Respirology Meds

    Respirology Medications

    • Inhaled Corticosteroids

      • Beclomethasone (QVAR)
      • Budesonide (Pulmicort) [ white/brown ]
      • Fluticasone (Flovent) [ orange/ peach ] 
      • Ciclesonide (Alvesco)
    • Long-Acting Beta-Agnosits

      • Do not use as monotherapy in asthma b/c keep airways open, pt expose to allergens, HUGE exacerbation --> death.
      • Salmeterol (Serevent) [ teal ]
        • +  fluticasone (Advair) [ purple discus ]  (S/F 250mcg/50mcg one puff bid)
      • Formoterol (Oxeze)
        • + budesonide (Symbicort) [ red/white ]
        • + mometasone (Zenhale)
    • Short Acting B-agonist

      • Salbutamol (Ventolin) [ light blue ]
      • Terbutaline (Bricanyl)  [ blue/white ]
      • Albuterol (US only)
    • Short Acting Anticholinergic

      • Ipratropium bromide (Atrovent) [ clear/green ]
    • Long Acting Anticholinergics

      • Tiotropium bromide (Spireva) 18mcg [ white/turquoise ]
        • Salbutamol (Combivent) [ clear/orange ] (rare)
    • Leukotriene Receptor Angagonists (LTRA)

      • Zafirlukast (Accolade)

      • Montelukast (Singulair)

      • Zileuton (Zyflo, Zyflo CR)

    • Anti-IgE

      • Anti-IgE Antibody (omalizumab)

      • Recombinant DNA derived IgG that binds IgE.  Very expensive, SC injection q2w.  used in SEVERE allergic asthma.

     

    • inhalerDevices.png

     

    Rx Notes

    • Acute Exacerbations:
      • Atrovent 2cc + Ventolin 5mg nebulized by face mask

     

    Detailed Review

    • Inhaled Corticosteroids (ICS)
      • Decrease the number and activity of inflammatory cells.
      • Decrease symptoms and exacerbations.
      • Synergistic with LABA (increase B2 receptors).
      • Inhibits the "delayed phase" allergy response in airways.
      • Side Effects:
        • Local: Hoarseness, Oral Thrush, Cough.
          • Recommend adherence to asthma regimen (use spacer and rinse mouth after use).
          • Reduce ICS dose to safest lowest amount.  
          • Use Nystatin mouth wash if needed.
        • Systemic: Weight gain, adrenal suppression, osteopenia, glaucoma, skin thinning.
          • Risks very low (mostly in elderly).
    • Leukotriene Receptor Antagonists (LTRA) (Montelukast [Singulair], Zafirlukast [Accolate], Zileuton [Zyflo])
      • Leukotrienes promote asthma (mucous secretion, vasodilation, inflammation).
      • Anti-inflammatory and bronchodilator effect.
      • Improve symptoms, QOL, prevent exercise-induced sx, but not first line. 
      • Side/Effect:
        • Neuropsychiatric (Anxiety, Agitation, Hallucination, Depression). [uncommon, reported]
        • Zileutin can cause hepatotoxicity [monitor].
    • Theophylline
      • Very narrow therapeutic margin, target drug levels closely.
      • In the guidelines, but rarely used.
      • Targer 5-12 mcg/mL.
      • Many drug interactions (increased level with other drugs such as fluoroquinolones).
        • Cousel on side effects: tremor, headache, nausea, palpitations.
        • High risk of cardiac arrhythmias and seizure.
      • DO NOT use for acute exacerbation, only chronic... 
    • Anti-IgE Antibody
      • Recombinant antibody, blocks Fc portion of IgE.
      • Reduces exacerbations, improve symptoms, reduces systemic and ICS dose.
      • Only reserved for severe asthma refractory to therapy with evidence of allergies. (IgE level 30-700 IU [normal 0-90]).  --> very expensive.
      • Requires monitoring with anaphylactoid reactions. (1 in 1000)  Observe 2h post-dose x3 doses then x1h thereafter.
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