DRUG THERAPY FOR ALLERGY

DISEASES AND
ROUTE OF ADMINISTRATION

Mae Sri Hartati Wahyuningsih

Pharmacology and Therapy Dept.
Faculty of Medicine
UGM-Yogyakarta
OBJECTIVES
The students are expected to:
1. Know the kind of allergy diseases
2. Describe the drug therapy for allergic diseases
3. Know the route of administration
4. Know the kind of drug administration
5. Know the dosage and preparation of anti allergy
medications
P
A
T
Allergic Reaction:

H response
- Immediate

O (3-24 hour)
- Late response

G
E
N
E
S
I
S
 Factors Affecting Clinical Outcomes
of Allergic Diseases
Treatment
Environmental • Anti-inflammatory
• Allergens Genetic • Anti-allergic
• Irritants • Relievers
• Westernization Degree of atopy
Compliance
Infection • Avoidance
• Medication uses
• Viral
• Bacterial Allergen
Immunotherapy

Allergic Diseases Future Therapy ?

Remission Mild Moderate Severe

AllergyChula
Epidemiology of Allergic Diseases
in Thai Children

13 1990 1995
Asthma 4.2
40

Allergic
Rhinitis 17.9

Atopic 13
Dermatitis
0 10 20 30 40
Prevalence (%)
 RHINITIS ALLERGIC

Inflamasi pada membran mukosa hidung disebabkan

oleh adanya alergen yang terhirup dan dapat memicu
respon hipersensitivitas
Pattern of symptoms in intermittent and
persistent allergic rhinitis

Characteristic Intermittent Persistent (gejala >4hr/mg)

(gejala <4 hr/mg)
Obstruction Variable Always, predominant

Secretion Watery, common Seromucous, postnasal drip,

variable
Sneezing/bersin Always Variable

Smell disturbance Variable Common

Eye symptoms Common Rare

Asthma Variable Common

Chronic sinusitis Occasional Frequent

(van Cauwenburge et al, 2000)

 Management of therapy

Using medications to reduce symptoms

Antihistamines
Decongestants
Corticosteroid nasal
Cromolyn sodium
Ipratropium bromide
Leukotriene antagonist
Treatment options for allergic rhinitis adapted
from ARIA, 2001.

Type of First-line Alternative or add- Comment

allergic treatments on treatments*
rhinitis
Mild Oral antihistamines, Intranasal decongestants Allergen avoidance may
intermittent Intranasal eliminate need for drugs.
Antihistamines
Mild persistent Oral antihistamines, Intranasal decongestants, Sodium cromoglicate is a
or moderate Intranasal Sodium cromoglicate useful alternative to
severe corticosteroids, antihistamines and
intermittent intranasal corticosteroids, especially in
Antihistamines children.
Moderate severe Intranasal Oral antihistamines, Ipratropium bromide is
Persistent corticosteroids intranasal antihistamines, useful for persistent runny
sodium cromoglicate, nose. Leukotriene
Ipratropium bromide, antagonists may be useful if
Leukotriene antagonists† there is coexisting asthma.

ARIA=Alergic Rhinitis and its Impact on Asthma

Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):S147
Kind of Antihistamin
Nama Obat Penggunaan umum Efek samping Durasi
aksi
Rinitis Alergi Sedasi Premedika Mual/ Sedasi Antikoli
(jam)
kulit si muntah nergik
Klorfeniramin   Sedang Minimal 6-12
Bromfeniramin   sedang minimal 4-6
Deksklofeniramin   Sedang Minimal 4-6
Difenhidramin   kuat Sedang 4-6
Dimenhidrinat  sedang sedang 4-6
Prometazin     kuat sedang 4-6
Astemizol   minimal minimal >12
Cetirizin   minimal minimal >12
Loratadin   minimal minimal >12
Terfenadin   minimal minimal >12
Triprolidin   Sedang minimal 6-12
Fexofenadin   minimal minimal >12
Desloratadin   minimal minimal >12
Levocetirizin   minimal minimal >12
• First-line treatment of allergic
• Not selective - Anticholinergic effects (what?)
• Well absorbed and metabolized in the liver
• The first generation: effect of sedatives, short duration of action
• The second generation: no sedative effect, duration of action is
more long
• The third generation?
1. Alkylamines
2. Ethanolamines
3. Ethylenediamines
4. Piperazines
5. Phenothiazines
6. Piperadines
 Alkylamines

