# Key factors for implementing inhaler regimen switches in respiratory diseases: international expert consensus generated using a modified nominal group technique (NGT)

## TL;DR

Experts agree on when and how to switch inhalers for asthma and COPD patients, emphasizing patient safety and clinical need over cost.

## Contribution

Generated international expert consensus on inhaler regimen switches using a modified nominal group technique.

## Key findings

- Clinical and patient-focused drivers were rated most important for inhaler switching.
- Patient safety factors were identified as critical for appropriate switching.
- Consultation for inhaler switches requires a median of 36 minutes.

## Abstract

To develop international expert consensus statements on when and how to implement inhaler switches for patients with asthma or chronic obstructive pulmonary disease, informing clinicians and decision-makers on appropriate circumstances, stakeholder roles, and essential steps for safe and effective switching. An international panel of eight clinical, payer, and patient experts participated in a nominal group technique. Ideas were generated in response to four research questions and rated on a 7-point Likert scale (1 = not at all important; 7 = extremely important). The decision-making unit framework was applied for stakeholder mapping. Clinical and patient-focused drivers were identified as the most important drivers for inhaler switching (rated very or extremely important by >60% of experts), which included inadequate disease control, inhaler technique errors, switching to maintenance and reliever therapy, adding a spacer, and addressing poor satisfaction. Operational factors such as supply shortages were considered moderately important, while environmental and cost-related drivers were considered least important (rated not at all important to neutral by >60% of experts). Inappropriate circumstances for inhaler switching centred on patient safety (rated very or extremely important by >85% of experts), including lack of consultation, consent, education, or follow-up, switching clinically stable patients, and introducing complex regimens. Of essential activities required for a consultation, experts estimated a median time of 36 min would be required. Experts suggest inhaler switches should prioritise clinical need and patient involvement over cost or sustainability goals, and suggest policymakers consider the time and complexity required for implementation at scale.