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Old Doc, New Drug: Umeclidinium

When I first saw the name of this medication… I honestly thought that some smart physicist had discovered a new element way down the bottom of the period table.  Naturally, being a total chemistry nerd, I was excited… until I realised that it was in fact just another boring drug to treat the most mundane disease… chronic bronchitis!

Now, it turns out that this drug has been on the market for about 4 years.  This gives me a good measure of the educational and clinical lag  that we experience as rural, remote doctors!  In recent times it has become an unavoidable torture to try and spell out this name “U-M-E-C…” on medication charts.  So along with getting the spelling right – I am going to explore the pharmacology and evidence a bit.

To make it simple I will build on my existing pharmo-skills.  We have been using ipratropium for decades as an anti-cholinergic agent in nebulised form for acute airways disease.  Then about 10 years ago we met tiotropium  – the long acting, once a day long-acting anticholinergic inhaler…  this all made sense as they were vaguely spelled the same!  My brain was happy with that.

Now enter the frame – a new anticholinergic, with no grammatical resemblance whatsoever to the others!  To make things worse it often gets combined with another new drug named vilanterol, which sounds exactly like a modern snake-oil to me!  So it took me a while to get my head around this new diabolic duo of drugs.  What were they adding to my current practice? Was it worth learning?

UMECLIDINIUM is a long-acting (anti-muscarinic) anticholinergic medication.  It is packaged in a dry powder inhaler device known as an “Ellipta” (this is also confusing as the actual plastic bit is called the Ellipta, not the drug.  The Ellipta can be used for a number of different inhaled combinations eg:

  • Anoro  = umeclidinium plus vilanterol
  • Breo = fluticasone furoate plus vilanterol
  • Incruse = umeclidinium

It really is enough to confuse even the most drug-company-sponsored practitioner!  I assume Dr. Seuss is the head of the marketing department?  So when your patient tells you that they have been using their ‘Ellipta’ you will have to guess exactly what they have been sucking!

Vilanterol is of course a long-acting b-agonist similar to salmeterol or efometerol.  It sits on your airway B receptors all day supposedly relaxing the smooth muscles. (at least the suffix stayed the same here!)  OK, so now we know who is who… the better question:  DO THEY WORK?

Well I found one reasonably-sized, GSK-sponsored head to head trial of UMECLINIDIUM vs. TIOTROPIUM here in the . 2016; 11: 719–730.  My summary of this comparison trial is below:

  • They both worked
  • There was maybe slightly better spirometry (the primary outcome) in the UMEC group
  • There was no difference in patient-based / subjective symptom reduction scores
  • It seemed that more patients preferred the new delivery device (Ellipta) over the older Handihaler
    • so UMECLIDINIUM might nudge out TIOTROPIUM based on engineering rather than pharmacology
  • REMEMBER: Neither drug makes your patient quit smoking… this is probably the best way to fix their lungs!
    • Half of the patients in this trial were still smoking!

Now UMEC comes as a combination inhaler with the long-acting B-agonist component.  So if this works better as a combination of drugs that would be handy.  However, as with asthma in the past we have seen aggressive marketing of combination inhalers result in widespread over-treatment of folk with mild or moderate disease.  So I think we need to remind ourselves that these combination puffers are really most likely to be beneficial in patients with more severe disease, symptoms or those who have already failed monotherapy.  All of the data supporting combination therapy is sponsored by the company that makes the drugs as far as I can see…. so a pinch of salt for now until more longer-term, real world outcomes are published.

Last big question:  Are they safe?  It is early days, not many adverse event reports have yet been filed.  If you read the trials then you will see that the main downer / side effects of UMECLINIDIUM are : headaches, nasopharyngitis.

At higher doses (eg. 2 puffs a day) there may be a risk of tachycardia / SVT etc.  So you might want to be cautious in patient with sensitive tickers / AF or ischaemic hearts…  ie. almost all of the patients with the disease!  The other common anticholinergic symptoms include glaucoma issues, urinary retention etc…

Ok that is it for another voyage into the new world of modern Pharma.  Comments, questions and suggested targets are appreciated!

Casey

 

Comments

  1. Riana Janse van Rensburg says:

    I had and older and younger patient trailed on it for asthma by the local respiratory specialist. The younger patient improved her asthma control significantly and continued it, the older patient felt worse on it and had increased coughing ( Breo) and changed back to her usual inhalers. They are from the same family.

  2. Melissa Morison says:

    As you said Casey, for the patients at the more severe end of disease spectrum I have found the Anora combo beneficial. I haven’t really seen any benefit in changing to Breo for the asthmatics. Thanks for the update.

  3. Nic Gilbert says:

    … and also recently added to the PBS the first triple agent – Trelegy Ellipta : uneclidinium + fluticasone + vilanterol. Being marketed fairly heavily by drug companies and a few patients requesting it thinking it’s a miracle https://m.pbs.gov.au/industry/listing/elements/pbac-meetings/psd/2017-12/files/fluticasone-furoate-umeclidinium-vilanterol-psd-12-2017.docx

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