Chlorpheniramine maleate (Chlor Trimeton®)

• CTM : Agen antialergi (Histamin)
-- H1-receptor antagonist.
• Nama kimia :
2-Pyridinepropanamine, b-(4-chlorophenyl)-N,N-dimethyl.
• Indication: Allergy, urticaria, food allery, Emergency treatment of
anaphylaxis
• Dosage :
- Oral 0.1 mg/kg/dose (adult 4 mg) every 6-8 hour
• Side effects : Drowsiness, sedation, digestive tract
disorders,hypotension, and Pain head.
• Contraindications : Epilepsi, liver, hypersensitivity
Ethanolamines/Benadryl C
H
O C C N
H2 H2
CH3

CH3
HCl

• Relieve allergic rhinitis (seasonal allergy) Diphenhydramine Hydrochloride

symptoms including sneezing, runny nose, itching,
and watery eyes
• Relieve itching and swelling associated with uncomplicated allergic skin
reactions.
• Control coughs due to colds or allergy.

Side Effects: fatigue, dizziness, and sedation.

Due to: the peripheral anticholinergic effects and the “interactions with a
number of neurotransmitter systems in the CNS”

Structure fits relatively well to serve as an anticholinergic agent (specifically

at the muscarinic receptor) and has the ability to penetrate the blood brain
barrier due to their relative lipophilicity.
(Piperazines)
Hydroxyzine HCl (Atarax)

(Phenothiazines)
Promethazine HCl (Phenergan®)

(Piperadines)
Azatadine (Optimine®)
See the MIMS
Terfenadine (Seldane®)
 Non-sedating
 Dosage:
Children: 1 mg/kg/dose (adult 60 mg) 12 H oral.

• Low lipid solubility, does not cross the blood-brain barrier,

binds to plasma proteins, long half-life. Metabolized by
cytochrome P450. If excretion impaired, may be toxic to CNS.
• Ineffective in motion sickness.
• Serious side effects in case of hepatic dysfunction,
concomitant administration of some drugs (erythromycin) or
overdose. Erythromycin inhibits cytochrome P450.
Second…………….

Fexofenadine HCl(Allegra®)
• Safe metabolite of Terfenadine
• Non-sedating
• Clinical studies showed no cardiac side effects

- Active metabolite of terfenadine

- Does not cross the blood-brain barrier, no anticholinergic
or a1- adrenergic receptor blocking effect
- Half life of 14 hrs., 95% excreted in urine unmetabolized.
Loratadine (Claritin®)
 Developed from Azatadine
 Non-sedating
 No reported cardiac side effects up to 160 mg
 Dosage (Oral)
- Children 0.2 mg/kg
- Adult 10 mg) daily

INDICATION:
Claritin (Loratadine) is indicated for the relief of nasal and non-nasal
symptoms of seasonal Allergic Rhinitis and for the treatment of Chronic
idiopathic urticaria in patients 2 years of age or older.
Loratadine (Claritin®)

Dosage:
Adults and children 6 years : 10 mg tablet or reditab, or 2
teaspoonfuls (10 mg) of syrup once daily.
Children 2 to 5 years of age : Syrup is 5 mg
(1 teaspoonful) once daily.
 Cetirizine (Zyrtec®)
 Metabolite of hydroxyzine Effective against rash/hives
 No reported cardiac side effects
 Potential for sedation

