COMPLETE - asthma/COPD

COPD (general)

Chronic, irreversible

Common in smokers

Not due to inflammation → ICS not used first line (increase risk of pneumonia instead)

SMI; Respimat

Counseling Tips

Dont…

Discard after

P-TOP

Prime. Turn. Open. Press

Dont need to shake or require spacer

Discard after 3 months

Anticholinergic oral inhalers

Frequency and CI in…

Ipratropium

Tiotropium

Umeclidnium

Aclidinium

Glycopyrrolate

do NOT give 2 anticholinergics together

Dont use with allergy to atropine

Atorvent HFA

Frequency

Comment

Ipratropium (Atorvent HFA) solution → QID

MDI that does NOT need shaking (other one is Ciclesonide (Alvesco))

Combivent Respimat

Comment

Not CI…

Discard when

Ipratropium + Albuterol

SMI → shaking NOT needed

NOT contraindicated with soybean or peanut allergy

Discard 3 months after cartridge is inserted

Duoneb

Frequency

Ipratropium + Albuterol (neb)

QID PRN

Spiriva HandiHaler → Formulation and Counseling

Spiriva Respimat

Tiotropium

Incruse Ellipta

Frequency

Umeclidinium - QD

DPI

Tudorza Pressair

Frequency

Dont…

Discard when… (2)

How to use

Aclidinium - BID

Seebri Neohaler

Frequency

Glycopyrrolate caps in Neohaler - BID

Lonhala Magnair

Frequency

Glycopyrrolate neb - BID

LABA for COPD: know frequency

Olodaterol

Indacaterol

Formoterol

Arformoterol

Salmeterol

Vilanterol

Striverdi Respimat

Frequency

Olodaterol - QD

SMI

Stiolto Respimat

Frequency

Discard when

Olodaterol + Tiotropium - QD

SMI

Discard 3 months

Arcapta Neohaler

Frequency

Formulation

Indacaterol - QD capsule

Utibron neohaler

Frequency

Formulation

Indacaterol + Glycopyrrolate - BID

Capsule inhale

Perforomist

Frequency

Formoterol Nebulizer Sol - BID

Brovana

Frequency

Arformoterol Nebulizer Sol - BID

Breo Ellipta

Frequency

Vilanterol + Fluticasone - QD

Anoro Ellipta

Vilanterol + Umeclidinium

Bevespi Aerosphere

Formulation

Frequency

Reprime when…

Formoterol + glycopyrrolate

MDI, BID

Shake, reprime if not used in 7 days

Trelegy Ellipta

Formulation

Frequency

Discard after

Umeclidinium + Vilanterol + Fluticasone furoate

DPI

QD

Breztri Aerosphere

Glcyopyrrolate + Formoterol + Budesonide

Daliresp

When to use

Dosing

ADE

CI

DDI

Roflumilast

Last line in COPD

Dosing: mcg PO QD

ADE: suicidality, weight loss

CI in hepatic impairment`

DDI: CYP3A4 and 1A2 substrate → avoid strong inducers

Beconase AQ, Qnasl

Beclomethasone (steroid for allergic rhinitis)

Nasonex

Mometasone (steroid for allergic rhinitis)

Omnaris, Zetonna

Ciclesonide (steroid for allergic rhinitis)

Nasacort Allergy 24HR

Triamcinolone (steroid for allergic rhinitis) OTC

Rhinocort Aqua

Budesonide (steroid for allergic rhinitis) OTC

Flonase Sensimist

Fluticasone furoate (steroid for allergic rhinitis) OTC

Asteopro 0.1% / 0.15%

Azelastine

Patanase

Olopatadine (antihistamine for allergic rhinitis)

Dymista

Azelastine / Fluticasone Propionate (Anithistamine/steroid for allergic rhinitis)

NasalCrom

Cromolyn (Mast cell stabilizer for allergic rhinitis) OTC

Ipratropium 0.03% / 0.06%

Anticholinergic used for allergic rhinitis

Allergic Rhinitis Med Summary

Antihistamine

Antihistamine/steroid

Mast cell stabilizer

Anticholinergic

Focus on the names and what meds are OTC

Nasal corticosteroid used in allergic rhinitis

Focus on the names and what meds are OTC

Asthma

Bronchodilatory reversibility percentage

Med Triggers

Reversible inflammatory disorder of the airways

Bronchodilatory reversibility → lung function increase by at least >12%

Med triggers: NSAID (aspirin) and beta-blockers

FEV1

FVC

FEV1/FVC: # to diagnosis COPD

FEV1: how much air can you get out in 1 second → lower in both asthma and COPD, good predictor of M/M in COPD

FVC: how much air can you get out in total

FEV1/FVC: ratio <0.7 required for diagnosis COPD (usually doesnt change that much in asthma)

PEF Readings and Asthma Exacerbation

Green, yellow, red zone

Red zone = go to emergency room

Red/yellow zone: be on rescue inhaler

• Preferred: Low dose ICS + formoterol (1 inhaler)

