1. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.1 Respiratory Medications

2. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.2 Is your patient breathing?? When you can’t breathe… nothing else matters.

3. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.3 Asthma  Chronic inflammatory disorder of the airway  Characteristic signs and symptoms: Sense of breathlessness Tightening of the chest Wheezing Dyspnea Cough  Cause: immune-mediated airway inflammation

4. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.4 Allergen-induced inflammation & bronchospasm in asthma  Symptoms result from a combination of inflammation & bronchoconstriction, so treatment must address both components.

5. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.5 Inhalation Drug Therapy  Three obvious advantages: Therapeutic effects are enhanced Systemic effects are minimized Relief of acute attacks is rapid  Three types: Metered-dose inhalers (MDIs) Dry-powder inhalers (DPIs) Nebulizers

6. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.6 Note that, when a spacer is used, more medication reaches its site of action in the lungs, and less is deposited in the mouth and throat. Impact of a spacer device on the distribution of inhaled medication

7. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.7 Overview of Drugs for Asthma  Two main pharmacologic classes: Bronchodilators Beta 2 agonists (albuterol) Anti-inflammatory agents Glucocorticoids (prednisone)

8. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.8 Relievers  Alleviate symptoms immediately  Do no not address underlying problem of inflammation.  Short-term solution  Indicative that there is underlying inflammation present that requires a controller medication.  Teach patients to monitor how often you use your reliever.  ↑↑ use over time → asthma is worsening.

9. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.9 Relievers AKA… Short-acting bronchodilators (SABAs), β 2 -agonists or rescuers or rescue medication Examples of reliever medications include: Fenoterol (sold as Berotec®) Formoterol (sold as Foradil®, Oxeze®) Ipratropium (sold as Atrovent®) Isoproterenol (sold as Isuprel®) Orciprenaline (sold as Alupent®) Salbutamol (sold as Ventolin® HFA, Apo-Salvent® CFC Free, Ratio-Salbutamol HFA) Terbutaline (sold as Bricanyl®)

10. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.10 Bronchodilators  Provide symptomatic relief but do not alter the underlying disease process (inflammation)  In almost all cases, patient taking a bronchodilator should also be taking a glucocorticoid for long-term suppression of inflammation  Principal bronchodilators are the β 2 -adrenergic agonists

11. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.11 Bronchodilators β 2 -Adrenergic Agonists  Include albuterol (Ventolin), salmeterol (Serevent), terbutaline (Bricanyl)  Most effective drugs for relief of acute bronchospasm and prevention of exercise-induced bronchospasm  Use in asthma: both quick relief and long-term control

12. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.12 Bronchodilators β 2 -Adrenergic Agonists  Adverse effects Inhaled preparations Systemic effects – tachycardia, angina, and tremor Oral preparations Excessive dosage – angina pectoris, tachydysrhythmias Tremor

13. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.13 Bronchodilators β 2 -Adrenergic Agonists  Mechanism of action Activate beta 2 receptors in smooth muscle of lung, promoting bronchodilation and thereby relieving bronchospasm Also suppress histamine release in lung and increase ciliary motility

14. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.14 Controllers  Controllers = "preventers"  Reduce inflammation in the airways.  Should be taken every day.  If the controller medication is working, over time the patient will have ↓ & ↓ ↓ symptoms.  Even when asthma is totally controlled and the patient has no symptoms, advise not to stop taking controllers. If they do stop, the airway inflammation may return.

15. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.15 Anti-Inflammatory Drugs  Foundation of asthma therapy  Taken daily for long-term control  Principal anti-inflammatory drugs are the glucocorticoids

16. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.16 Anti-Inflammatory Drugs – Glucocorticoids  Include budesonide (Pulmicort) & fluticasone (Flovent)  Considered the most effective anti-asthma drugs available  Usually administered by inhalation, but IV and oral are also options

17. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.17 Anti-Inflammatory Drugs – Glucocorticoids  Mechanism of action = ↓↓ inflammation ↓↓synthesis and release of inflammatory mediators ↓↓ infiltration & activity of inflammatory cells ↓↓ edema of the airway mucosa

18. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.18 Anti-Inflammatory Drugs – Glucocorticoids  Adverse effects: Minor when taken acutely Can be severe when used long-term (adrenal suppression, osteoporosis, hyperglycemia, and others)

19. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.19 Caution: Steroids in Use 19

20. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.20 Anti-Inflammatory Drugs – Leukotriene Modifiers  Suppress effects of leukotrienes  Less effective than inhaled glucocorticoids  Available agents: Zafirlukast (Accolate) Montelukast (Singulair)

21. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.21 Anti-Inflammatory Drugs – Cromolyn  Used for prophylaxis, not quick relief  Suppresses inflammation; not a bronchodilator  Route – inhalation: Nebulizer MDI  Adverse effects Safest of all antiasthma medications Cough Bronchospasm

22. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.22 Glucocorticoid/LABA Combinations  Available combinations Fluticasone/salmeterol (Advair) Budesonide/formoterol (Symbicort)  Indicated for long-term maintenance in adults & children  Not recommended for initial therapy

23. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.23 Bronchodilators – Methylxanthines  Theophylline Benefits derive primarily from bronchodilation Narrow therapeutic index Plasma level 10 to 20 mcg/mL Toxicity is related to theophylline levels  Another methylxanthine - aminophylline

24. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.24 Chronic Asthma Management  Tests of lung function Forced expiratory volume in 1 second (FEV 1 ) Forced vital capacity (FVC) Peak expiratory flow (PEF)

25. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.25 Chronic Asthma Management  Four classes of chronic asthma Intermittent Mild persistent Moderate persistent Severe persistent

26. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.26 Asthma Severity IntermittentMild PersistentModerate PersistentSevere Persistent Symptoms2 or less days/weekMore than 2 days/ weekDaily Throughout the day Nighttime Awakenings 2 X's per month or less3-4 X's per month More than once/week but not nightly Nightly Rescue Inhaler Use 2 or less days/week More than 2 days/week, but not daily DailySeveral times/day Interference With Normal Activity NoneMinor limitationSome limitationExtremely limited Lung Function FEV1 >80% predicted and normal between exacerbations FEV1 >80% predictedFEV1 60-80% predicted FEV1 less than 60% predicted

27. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.27 Chronic Asthma Management  Treatment goals Reducing impairment Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime, in the night, or after exertion) Require infrequent use (≤2 days a week) of SABA for quick relief of symptoms Maintain (near) normal pulmonary function Maintain normal activity levels (including exercise and other physical activity and attendance at work or school) Meet patients' and families' expectations of and satisfaction with asthma care

28. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.28 Chronic Asthma Management 28  Reducing risk Prevent recurrent exacerbations of asthma, and minimize the need for ED visits or hospitalizations Prevent progressive loss of lung function; for youths, prevent reduced lung growth Provide optimal pharmacotherapy with minimal or no adverse effects

29. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.29 Chronic Asthma Management  Chronic drug therapy Agents for long-term control (e.g., inhaled glucocorticoids) Agents for quick relief of ongoing attack (e.g., inhaled SABAs)

30. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.30 Chronic Asthma Management  Stepwise therapy Step chosen for initial therapy is based on pretreatment classification of asthma severity Moving up or down a step is based on ongoing assessment of asthma control

31. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.31 Chronic Asthma Management  Important to reduce exposure to allergens and triggers  Sources of allergens: house dust mites, pets, cockroaches, mold  Factors that can exacerbate asthma: tobacco smoke, wood smoke, household sprays

32. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.32 Questions