Indication:
 Seasonal Allergic Rhinitis due to allergens such as ragweed, grass and
tree pollens in adults and children 2 years of age and older. Symptoms
treated effectively include sneezing, rhinorrhea, nasal pruritus, ocular
pruritus, tearing, and redness of the eyes.
 Perennial Allergic Rhinitis due to allergens such as dust mites, animal
dander and molds in adults and children 6 months of age and older.
Symptoms treated effectively include sneezing, rhinorrhea, postnasal
discharge, nasal pruritus, ocular pruritus, and tearing.
 Chronic Urticaria is indicated for the treatment of the uncomplicated skin
manifestations of chronic idiopathic urticaria in adults and children 6
months of age and older. It significantly reduces the occurrence, severity,
and duration of hives and significantly reduces pruritus.
Cetirizine (Zyrtec®)

Dosage Form:
Tablet : 5 mg and 10 mg
Syrup : 1 mg/mL
Chewable tab : 5 mg and 10 mg
Can be taken with or without water.
1. Cimetidine (Tagamet) associated with most side effects
2. Ranitidine (Zantac)
3. Famotidine (Pepcid)
4. Nizatidine (Axid)
5. Roxatidine
Properties of Histamine H2 Receptor Antagonists

CIMETIDINE RANITIDINE FAMOTIDINE NIZATIDINE

Bioavailability (%) 80 50 40 >90

Potency 1 5-10 32 5-10

Plasma half-life 1.5-2.3 1.6-2.4 2.5-4 1.1-1.6

(hrs.)
Approximate duration 6 8 12 8
of therapeutic effect
(hrs.)
Relative effect on 1 0.1 0 0
cytochrome P450
activity
Decongestants

• Sympathomimetic class -- act on adrenergic receptors in

the nasal mucosa to cause vasoconstriction, shrink the
swollen mucosa, and improve breathing.

• Use of topical decongestants do not cause or cause very

little systemic absorption

• The use of topical agents a long time (more than 3-5 days)
can cause medical rhinitis, in which nasal congestion due
back peripheral vasodilatation---restrict the use of
Topical decongestants and duration of drug
action

Drugs Duration of Action

Short action up to 4 hours
Fenilefrin HCl

Medium action 4-6 hours

Nafazolin HCl
Tetrahidrozolin HCl

Long action Up to 12 hours

Oximetazolin HCl
Xylometazolin HCl

(Schwinghammer, 2001)
Oral Decongestants

• Onset is slow, but the effects last longer and are less
- cause local irritation not present a risk rhinitis
medikamentosa
Example:
Phenylephrine
Fenilpropanilamin Narrow TI --- the risk of
hypertension
Pseudo ephedrine
Mast cell stabilizers

• Mast cell stabilizers untuk menstabilkan sel mast untuk

mencegah degranulasi dan pelepasan mediator. Obat ini
tidak biasanya digolongkan sebagai antagonis histamin,
tetapi memiliki indikasi serupa.
Sodium kromolin

• A mast cell stabilizer - prevent mast cell degranulation and release of

mediators, including histamine.
• Available as a nasal spray to prevent and treat allergic rhinitis.
• Side effects: local irritation (sneezing and pains in nasal mucous
membranes
• The dose for patients over 6 years old is 1 spray in each nostril 3-4 times
a day at regular intervals.
• For seasonal rhinitis, use of these drugs at the time of initial
allergy season and is used continuously throughout the season.
• For perennial rhinitis, the effect may not be visible within the first 2-4
weeks, for that decongestants and antihistamines may be required during
therapy is started.
Ipratropium bromida

• An anticholinergic agent shaped spray nose

• Useful in persistent allergic rhinitis or perennial
• Antisekretori properties if used locally and beneficial to
reduce runny nose that occurs in allergic rhinitis.
• Available in the form of a solution with a content of 0.03%,
given in 2 sprays (42 mg) 2-3 times a day.
• Mild side effects, including headache, epistaxis,
and nose feels dry.
Comparison of standard drugs used in
allergic rhinitis