• Alt: low dose ICS taken with SABA (2 inhalers)

• Start oral steroids as needed (preferred in red zone, use if patient remains in yellow zone despite rescue)

GINA (asthma) guidelines stepwise approach

TRACK 1: ICS-formoterol as reliever and controller

Symptoms <4-5 days a week

• PRN low dose

Symptoms most days of the week

• Daily low dose

Symptoms every day or waking with asthma

• Daily medium dose

• Add LAMA or anti-IgE, anti IL5/5R, anti-IL4R

-

Note:

• only the dose of the ICS portion will increase (not formoterol portion)

• both Track 1 and 2 use daily low dose maintenance with ICS-LABA with symptoms most days

GINA (asthma) guidelines stepwise approach

TRACK 2: SABA + ICS as reliever

Symptoms < twice a month

• PRN SABA (with ICS each use)

Symptoms > twice a month but <4-5x a week

• Daily low dose ICS

Symptoms most days or waking with asthma

• Daily low dose ICS + LABA

Symptoms every day or waking up with asthma

• Daily med-high dose ICS + LABA

• Add LAMA or anti-IgE, anti IL5/5R, anti-IL4R

-

Note:

• only the dose of the ICS portion will increase (not formoterol portion)

• both Track 1 and 2 use daily low dose maintenance with ICS-LABA with symptoms most days

• Remember that ICS dose will always be higher than LABA in combination inhalers

COPD GOLD Grades based on FEV1

COPD GOLD Groups Initial Treatment

Vaccines recommended for asthma/COPD patients

COPD patients can get pertussis (Tdap) and shingles

SABA, LABA

MOA

Dont use LABA when?

ADE

Bronchodilators

LABA never use alone without ICS or never for acute asthma attack

ADE:

• Palpitations, tachycardia, tremor (think opposite of Beta-blockers used for HTN/HF)

• Hypokalemia (high doses)

• Hyperthyroidism, glaucoma, seizures, increased glucose

Albuterol Formulation

MDI - Ventolin HFA, Proventil HFA, ProAir HFA

DPI - ProAir RespiClick

-

Also comes as neb, syrup and tabs

MDI counseling points

Shake all except ciclesonide (Alvesco) and ipratropium (Atrovent HFA)

Prime before use.

Most reprimed after 3-7 days of non-use except for Albuterol (Ventolin HFA, Proventil HFA, ProAir HFA) → 14 days

Use a spacer (never with SMI, DPI). Whistling sound from chamber → slow down rate of inhalation

Breathe in slowly and deeply (vs DPI → quickly)

Clean mouthpiece weekly

-

**MDI Suffix: HFA**

DPI Counseling Points

Don’t…

CI in

Inhale how

No shaking. No priming (except for Pumicort Flexhaler). No spacer use.

CI in milk protein allergy

Inhale quickly and deeply

When you open it and hear the click, thats one dose loaded. If you close it without using it, you lost a dose.

-

DPI Suffix: Twisthaler, Diskus, Ellipta, Flixhaler, HandiHaler, RespiClick, Neohaler, Pressair

DPI

Asmanex, Pressair, Ellipta, RespiClick : discard after

Asmanex Twisthaler and Tudorza Pressair: discard after 45 days

Ellipta: discard after 6 weeks

• (Arunity, Breo, Incruse, Anoro, Trelegy)

ProAir RespiClick: discard after 13 months

Neohaler Counseling tips

DPI with capsule in device

Hold device with mouthpiece upwards, the press the piercing button completely in one time and release

Breath rapidly and steadily

-

Indacaterol (Arcapta Neohaler)

Glycopyrrolate (Seebri Meohaler)

Indacaterol/Glycopyrrolate (Utibron Neohaler)

Respiclick counseling tips

Discard after

Device has

Discard after 13 months

Device has dose counter attached to actuator

-

Note: all RespiClicks have the name “Air” in them

Xopenex HFA

Xopenex Neb → good for how long?

Levalbuterol (Xopenex): R-isomer of albuterol

-

Xopenex HFA: MDI

Xopenex Neb

• once the foil is open but kept IN the foil → good for 2 weeks

• kept OUT of the foil → good for 1 week

Terbutaline

Formulation, indication

Other agents for…

Beta2-agonist

Oral: used for asthma, NEVER used for preterm labor

Injectable (SQ/IV): off label to stop preterm labor, no longer than 72 hrs

Side note: other agents for preterm labor → Magnesium sulfate, Indomethacin, Nifedipine

Corticosteroids Names and Side effects

Beclomethasone (Qvar RediHaler)

Budesonide (Pulmicort Flexhaler)

Mometasone (Asmanex Twisthaler/HFA)

Fluticasone (Flovent HFA/Diskus, Arnuity Ellipta, Flonase)

Ciclesonide (Alvesco)

-

Always rinse mouth → decrease thrush

QVAR RediHaler

Generic

Counseling

What not to do

Beclomethasone: Breath-actuated aerosol inhaler

Pulmicort Flexhaler

Pulmicort Respules

Comments for both

Budesonide

-

Pulmicort Flexhaler: DPI

• Only DPI that needs to be prime → prime before first use ONLY

Pulmicort Respules: neb, at least 1 yo (very young)

• Only neb formulation in corticosteroids

Asmanex HFA

Asmanex Twisthaler → good for how long?

