Respiratory Flashcards
Long-term asthma management medication classes
-Inhaled corticosteroids
-Long-acting inhaled beta-2 agonists (LABA)
- Leukotriene modifiers
- Tiotropium (12 yrs and older)
- Injectable monoclonal antibodies
Quick Asthma Relief medication classes
- Short-Acting inhaled beta-2 agonist (SABA)
- Systemic corticosteroids
- Inhaled, short-acting anticholinergics (ipratropium)
SABAs for asthma
albuterol (Ventolin, Proventil, ProAir), levalbuterol (Xopenex)
- Bronchodilator
- Onset: 5-15 mins, DOA: 3-4 hrs
- Should not need > 2x/week for asthma
SABA Adverse Effects
-Tachycardia (not HTN), tremors
- overuse can cause hypokalemia and hypomagnesemiaE
Epinephrine aerosol inhalation
Primatene Mist
-Bronchodilator
-Does not address underlying inflammation which can lead to airway remodeling
LABAs - for asthma
salmeterol (Serevent) onset: ~ 30 mins
formoterol (Foradil) onset: ~ 3-5 mins
MUST be combined with an inhaled corticosteroid when used in patients with asthma
Inhaled Corticosteroid Medications
- beclomethasone (QVAR)
- budesonide (Pulmicort)- only inhaled corticosteroid that also comes as neb solution
- ciclesonide (Alvesco) - prodrug (decreased adverse effects)
- fluticasone furoate (Arnuity)
- fluticasone propionate (Flovent)
- mometasone (Asmanex)
Inhaled Corticosteroids Use
Prevent and treat inflammation and bronchial hyper-responsiveness, thereby reducing symptoms and preventing exacerbations
- Used as daily treatment
Inhaled Corticosteroids Adverse Effects
- Oral candidiasis
- Hoarseness, cough - ciclesonide less likely
- Impaired growth rate in children
Combined inhaled corticosteroids/LABAs
BID:
Fluticasone propionate/salmeterol (Advair)
Budesonide/formoterol (Symbicort)
Mometasone/formoterol (Dulera)
Daily:
Fluticasone furoate/vilanterol (Breo, Ellipta)
Leukotriene Modifiers
- Decrease levels of circulating blood eosinophils
- Bronchodilation occurs within hours of first dose
-DOA ~ 24 hrs
Leukotriene Modifier Medications
- zafirlukast (Accolate) - rarely used, potential for hepatotoxicity
- zileuton (Zyflo) - only for 12 yrs of age or older
- montelukast (Singulair) - most common, well tolerated, small chance for neuropsychiatric symptoms
Monoclonal Antibodies
- used for allergic asthma
- prescribed with epi pen due to risk for anaphylaxis
SABAs for COPD
- may be used as monotherapy or in addition to other meds
- utilize max daily dose as needed (unlike for asthma)
Short-acting inhaled muscarinic antagonists/ anticholinergic combo
- help decrease secretion
- ipratopium - comes alone or in combo with albuterol in Combivent Respimal inhaler
- May need to schedule doses due to longer onset of action
- max 12 puffs/day
Long-acting muscarinic antagonist (LAMA)
- tiotropium (Spiriva), umeclidinium (Incruse, Ellipta) - daily
- aclidinium bromide (Tudorza, Pressair) - BID
LAMA Adverse Effects
- anticholinergic effects - constipation, urinary retention, blurred vision, and dry mouth
- dry mouth is common
LABA for COPD
- salmeterol and formoterol can be used alone and may be added to an anticholinergic.
- olodaterol (Striverdi Respimat) - ultra-long acting beta-2 agonist, daily
- arformoterol (Brovana) - administered via NEB
LABA/LAMA for COPD
vilanterol/umeclidinium (Anoro, Ellipta), olodaterol/tiotropium (Stiolto, Respimat)
Role of inhaled corticosteroids in COPD
To prevent exacerbation
- the higher the eosinophil count, the better the ICS response
- oral steroids are contraindicated due to the risk of myopathy
ICS Adverse Effects
- Oral candidiasis
- Hoarseness, cough
- Increased risk of pneumonia
ICS/LABA for COPD
- salmeterol/fluticasone (Advair), formoterol/budesonide (Symbicort) - BID
- vilanterol/fluticasone furoate (Breo, Ellipta) -daily
ICS/LAMA/LABA for COPD
- fluticasone furoate/vilanterol/umeclidinium (Trelegy, Ellipta) - daily
- budesonide/glycopyrrolate/formoterol (Breztri Aerosphere) - BID
Phosphodiesterase-4 inhibitor
- roflumilast (Daliresp)
- decrease inflammation by inhibiting breakdown of intracellular cAMP; NO bronchodilator
- indicated for pts with SVR COPD associated with chronic bronchitis and a history of repeated exacerbations
Phosphodiesterase-4 Inhibitor Adverse Effects
- Primarily Gi - nausea, appetite suppression, abdominal pain, weight loss
- psychiatric effects - sleep disturbances, increased anxiety, depression
What NOT to do for COPD
- Chronic, daily oral corticosteroids
- Antitussives
- Mucolytics - no harm but no benefit
- Prophylactic, continuous abx- study showed daily azithromycin decreased exacerbations at expense of decline in auditory function and increased bacterial resistance
Exacerbation Treatment Plan for Asthma
Adults: oral prednisone 40-60 mg daily for 5-10 days
Children: oral prednisone (or equivalent) 1-2 mg/kg/day for 3-10 days
Exacerbation Treatment Plan for COPD
Initial oral prednisone 30-40 mg/day for 5 days
- May also require abx