Oral Nasal Nasal Nasal Nasal Nasal

antihist antihist Steroids decong Ipratropium Cromoglic
ate

Runny nose ++ ++ +++ 0 ++ +

Sneezing ++ ++ +++ 0 0 +
Itching ++ ++ +++ 0 0 +
Blockage + + +++ ++++ 0 +
Eye ++ 0 ++ 0 0 +
symptoms
Onset of 1h 15 min 12 h 5–15 min 15–30 min Variable
action
Duration 12–24 h 6–12 h 12–48 h 3–6 h 4–12 h Variable
 ATOPIC DERMATITIS
Common immune-mediated inflammatory skin disorder
Prevalence in general population in Western industrialized countries:
10-20%
Multi-factorial etiology
Interactions of genes and environment
Family history of disease usually positive for affected blood
relatives
AD genes localized to certain chromosomes-known genes in these
areas control immune response and inflammation
FLARE FACTORS IN ATOPIC DERMATITIS
SIGNS AND SYMPTOMS
 Pruritus (itching)
 Dry, scaly skin
 Ruam di wajah, kulit kepala, tangan, kaki
 Benjolan kecil terbuka
 Kemerahan dan pembengkakan kulit
 Penebalan kulit (with chronic dermatitis)
 Location of Dermatitis
Lutut, Tikungan siku
Wajah
Bagian luar pergelangan kaki
Leher
TREATMENT OF ATOPIC DERMATITIS
• Identify and control “flare factors”
• Topical treatments
– Glucocorticosteroids
– Newer “non-steroidal” TIMs
• Emollients
– Moisturizers
– Baths with added lubricants
• Systemic treatments
– Oral antihistamine (a cornerstone of treatment)
– Oral antibiotics
– Systemic steroids
– Immunosuppression (phototherapy, cytotoxic drugs)
 TOPICAL GLUCOCORTICOIDS

STEROID ADVANTAGE DISADVANTAGE

CLASS I SUPER-POTENT, CAUSES THIN SKIN,

FAST ACTING NOT SAFE IN KIDS
SHORT-TERM USE ONLY

CLASS III INTERMEDIATE,STILL CAUSES

SAFER FOR THINNING OVER
CHRONIC USE LONG-TERM

CLASS VI LOW POTENCY, LIMITED

SAFE IN KIDS, EFFECTIVENESS
THIN SKIN AREAS
Betamethasone Propionate - Approved
in 2001

• Diprolene AF Cream, 0.05% - a Class II steroid

• Diprosone Ointment, 0.05% - a Class II steroid

• Diprosone Cream, 0.05% - a Class III steroid

• Diprosone Lotion, 0.05% - a Class V steroid

• Lotrisone Cream and Lotion (clotrimazole and

betamethasone propionate)
• Contents : Gel (0168-0266) betamethasone dipropionate 0.5 milligram
in 1 gram
• Indications :
- The relief of the inflammatory and pruritic manifestations of
corticosteroid-responsive dermatoses.
- This product is not recommended for use in pediatric patients under 12
years of age.
• Dosage : Apply a thin layer of betamethasone dipropionate gel
(augmented) to the affected skin once or twice daily and rub it in gently
and completely.
• Betamethasone dipropionate gel (augmented) should not be used with
occlusive dressings.
• Overdosage : Topically applied betamethasone dipropionate gel
(augmented) can be absorbed in sufficient amounts to produce systemic
effects
2002 Guidelines Update: An Overview
of the Pathogenesis of Asthma

• “Asthma is a chronic inflammatory disease of the airways”

posing “a significant health burden”
• Many cell types and cellular elements mediate the
inflammation
• In susceptible individuals, inflammation causes:
– Increased bronchial hyperresponsiveness to various
stimuli
– Recurrent episodes of wheezing, breathlessness, chest
tightness, and cough
– Widespread, variable airflow obstruction that is often
reversible with treatment

41 2002;110(pt 2):S141-219.
NAEPP. Guidelines update 2002. J Allergy Clin Immunol.
Stepwise Approach to Asthma Therapy for
Children Aged 5 Years

Step 4
Severe Persistent

Step 3 High-dose ICS + LABA

Moderate Persistent
(+ systemic
Step 2 Preferred: corticosteroids
Mild Persistent low-dose ICS + LABA if needed)
or
medium-dose ICS
Step 1 Preferred: (+ LABA if needed)
Mild Intermittent low-dose ICS
Alternative:
No daily medication Alternative: low- to med-dose ICS
cromolyn + LTRA or
or theophylline
LTRA
ICS = inhaled corticosteroid; LTRA = leukotriene receptor antagonist; LABA = long-acting 2-adrenergic
agonist.
42
NAEPP. J Allergy Clin Immunol. 2002;110(pt 2):S141-S219.
Overlapping Symptoms LRDs

“All that wheezes is not asthma.”