Mometasone (Asmanex)

-

Asmanex HFA: MDI

Asmanex Twisthaler: DPI

• Discard 45 days after removal from pouch

Flovent HFA

Flovent Diskus → good for how long?

Arunity Ellipta

ArmonAir Respiclick

Flonase nasal spray

Fluticasone

Flovent HFA: MDI

-

DPI

Flovent Diskus → after removal of foil, good for 6 weeks (50 mcg) or 2 months (100 and 250 mcg)

Arunity Ellipta

ArmonAir Respiclick

-

Flonase nasal spray

Alvesco → comments

Omnaris, Zetonna

Ciclesonide (Alvesco)

• MDI: shaking not necessary bc comes as solution

• Prodrug via hydroxylation

Also comes as nasal spray (Omnaris, Zetonna)

Systemic steroids

Oral Prednisone

Dexamethasone

Methylprednisolone

Rayos

Comments for all

Oral Prednisone: no need to taper if short term (only if high doses for extend period of timne)

Dexamethasone: more potent and longer half life than prednisone

Methylprednisolone: Taper 24 to 0 mg PO over 6 days. Start with 6, then 5, 4, 3, 2, then 1 tab. All tabs are 4 mg (total 21 tabs)

Rayos: delayed release prednisone for RA morning stiffness

Glucocorticoid Approximate Equivalent Dose

Steroid Systemic Side effects

TREATS nausea

Serevent Diskus

Good for how long?

Indications

Salmeterol (Serevent Diskus)

After opening from foil pouch, good for 6 weeks

Prevention of exercise-induced bronchospasm → but just usual use albuterol (works faster)

Advair Diskus/HFA

AirDuo RespiClick

Fluticasone + Salmeterol

Symbicort → good for how long?

Formoterol + Budesonide (MDI)

Good for 90 days after opening from foil wrap

(remember: Budesonide (Pulmicort))

Dulera

Formulation

Formoterol + Mometasone

MDI

SABA and LABA Names Used in Asthmatics with ICS

SABA: Albuterol, Levoalbuterol

LABA: Salmeterol, Formoterol

Anti-Leukotrienes Names

Leukotriene receptor antagonist

Zafirlukast (Accolate)

Montelukast (Singular)

-

5-lipoxygenase inhibitor

Zileuton (Zyflo, Zyflo CR)

Accolate

Regards to food

Zafirlukast (Accolate)

AccoLATE → eat later → empty stomach

Singular

Formulation

Regards to food

Dose

Precautions

Indications

Montelukast (Singular)

-

Comes as tabs, chewables and granules (good >6 months)

Packets mixed with solid foods (applesauce, carrots, rice, ice cream) OR baby formula/milk. Use within 15 min

-

Dosing

• 6-23 months — 4 mg granules

• 2-5 yo — 4 mg QHS

• 6-14 yo — 5 mg QHS

• >/= 15 yo — 10 mg QHS

Precautions

• Chewable tabs and phenylalanine allergy

• Mood and behavior changes

• restlessness

-

Indication: asthma, allergic rhinitis, prevention of exercise induced asthma

Take 2 hrs before exercise for exercise-induced bronchospasm → still prefer albuterol (fast-acting)

Zyflo

Zyflo CR → frequency, regards to food

Check what lab

Zileuton (Zyflo, Zyflo CR)

-

ziLeuton → check LFTs

Most CR taken QD but Zyflo CR taken twice daily with food

Xolair

MOA

Indications

Formulation

Omalizumab (Xolair)

IgG monoclonal antibody bind to IgE → Only used for allergy related asthma

Also for chronic idiopathic urticaria (hives)

SubQ given once/twice a month

Cinqair

Nucala

Fasenra

MOA, indication, formulation/frequency

Interleukin-5 receptor antagonist for eosinophilic asthma

Reslizumab (Cinqair) → IV q4 weeks

Mepolizumab (Nucala) → SQ q4 weeks

Benralizumab (Fasenra) → SQ q4 weeks x3 doses then q8 weeks

Theophyllines

MOA

Max dose

Therapeutic level

S/E at different levels

DDI

Can be used for apnea of prematurity (although IV caffeine citrate is preferred)

Theophylline ←→ Aminophylline Conversion

Cromolyn

MOA

Formulation

Indication

Mast cell stabilizer

Comes only as nebulized solution

Usually used for allergies, can be used for asthma