5070: asthma/COPD meds

what are bronchodilators?

bronchodilators

what are often prescribed as rescue medications?

short acting B2 agoninsts

what are 5 anti-inflammatory agents used for asthma/copd?

1. corticosteroids

2. mast cell stabilizers

3. leukotriene inhibitors/receptor blockers

4. PDE 4 inhibitors

5. monoclonal antibodies

what combo of 2 meds is used as daily meds and “reliever” medication for pts?

inhaled corticosteroid

long acting B2 agonist

what is the OTC that used to contain epinephrine?

primatene mist

what is abluterol + ipratropium?

what does this result in ?

combo short-acting B2 agonist

short -acting muscarinic antagonist

2 MOAs for bronchodilation

what is another combo of drugs that is common ?

what is the result of this?

what is a common example of this?

inhaled corticosteroid andn

long-acting B2 agonist (LABA)

bronchodilator and anti-inflammatory

budesonide + formotoerol

what are three types of bronchodilators?

B2 agonists

muscarinic antagonists aka anticholinergics

phosphodiesterase inhibitors, nonspecific

what does phosphodiesterase break down?

cAMP to AMP

what do corticosteroids alter?

what do they inhibit?

how quicky do they work?

gene transcription

phospholipases

not quickly

what are 3 reasons why inhalation is preferred for asthma/copd meds?

1. direct delivery to site of action

2. limited (not absent) systemic effects

   1. rapid relief possible

what is an MDI?

what is drug delivery dependent on?

metered dose inhaler

good technique and ability of pt to coordinate hang/mouth/airway actions

what population are spacers usually used for?

what happens to medication in the lungs when a spacer is used?

children

more medication reaches its site of action in the lungs, less in mouth and throat

what is a DPI?

what is drug delivery dependent on w these?

dry-powdered inhaler (micronized powder)

patient being able to breathe in deeply enough

do patients have to breathe deeply with nebulizers?

how is the dose delivered?

no

w normal quiet breathing over 5-15 min

is MDI or nebulizers more cheap?

which has the higher dose?

nebulizers

nebulizers

why can patients get systemic effects from inhaled meds?

enter bloodstream via lungs/mouth/throat

what should ALL asthma and COPD patients have ?

what are these used for?

rescue/reliever medication

PRN (rapid) relief of SOB, bronchospasm, wheezing, worsening sx

what is the rescue/reliever med for COPD?

SABA or short-acting muscarinic antagonist (SAMA)

what is the rescue/reliever med for asthma?

SABA or ICS + LABA

even if people with asthma/COPD (severe asthma too) feel good, should they still use their daily inhaler prescribed med?

yes

what must people who use an MDI be taught to know when this occurs?

when the inhaler is empty

what is the indication for albuterol?

acute reversible airway obstruction

what are 4 ADEs for albuterol?

tremor, tachycardia, palpitations

may provoke intense coughing

what are some interactions for albuterol?

why is this??????

patients with what disease does this apply to the most?

oral NONSPECIFIC Beta Blockers

may block the effects of albuterol

cardiac disease

what forms is albuterol available in?

which is the most common?

are all forms rescue meds?

tablet, liquid, inhalant

inhalant

no, only inhalant

what is one pt teaching point about albuterol puff separation?

what does this do?

separate 2 puffs by 1 min

1. first starts bronchodilation process

2. second penetrates deeper into airway

what is the max dose of albuterol inhaler ?

what should they do if this isn’t working

q20 min for max 3 doses

if this isn’t working, should call 911

what is the indication for formoterol?

COPD - long term maintenance control of bronchospasm

what are 5 ADEs of formoterol?

N/V/D, HSR

dizzy, paradoxical bronchospasm

BBW: incr risk of asthma-related death, esp when not used w ICS

what is an interaction w formoterol?

Beta Blocker, esp non-selective bb’s

why is the use of LABAs as a monotherapy in asthma contraindicated?

what about COPD?

must be used in combo w ICS in asthma

may be used as monotherapy in COPD

what class is ipratropium?

muscarinic antagonist

what medication has synergistic effect with B2 adrenergic bronchodilators?

ipratropium

what is the MOA of ipratropium?

SAMA- blocks acetylcholine-caused bronchoconstriction

what is the indication of ipratropium?

maintenance treatment of bronchospasm in COPD (off label in asthma)

why is ipratropium a good choice for COPD bronchodilator? x 2 reasons

fewer side effects

increased effectiveness than B2 agonists alone

ipratropium and tiotropium have ____ systemic absorption due to being ____ ____ ____ , carrying a positive charge.

low

quaternary ammonium compound

what are 3 ADEs of ipratropium and tiotropium?

dry mouth, HA,

INCR IOP

what is one interaction with ipratropium and tiotropium?

why is this?

anticholinergics

additive effect

what class is tiotropium?

what is its MOA?

muscarinic antagonist

LAMA, bronchial muscarinic receptor agonist

what is the indication of tiotropium?

what is this NOT?

maintenance therapy of bronchospasm associated with COPD

PRN rescue medication

theophylline is in the same drug family as what common stimulant?

the metabolism of theophylline can reform what?

caffeine

caffeine

what class is theophylline?

what is the moa for this drug?

what is the pathway of this occuring?

phosphodiesterase inhibitor (PDE)

non-selective PDE

increases cAMP→ incr PKA → incr bronchodilation

what is the indication for theophylline?