– Chevalier Jackson [1865-1958]

Allergic Asthma Non-allergic Asthma “Bronchitis”

– Wheezing/Mengi – Wheezing – Wheezing
– Cough – Cough – Cough
– Dyspnea – Dyspnea – Dyspnea
– Chest tightness – Chest tightness
– Rhinitis
– Conjunctivitis

LRDs
Medication: Determined By Severity Level
Classification

1. Mild Intermittent
Reliever only prn
2. Mild Persistent
Controller and reliever
3. Moderate Persistent
Controller plus long-acting bronchodilator and reliever
4. Severe Persistent
Controller plus long-acting bronchodilator and reliever
A. Tujuan terapi --- Indikasi penyakit
 Cara pemberian obat
 Sifat dan durasi obat

B. Kondisi Pasien
• Kenyamanan pasien
• Keamanan
• Dapat menelan/tidak
• Kondisi sadar/tidak

C. Sifat-sifat fisika-kimia obat

• Stabilitas
• Iritasi/tidak
 KIND OF DRUG ADMINISTRATION
Route of Location Pharmaceutical dosage
administration form
Oral (Peroral, Peros) Mouth, GIT System Tablet, Capsul, Lotions, Syrups,
Through The Mouth Elixsir, Suspension, Jel, Powder
Sublingual Under The Tongue Tablet, Lozenges, Trochici
Parenteral By Injection Lotions, Suspension,
Intravena (I.V.) Vena
Artery The pPowder is dissolved in aqua
Intraarterial (I.A.)
Skin pro injection
Intrakutan/Intradermal (I.C.)
Subkutan (S.C.) Under the skin
Muscle
Intramuskuler (I.M.)
Epikutan (Topical) Skin Surface Oinment, Cream, Pasta, Plester,
Powder, Aerosol, Lotion,
Suspension.
Transdermal Skin Surface Cream, Plester, Powder, Aerosol,
Transdermal Dosage Form (Tempel)
Cont....

Route of Adm Location PDF

Conjungtivital Cornea Ointment
Intraocular Eye Solutio, Suspension
Intranasal Nose Solutio, Spray, Inhalation

Aural Ear Solutio, Suspension

Intrarespiratori Pulmonary Through The Aerosol (Spray ),

Mouth(inhaled) Turbohaler, Diskinhaler,
Rotahaler
Rectal Rectum Solution, Ointment,
Suppositoria
Vaginal Vagina Solution, Ointment,
Emulsion, Tablet,
Supositoria (Ovula)
Uretral Uretra Solution, Bacilla
HOW TO USE SPECIAL DOSAGE FORM

 Information drug rules for special preparations to

be seen/read clearly by doctors

The number of PDF required one

time use needs to be calculated
carefully

 How to use special PDF should be well understood

and correctly by doctors

Instructions on the following

images
 KINDS OF DRUG ADMINISTRATION

1. ORAL
(Drug-->mouth--> esophagus ---> GIT)
 Cetirizine
Zyrtec Allergy Syrup
Children:
6 to 12 months : 1/2 tsp. (2.5 mg) once a day.
1 to 5 years : 1/2 tsp. [2.5 mg] Once or twice a day.
6 to 11 years : 1 or 2 tsp. [5 or 10 mg] Once a day.

