Asthma Drugs 03

8/6/2019 Asthma Drugs 03

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Pharmacology

1. Short acting bronchodilators

a. Short Acting β2 Agonists (SABA)

i. Relax smooth muscle quickly, within 3-5 minutes

ii. Lasting approximately 4-6 hours

iii. Agents

1. Albuterol (Ventolin, Proventil)

a. MDI 90mcg/puff 200 puffs per canister

2. Pirbuterol (Maxair)

a. 400 puffs per canister3. Levalbuterol (Xopenex)

4. Terbutaline (Bricanyl <oral>, Brethaire <MDI>)

5. Metaproteronol (Alupent, Metaprel)

b. Short Acting Catecholamine Agents

i. Act on all receptor sites (α1, β1, β2) resulting in increased heart rate andblood pressure along with bronchodilation

ii. Exposure to light, heat or alkaline solution causes the drug to oxidize. Thiscauses the color to change to pink, then brown. Do not use if color haschanged.

iii. Agents

1. Epinephrine (Adrenaline, AsthmaHaler, Bronkaid)

a. Emergency Drug

2. Racemic Epinephrine (Mirconefrin, Vaponefrin, Asthmanefrin)

a. Indicated for symptomatic relief of bronchospasm and mucusproducion

3. Bitolterol (Tornolate)



Pharmacology

2. Inhaled Corticosteroids

i. Most effective long term control medication for asthma by reducinginflammation.

ii. Advise patients to rinse their mouth with water and spit after each dose(thrust)

iii. Once asthma is under control, the steroid therapy dose should be reduced tothe lowest possible dose that maintains control

iv. Monitor growth in children

1. May be suppression or delay in growth, although asthma that is not wellcontrolled will also contribute to growth delay

v. Agents

1. Fluticasone HFA (Flovent)

a. MDI

i. starting dose 88mcg BID (each puff is 44 mcg)

1. 44 mcg/inhalation in 120 inhalations



ii. There is a dose counter that will count down to 0

iii. Prime when opened and if not used for 7 days or dropped

b. DPI

i. Three strengths 50, 100 or 250 mcg

ii. Each diskus has 60 preloaded doses

iii. When the dose counter reaches 5, the number turns red

2. Budesonidea. Pulmicort is a Category B pregnancy rating

b. Pulmicort Turbuhaler DPI

i. 200 preloaded doses (200mcg per inhalation)



Pharmacology

ii. When a red line appears, 20 doses are left. When the linereaches the bottom of the window, no medication is left

iii. Prime before first dose, then never reprime again

c. Pulmicort Respules

i. Indicated for children 1-8 years

ii. Delivered via SVN

d. Pulmicort Flexhaler

e. Rhinocort

3. Beclomethasone CFC (Vanceril)

4. Beclomethasone HFA (QVAR)

5. Triamccinolone (Azmacort)

a. Built in spacer

6. Flunisolide (AeroBID)

7. Flunisolide HFA (Aerospan)

8. Mometasone

a. Nasonex <Nasal Spray>

b. Asmnex Twisthaler <DPI>

9. Ciclesonide (Alvesco)

a. Newer, Pro drug

b. Long Acting Beta2 Agonists (LABA)

i. Controller drugs

ii. Effect last approximately 12 hours

iii. Should be used in combination with inhaled corticosteroids

iv. Useful for preventing EIB, although frequent use may mask uncontrolledasthma

v. Agents



Pharmacology

1. Salmeterol (Serevent)

a. 60 preloaded blisters in a foil pouch

b. When 5 doses left, the numbers will appear in red

c. Once the pouch is opened, the medication will expire in 6 weeks

d. DPI

i. 50mcg/puff BID

2. Formoterol (Foradil Aerolier)

c. Oral Systemic Corticosteroids

i. Used on a short term basis (bursts) to gain control during an exacerbationii. The management plan should be re-evaluated if they require more than 3

courses of steroids a year

iii. Side Effects

1. Hypertension, Cushing’s syndrome, growth suppression, muscleweakness, fluid retention, weight gain, diabetes

iv. Coexisting conditions that may be aggravated by steroid therapy

1. Varicella, TB, Strongyloides (worms), Hypertension, diabtes, Herpesvirus infections

v. Agents

1. Methylpredniolone (Medrol, SoluMedrol)

2. Prednisolone (Delta-Cortef, Pediapred, Hydeltrasol)

3. Prednisone (Deltasone, Meticorten, Orasone)

4. Methylprednisolone Acetate (Depo-medrol)

d. Mast Cell Stabilizers

i. Stabilize the mast cell and inhibit the release of mediators

ii. Used to be very common but not prescribed as often



Pharmacology

iii. Agents

1. Cromolyn Sodium (Intal)

a. Spinhaler

b. Blocks early and late phase reactions

c. 4-6 week trial to determine effectiveness

d. Available and MDI form

2. Nedocromil Sodium (Tilade)

a. Reported nasty taste

e. Leukotriene Inhibitors (Modifiers)i. Leukotrienes bind with their receptor sites and result in an increase in

bronchial hyperresponsiveness, increased mucus production and cell walledema

ii. Designed to block the block the binding at receptor sites or inhibit production

iii. Used for maintenance

iv. Agents

1. Montelukast (Singular)a. No known drug interactions

2. Zafirlukast (Accolate)

a. Inhibits metabolism of warfarin and increases prothrombin time

b. Take on an empty stomach

3. Zileuton (Zyflo CR)

a. 5-lipooxygenase inhibitor (5LO)

b. Avoid use with warfarin, theophylline or propranolol

c. Measure LTF’s

f. Methylyxanthine Bronchodilators



Pharmacology

i. Relax airway smooth muscle, reduce glandular secretions and delay therelease of histamine and leukotrienes

ii. Agents

1. Theophylline (Slo-Bid, Bronkodyl, Theo-Dur, Theolair)

a. Increases the effects of anticoagulants

b. Theophylline levels increased by Cimetidine, propranolol,erythromycin, troleadndomycin, phenobarbital, phenytoin, zileutin,smoking

g. Anticholinergic Bronchodilators

i. Recommended for moderate to severe exacerbations in the ED

ii. Block the effect of cholinergic nerves, causing the muscles to relate and thebronchi to dilate

iii. Used in conjunction with SABA

iv. Not recommended for EIB

v. Recommended for bronchospasm due to β-blocker medications

vi. Agents

1. Ipatropium Bromide (Atrovent)

h. Immunomodulator

i. Adjunct medication for patients with allergies and persistent asthma that isnot controlled with LABA and high dose ICS

ii. Block the IgE antibody from binding to their receptor sites on basophils andmast cells

iii. Use for ages 12 and older

iv. Agents

1. Omalizumab (Xolair)

2. Black box warning – potential for anaphylaxis

3. 0.5% of malignant neoplasms (cancers)



Pharmacology

i. Combination Drugs

i. Steroid and LABA

1. Fluticasone and Salmeterol (Advair)

a. Available as Diskus and newer MDI

2. Budesonide and Formoterol (Symbicort)

ii. SABA and Anticholinergic

1. Albuterol and Ipatropium Bromide (DuoNeb)

2. Albuterol and Ipatropium Bromide (Combivent)

j. Drug Interactions

i. Aspirin/NSAID’s

1. Anaphylaxis

ii. Beta-Blocker

1. Bronchospasm

iii. ACE inhibitors

1. Cause a cough

3. Devices

a. Metered Dose Inhalers

i. Require 25-60 L/min inspiratory flow

ii. Propellant: CFC vs HFA

1. All albuterol must be HFA

Asthma Drugs 03

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