WHAT IS THIS NOT?

maintenance therapy of chronic stable asthma and COPD

a rescue med

what two asthma copd meds are avail in IV FORM?

albuterol and theophylline

which drug has a narrow therapeutic range?

theophylline

what are the toxic reactions of theophylline?

what must be done to monitor these levels?

N/V/D, dysrhythmias, seizures, death

obtain serum drug levels

what are 2 general things to now about the metabolism of theophylline?

1. rate varies among pts

2. rate influenced by cigs/pot

HOW IS THE RATE OF METABOLISM OF THEOPHYLLINE INFLUENCED BY SMOKING cigs or marijuana?

can induce metabolism which increases drug clearance

what are 5 ADEs of theophylline?

N, Tachycardia, tremor, dizzy

toxic reactions (dysrhythmias, seizures, death)

what drug interactions are there w theophylline?

caffeine (intensify CNS +heart effects)

fluoroquinolone abx elevate plasma levels

what 2 meds in asthma and hyperlipidemia have ades with what medication

theophylline and bempedoic acid

fluoroquinolone abx

what class is budesonide?

what is the MOA for this med?

corticosteroid, ICS

gene transcription mech → decr mediator synthesis, release, infiltration of inflammatory cells

what is the indication of budesonide?

daily controller med for asthma » COPD

what is the onset of budesonide’s anti-inflammatory effects?

how long does it take for it to become fully effective?

~4-6 hrs

1-2 wks for fully effective

what are 3 ADE’s associated with budesonide?

w what length + strength of treatment do these occur?

what is something else that is possible at high doses?

candidiasis, dysphonia, adrenal suppression

long term, high dose

cataract and glaucoma

what is a pt teaching pt regarding budesonide?

rinse mouth after inhaling med to prevent candidiasis

what is an interaction with BUDESONIDE?

what could these do to circulating drug levels?

strong CYP3A4 inhibitors

increase

what is ritonavir?

what is the interaction between ritonavir and budesonide?

what can use together cause?

a potent CYP3A4 inhibitor used for HIV treatment

dramatically increases serum CSD levels (even inhaled ones)

cushing syndrome and adrenal suppression

what are 2 examples of daily meds that are combined for use in asthma and COPD patients?

what is a real-life example of this?

1. ICS + LABA

2. LABA +LAMA

budesonide + formoterol (symbicort)

why is formoterol acceptable for as-needed use in SMART in combo w an ICS? x 2 things

rapid onset of action compared to other LABAs

was the only LABA in SMART/MART studies

what does SMART stand for?

what does it consist of?

what is it recommended for?

single maintenance and reliever therapy

ICS + formoteral (LABA)

moderate persistent asthma

what is MART?

what does it consist of?

what is it recommended for?

maintenance and reliever therapy

consists of ICS +formoterol

reccd for all pts with asthma

what do both SMART and MART utilize ICS + formoterol for ? x 2 things

1. daily controller/maintenance med

   1. rescue/reliever med,

why moving away from SABAs as only rescue meds?

1. simplicity of regimen

2. strong evidence that ICS + formoterol reduces the risk of severe exacerbations and produces similar sx control compared to SABA rescue

in COPD, what can shorten recovery time from exacerbations, improve lung fx (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay?

corticosteroids + abx (if appropriate)

what is the indication for roflumilast?

who is this not for?

decr risk of exacerbations in pts with severe COPD associated w chronic bronchitis

asthma

how specific is roflumilast?

what is the MOA of roflumilast?

what is the result of this?

highly specific

PDE 4 inhibitor in neutrophils, eosinophils, macrophages, and T-cells in lung tissue

decr inflammatory activity and signaling, decr fibrosis

is roflumilast an acute/effective bronchodilator?

no

roflumilast is CI in patients with moderate/severe what?

liver disease

what are 4 ADEs of roflumilast?

insomnia

anxiety, depression, suicidal ideation

what is an interaction of roflumilast?

grapefruit juice

what is the class of montelukast?

what is the moa of it?

leukotriene receptor antagonist

leukotriene receptor antagonist (Cys-LT1 receptor antagonist)

what is the indication of montelukast?

prophylaxis and maintenance therapy for asthma (including exercise induced)

allergic rhinitis when other therapies fail/aren’t appropriate

what are 2 ADEs of montelukast?

HA, BBW for serious neuropsychiatric events like aggression, depression, sleep disturbances, suicidal thoughts and behavior

what is an interaction for montelukast?

grapefruit juice

the GOLD guidelines state that abx should be given to _____ patients, with what 3 cardinal sx?

what is the 2nd way abx could be given to these patients?

COPD

incr dyspnea, incr sputum vol, incr sputum purulence

2 cardinal sx if incr sputum purulence is one of the sx

or who require mechanical ventilation

which guidelines DO NOT recommend abx during _____ exacerbations, except to treat comorbid conditions?

asthma

Asthma

How to avoid or reduce exacerbations, including avoiding triggers

Self-monitoring of symptoms; call or visit provider if deterioration from baseline.

How to use inhalers and other meds; importance of maintaining consistent use of controller medications.

Annual flu vaccination; pneumococcal vaccination appropriate for many asthma patients. Pertussis and COVID vaccination.

Stop smoking!

COPD

Same as 1. and 2. above

How to use inhalers and other meds; importance of consistent use, not just when feeling worse.

Education re: energy conservation, nutrition, pursed-lip breathing

Annual flu, pneumococcal, pertussis and COVID vaccinations.

Stop smoking if haven't already done so!