Loratadine
Claritin Syrup (1 mg/mL)
Age 2 to 6 : 5 mg daily (1 tsp).
Age 7 and above : 10 mg daily (2 tsp).
2. PARENTERAL
With injections
- Im, iv, ip, intracardiac
- Sc, sc, intra-arterial

Intra muskuler Intra vena subkutan

Injection Dosage form
Aspiration of ampoules (glass and plastic)
Injection dissolving dosage (in powder form)
Injection preparations (aspiration of
vials)
Techniques / How to use
subcutaneous injections
Techniques / How to use
Intramuscular injections
Techniques / How to use
Intravenous injections
 How to use Injections dosage form

The reason for giving the drug by injection

1. - Want a quick effect
- The only preparation that can produce the
expected effect

It should be noted in the use of dosage form of

injection / infusion i.v. :

 The effect (also undesirable effects )

 Actions to take if there were any side effects
 Terms of use syringe
 Calculation of the volume of injection and drip infusion
(according to the administered dose)
3. INHALASI
Through endothelial alveoli, how inhaled through the
mouth, nose (drug: solid /volatile liquid / gas)

Aerosol Inhaler (Turbuhaler)

 NASAL SOLUTION

Azelastine (Astelin)
Nasal solution 0,1%, 0,137mg/spray
Topical : 1-2 spray/nostril 2x daily

Levocabastine (Livostin)
Microsuspension Nasal Spray 0,5 mg/mL
Topical : 2 spray/nostril 2-4x daily
 OPHTHALMIC SOLUTION

Ketotifen (Zaditen)
Ophthalmic solution 0,025%
≥ 3 years : 1 drop 8-12 hours (each eye)
BRONCHODILATORS

Example : Ventolin
Trade Name : Ventolin
Generic Name : Salbutamol
Therapeutic class : Sympathomimetic, Bronchodilators
These medications quickly control
acute asthma attacks.

Short-Acting Beta2-Agonists
Beta2-agonists do not reduce inflammation or airway responsiveness
but serve as bronchodilators, relaxing and opening constricted airways
during an acute asthma attack. They are used alone only for patients
with mild and intermittent asthma. Patients with more severe
cases should use them in combination with other drugs.
Short-acting bronchodilators are generally administered through inhalation and
are effective for 3 - 6 hours. They relieve the symptoms of acute attacks, but
they do not control the underlying inflammation. If asthma continues to worsen
with the use of these drugs, patients should discuss corticosteroids or other
drugs to treat underlying inflammation.

Side Effects of Beta2-Agonists. Side effects of all beta2-agonists include:

• Anxiety
• Tremor
• Restlessness
• Headache
• Fast and irregular heartbeats.
 Mode of administration and dosage of
drugs
Inhalation , oral, parenteral
• Dosage
– Adult inhalation: 100-200 mcg, 3-4 times a day
Oral - Adult: 2-4 mg / time, 3-4 times a day
Children <2 years: 100 ug / kg, 4 times a day
2-6 years :1-2 mg / time, 3-4 times daily
6-12 yr : 2 mg / time, 3-4 times a day

Preparations:
100 mcg / times, 200 dose MDI (Metered-dose inhaler)
- Tablets 2 mg, 4 mg
- 2 mg/5ml syrup, 60 ml
INHALER
Background
An inhaler - no spacer
 Using a metered-dose inhaler (MDI) seems simple, but many people do
not use them the right way. If you use your MDI the wrong way, less
medicine gets to your lungs. If you have a spacer, you should use it
because it helps get more of the medicine into your airways.
VENTOLIN

• MDI with cap

removed from
mouthpiece
• Vertical portion of
device must be held
at 90 degrees
Getting Ready
 Take off the cap and shake the inhaler hard.
 If you have not used the inhaler in a while, you may need to prime it. See the instructions that your
inhaler came with for how to do this.
 Breathe out all the way.
 Hold the inhaler 1 - 2 inches in front of your mouth (about the width of 2 fingers).

Breathe in Slowly
 Start breathing in slowly through your mouth, and then press down on the inhaler 1 time. (If you use a
spacer, press down on the inhaler before you breathe in. Within 5 seconds, begin to breathe in
slowly.)
 Keep breathing in slowly, as deeply as you can.

