
Out of the 102 patients who reported having local
side effects of inhalers, 82 patients (80%) admitted
that they don't rinse their mouth after inhaler
use. Out of the 25 patients who didn't have adverse
local side effects from the inhalers, only 2 patients
(8%) admitted that they don't rinse their mouth
regularly after inhaler use.
In our study, adverse local side
effects of inhaler therapy in patients with COPD
were found to be high, with about 80% of the patients
having at least one local side effect. This proves
that there is a high prevalence of local side
effects of inhalers. Many other studies found
the same observation regarding the prevalence
of side effects of inhalers. (12-14) The most
common side effects mentioned by the patients
were mainly sore throat and throat dryness, both
of which accounted for more than half the side
effects mentioned by the patients (44% of all
the patients, and 55% of those who had side effects).
This was also observed by other studies, which
found a high prevalence of throat symptoms in
patients using inhalers. (12,13) Oral cavity side
effects, such as oral candidiasis and oral ulcers
were seen in only 7% of the patients. In other
studies, the rates of oral cavity side effects
vary widely, with studies estimating the prevalence
of oral candidiasis to range between 0-70%. (4,5,15)
This wide range may be caused by the dose of the
inhalers, mainly the inhaled corticosteroid dose,
and the duration of the therapy.
Thirst was observed as a side effect in 17% of
the patients in our study. In one cross sectional
study, this side effect was seen in 42-60% of
the patients included in the study. (6) However,
this high rate might be explained by the fact
that this cross sectional study was conducted
on patients with bronchial asthma rather than
COPD, who were maintained on a high dose of inhaled
corticosteroids.
Dysphonia was mentioned as a side effect in our
study by 18% of the patients. Many other studies
found dysphonia to be a common side effect of
inhalers, with rates ranging between 10-57%. (8,9,14)
The most acceptable mechanism for dysphonia is
attributed to the steroid component in the inhalers,
which will lead to steroid myopathy affecting
the vocal muscles, which causes a bilateral adduction
deformity. (16,17)
Mouth rinsing was found to be a very effective
method in preventing local side effects in our
study. While 80% of the patients who developed
local side effects didn't rinse their mouth regularly
after the use of their inhalers, only 8% of the
patients who didn't develop any local side effect
in our study didn't rinse their mouth regularly
after inhalers. This observation emphasizes the
importance of oral hygiene maintenance and mouth
rinsing in COPD patients using inhaler therapy,
in order to prevent the occurrence of local side
effects.
In conclusion, the rate of local side effects
of inhalers in COPD patients is high. Mouth rinsing
regularly is a very effective method to minimize
these side effects. Taking into consideration
the high rates of local side effects of inhalers,
the attending physician is advised to regularly
check for these side effects, and emphasize the
importance of maintaining good mouth hygiene and
mouth rinsing after inhaler use to his patients
during each visit to the clinic.
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