Pharmacology 1.

Short acting bronchodilators

a. Short Acting 2 Agonists (SABA) i. Relax smooth muscle quickly, within 3-5 minutes ii. Lasting approximately 4-6 hours iii. Agents 1. Albuterol (Ventolin, Proventil) a. MDI 90mcg/puff 200 puffs per canister 2. Pirbuterol (Maxair) a. 400 puffs per canister 3. Levalbuterol (Xopenex) 4. Terbutaline (Bricanyl <oral>, Brethaire <MDI>) 5. Metaproteronol (Alupent, Metaprel)

b. Short Acting Catecholamine Agents i. Act on all receptor sites (1, 1, 2) resulting in increased heart rate and blood pressure along with bronchodilation ii. Exposure to light, heat or alkaline solution causes the drug to oxidize. This causes the color to change to pink, then brown. Do not use if color has changed. iii. Agents 1. Epinephrine (Adrenaline, AsthmaHaler, Bronkaid) a. Emergency Drug 2. Racemic Epinephrine (Mirconefrin, Vaponefrin, Asthmanefrin) a. Indicated for symptomatic relief of bronchospasm and mucus producion 3. Bitolterol (Tornolate)

Pharmacology 2. Inhaled Corticosteroids i. Most effective long term control medication for asthma by reducing inflammation. ii. Advise patients to rinse their mouth with water and spit after each dose (thrust) iii. Once asthma is under control, the steroid therapy dose should be reduced to the lowest possible dose that maintains control iv. Monitor growth in children 1. May be suppression or delay in growth, although asthma that is not well controlled will also contribute to growth delay v. Agents 1. Fluticasone HFA (Flovent) a. MDI i. starting dose 88mcg BID (each puff is 44 mcg) 1. 44 mcg/inhalation in 120 inhalations 2. 88 mcg/inhalation in 120 inhalations 3. 220 mcg/inhalation in 120 inhalations ii. There is a dose counter that will count down to 0 iii. Prime when opened and if not used for 7 days or dropped b. DPI i. Three strengths 50, 100 or 250 mcg ii. Each diskus has 60 preloaded doses iii. When the dose counter reaches 5, the number turns red 2. Budesonide a. Pulmicort is a Category B pregnancy rating b. Pulmicort Turbuhaler DPI i. 200 preloaded doses (200mcg per inhalation)

Pharmacology ii. When a red line appears, 20 doses are left. When the line reaches the bottom of the window, no medication is left iii. Prime before first dose, then never reprime again c. Pulmicort Respules i. Indicated for children 1-8 years ii. Delivered via SVN d. Pulmicort Flexhaler e. Rhinocort 3. Beclomethasone CFC (Vanceril) 4. Beclomethasone HFA (QVAR) 5. Triamccinolone (Azmacort) a. Built in spacer 6. Flunisolide (AeroBID) 7. Flunisolide HFA (Aerospan) 8. Mometasone a. Nasonex <Nasal Spray> b. Asmnex Twisthaler <DPI> 9. Ciclesonide (Alvesco) a. Newer, Pro drug

b. Long Acting Beta2 Agonists (LABA) i. Controller drugs ii. Effect last approximately 12 hours iii. Should be used in combination with inhaled corticosteroids iv. Useful for preventing EIB, although frequent use may mask uncontrolled asthma v. Agents

Pharmacology 1. Salmeterol (Serevent) a. 60 preloaded blisters in a foil pouch b. When 5 doses left, the numbers will appear in red c. Once the pouch is opened, the medication will expire in 6 weeks d. DPI i. 50mcg/puff BID 2. Formoterol (Foradil Aerolier)

c. Oral Systemic Corticosteroids i. Used on a short term basis (bursts) to gain control during an exacerbation ii. The management plan should be re-evaluated if they require more than 3 courses of steroids a year iii. Side Effects 1. Hypertension, Cushings syndrome, growth suppression, muscle weakness, fluid retention, weight gain, diabetes iv. Coexisting conditions that may be aggravated by steroid therapy 1. Varicella, TB, Strongyloides (worms), Hypertension, diabtes, Herpes virus infections v. Agents 1. Methylpredniolone (Medrol, SoluMedrol) 2. Prednisolone (Delta-Cortef, Pediapred, Hydeltrasol) 3. Prednisone (Deltasone, Meticorten, Orasone) 4. Methylprednisolone Acetate (Depo-medrol)

d. Mast Cell Stabilizers i. Stabilize the mast cell and inhibit the release of mediators ii. Used to be very common but not prescribed as often

Pharmacology iii. Agents 1. Cromolyn Sodium (Intal) a. Spinhaler b. Blocks early and late phase reactions c. 4-6 week trial to determine effectiveness d. Available and MDI form 2. Nedocromil Sodium (Tilade) a. Reported nasty taste

e. Leukotriene Inhibitors (Modifiers) i. Leukotrienes bind with their receptor sites and result in an increase in bronchial hyperresponsiveness, increased mucus production and cell wall edema ii. Designed to block the block the binding at receptor sites or inhibit production iii. Used for maintenance iv. Agents 1. Montelukast (Singular) a. No known drug interactions 2. Zafirlukast (Accolate) a. Inhibits metabolism of warfarin and increases prothrombin time b. Take on an empty stomach 3. Zileuton (Zyflo CR) a. 5-lipooxygenase inhibitor (5LO) b. Avoid use with warfarin, theophylline or propranolol c. Measure LTFs

f. Methylyxanthine Bronchodilators

Pharmacology i. Relax airway smooth muscle, reduce glandular secretions and delay the release of histamine and leukotrienes ii. Agents 1. Theophylline (Slo-Bid, Bronkodyl, Theo-Dur, Theolair) a. Increases the effects of anticoagulants b. Theophylline levels increased by Cimetidine, propranolol, erythromycin, troleadndomycin, phenobarbital, phenytoin, zileutin, smoking

g. Anticholinergic Bronchodilators i. Recommended for moderate to severe exacerbations in the ED ii. Block the effect of cholinergic nerves, causing the muscles to relate and the bronchi to dilate iii. Used in conjunction with SABA iv. Not recommended for EIB v. Recommended for bronchospasm due to -blocker medications vi. Agents 1. Ipatropium Bromide (Atrovent)

h. Immunomodulator i. Adjunct medication for patients with allergies and persistent asthma that is not controlled with LABA and high dose ICS ii. Block the IgE antibody from binding to their receptor sites on basophils and mast cells iii. Use for ages 12 and older iv. Agents 1. Omalizumab (Xolair) 2. Black box warning potential for anaphylaxis 3. 0.5% of malignant neoplasms (cancers)

Pharmacology

i. Combination Drugs i. Steroid and LABA 1. Fluticasone and Salmeterol (Advair) a. Available as Diskus and newer MDI 2. Budesonide and Formoterol (Symbicort) ii. SABA and Anticholinergic 1. Albuterol and Ipatropium Bromide (DuoNeb) 2. Albuterol and Ipatropium Bromide (Combivent)

j. Drug Interactions i. Aspirin/NSAIDs 1. Anaphylaxis ii. Beta-Blocker 1. Bronchospasm iii. ACE inhibitors 1. Cause a cough

3. Devices a. Metered Dose Inhalers i. Require 25-60 L/min inspiratory flow ii. Propellant: CFC vs HFA 1. All albuterol must be HFA