Hold Your Breath

 Hold your breath as you count to 10 slowly, if you can. This lets the medicine reach deep into your
lungs.
 If you are using inhaled quick-relief medicine (beta-agonists), wait about 1 minute before you take
your next puff. You do not need to wait a minute between puffs for other medicines.
 After using your inhaler, rinse your mouth with water, gargle, and spit out. This will help reduce
unwanted side effects from your medicine.
INHALER MDI-SPACER
Background
An inhaler - with spacer

 If you use your inhaler the wrong way, less medicine gets to your lungs. A
spacer device will help. The spacer connects to the mouthpiece. The inhaled
medicine goes into the spacer tube first. Then you take two deep breaths to
get the medicine into your lungs. Using a spacer wastes a lot less medicine
than spraying the medicine into your mouth.

 Spacers come in different shapes and sizes. Ask your doctor which spacer is
best for you or your child. Almost all children can use a spacer. You do not
need a spacer for dry powder inhalers
VENTOLIN MDI - SPACER

• A spacer device
may be used to
better direct the
medication spray
• Remember to shake
the canister well
To Use a Spacer:
1. Shake the inhaler well before use (3-4 shakes)
2. Remove the cap from your inhaler, and from
your spacer, if it has one
3. Put the inhaler into the spacer
4. Breathe out, away from the spacer
5. Bring the spacer to your mouth, put the
mouthpiece between your teeth and close
your lips around it
6. Press the top of your inhaler once
7. Breathe in very slowly until you have taken a
full breath. If you hear a whistle sound, you
are breathing in too fast. Slowly breath in.
8. Hold your breath for about ten seconds, then
breath out.
HANDIHALER
Background
 Handihaler uses an inhalation capsule to deliver medicine to the
lungs. People often forget critical steps when using their
Handihaler which directly affects the medicine outcome.

 Studies show that annually $10 Billion are wasted just because
people don’t use their asthma inhalers correctly. It is not always
feasible to visit your doctor or the pharmacist in case you have
forgotten the steps or have misplaced the instructions that come
along with your Handihaler.

 Clinical studies have proved that Asthma and COPD patient's

inhaler techniques can be significantly improved by educating
the patients about their inhaler use. Inhaler education can be
best delivered to the Asthma and COPD patients through audio-
visual instructions performed by the skilled educator.
1. Dust cap (lid)
2. Mouthpiece
3. Mouthpiece ridge
4. Base
5. Green piercing
button
6. Center chamber
7. Air intake vents
1. Open the HandiHaler device. Separate only
one of the blisters from the blister card, then
open the blister
2. Insert the SPIRIVA capsule and close the
mouthpiece firmly against the gray base until
you hear a click
3. Press the green piercing button once until it is
flat (flush) against the base, then release
4. Breathe out completely. Then, with the
HandiHaler in your mouth, breathe in deeply
until your lungs are full. You should hear or
feel the SPIRIVA capsule vibrate (rattle).

Remember:
To take your full daily dose, you must inhale twice
From the same Spiriva capsule
DISKHALER
Background

 A Diskhaler® is a dry-powder inhaler that holds small

pouches (or blisters), each containing a dose of medication,
on a disk.
 The Diskhaler® punctures each blister so that its
medication can be inhaled.
How to use a Diskhaler®*
1. Remove the cover and check that the device and mouthpiece are
clean.
2. If a new medication disk is needed, pull the corners of the white
cartridge out as far as it will go, then press the ridges on the sides
inwards to remove the cartridge.
3. Place the medication disk with its numbers facing up on the white
rotating wheel. Then slide the cartridge all the way back in.
4. Pull the cartridge all the way out, then push it all the way in until the
highest number on the medication disk can be seen in the indicator
window.
5. With the cartridge fully inserted, and the device kept flat, raise the
lid as far as it goes, to pierce both sides of the medication blister.
6. Move the Diskhaler® away from your mouth and breathe out as
much as you can until no air is left in your lungs.
7. Place the mouthpiece between your teeth and lips, making sure you
do not cover the air holes on the mouthpiece. Inhale as quickly and
deeply as you can. Do not breathe out.
8. Move the Diskhaler® away from your mouth and continue holding
your breath for about 10 seconds.
9. Breathe out slowly.
10. If you need another dose, pull the cartridge out all the way and then
push it back in all the way. This will move the next blister into place.
Repeat steps 5 through 9.
11. After you have finished using the Diskhaler®, put the mouthpiece
cap back on.
TURBOHALER
Background
How does it work?
 The Turbohaler can be used to provide different types of medication depending
on your problem and how severe it is
 It is likely to be either: Terbutaline (Bricanyl) or Formoterol (Oxis) and
Budesonide (Pulmicort) or Symbicort. Budesonide and Symicort contain a
steroid.
 If you have an inhaler that contains a steroid you must rinse your mouth out with
water to prevent developing a sore mouth, husky voice or oral thrush.
 These inhalers work by relaxing the muscles of the large airways and/or reducing
inflammation.
How to use Turbuhaler

1. Unscrew the protective cap and take it off.

Check the number of remaining doses in the
dose counter window.
2. Hold the Turbohaler® in an upright position
and hold the white section securely with one
hand. With the other hand, first rotate the red
grip to the right and then to the left, until you
hear a click
3. First breathe out. Only then, place the
mouthpiece between your teeth, close your
lips around it and breathe in forcefully and
deeply.
4. Remove the Turbohaler® from your mouth,
hold your breath for 7 to 10 seconds, and
then breathe out.
5. If you have to take multiple doses, then
repeat steps 2, 3 and 4 after 30 seconds.
6. Clean the Turbohaler® with a dry cloth –
avoid any contact with water. Replace the
protective cap and store the Turbohaler in a
dry place.
7. Finally, rinse your mouth with water.
NEBULIZER
Background

 A nebulizer is a small machine that turns liquid medicine into a mist. You
sit with the machine and breathe in through a connected mouthpiece.
Medicine goes into your lungs as you take slow, deep breaths for 10 to
15 minutes. It is easy and pleasant to breathe the medicine into your
lungs this way.

 If you have asthma, you may not need to use a nebulizer. You may use
an inhaler instead, which is usually just as effective. But a nebulizer can
deliver medicine with less effort than an inhaler. You and your doctor
can decide if a nebulizer is the best way to get the medicine you need.
The choice of device may be based on whether you find a nebulizer
easier to use and what type of medicine you take.

 Most nebulizers are small, so they are easy to transport. Most nebulizers
also work by using air compressors. A different kind, called an ultrasonic
nebulizer, uses sound vibrations. This kind of nebulizer is quieter, but
costs more money.

 Nebulizer for asthma, COPD, or another lung disease

How to use nebulizer
1. Connect the hose to an air compressor.
2. Fill the medicine cup with your prescription. To avoid spills, close the
medicine cup tightly and always hold the mouthpiece straight up and
down.
3. Attach the hose and mouthpiece to the medicine cup.
4. Place the mouthpiece in your mouth. Keep your lips firm around the
mouthpiece so that all of the medicine goes into your lungs.
5. Breathe through your mouth until all the medicine is used. This takes 10
to 15 minutes. If needed, use a nose clip so that you breathe only
through your mouth. Small children usually do better if they wear a
mask.
6. Turn off the machine when done.
7. Wash the medicine cup and mouthpiece with water and air dry until your
next treatment.
REFERENCES :

• Gennaro,A.F. Remington : The Science and Practice of Pharmacy,

Philadelphia 2000
• WHO Model Formulary, World Health Organization, Geneva, 2004
• Hay, W.W., Hayward, A.R., Levin, M.J., and Soudheimer, J.M., 2002.
Current Pediatric Diagnosis and Treatment, E Bood : Mc Graw Hill
Education, Europe.
• The handbook on Injectable Drugs, 14th ed. (Trissel, 2007)
• Michael A Kaliner, 2005, Histamine and H1-Antihistamines in Allergic
disease, Clinical allergy and immunology , 2nd Ed
• Laube BL, Dolovich MB. Aerosols and aerosol drug delivery systems. In:
Adkinson NF Jr, Bochner BS, Burks AW, et al., eds. In: Middleton's Allergy
Principles and Practice. 8th ed. Philadelphia, PA: Elsevier Mosby;
2013:chap 66
THANK YOU