Transcript Inhaled corticosteroids

 is
a disease of diffuse airway inflammation
caused by a variety of triggering stimuli
resulting in partially or completely
reversible bronchoconstriction.
Factors that can contribute to asthma or airway hyperreactivity may
include any of the following:

Environmental allergens (eg, house dust mites; animal allergens,
especially cat and dog; cockroach allergens; and fungi)

Viral respiratory tract infections

Exercise, hyperventilation

Chronic sinusitis or rhinitis

Aspirin or nonsteroidal anti-inflammatory drug (NSAID)

Use of beta-adrenergic receptor blockers
(including ophthalmic preparations)

Obesity

Environmental pollutants, tobacco smoke

Irritants (eg, household sprays, paint fumes)

Emotional factors or stress

Perinatal factors

Epidemiology. Asthma affects 5-10% of
the population or an estimated 23.4 million
persons, including 7 million children.

Mortality/Morbidity: About 4000 deaths
occur from asthma annually in the US.
Asthma involves:
 bronchoconstriction,
 airway edema and inflammation,
 airway hyperreactivity,
 airway remodeling.
Asthma severity is categorized as
 Intermittent,
 Mild persistent,
 Moderate persistent,
 Severe persistent.
The term status asthmaticus describes
severe, intense, prolonged bronchospasm
that is resistant to treatment.
Shortness of breath, especially
with exertion or at night
 Wheezing is a whistling or hissing
sound when breathing out
 Coughing may be chronic, is usually worse
at night and early morning
 Pulsus paradoxus, tachypnea,
tachycardia
 Visible efforts to breathe (use of neck
and suprasternal muscles, upright posture,
pursed lips, inability to speak)
 The expiratory phase of respiration is
prolonged

Treatment includes
 control of triggers,
 drug therapy,
 monitoring,
 patient education,
 treatment of acute exacerbations.
Asthma medications are generally divided
into 2 categories:
 quick relief (also called reliever
medications);
 long-term control (also called controller
medications).
QUICK RELIEF MEDICATIONS
are used to relieve acute asthma
exacerbations and to prevent exerciseinduced asthma or exercise-induced
bronchospasm symptoms.
These medications include
 Short-acting beta agonists (SABAs)
 Anticholinergics (used only for severe
exacerbation)
 Systemic corticosteroids.
 Short-acting
beta2 agonists (SABAs)
 Albuterol sulfate.
Dosing and Uses:
0.5 mL of 0.5% solution (2.5 mg) nebulized
q4-8hr PRN.
Inhaler: 2 puffs inhaled PO q4-6hr.
Tablets: 2-4 mg PO TID/QID; 32 mg/day
maximum.
Short-acting beta2 agonists (SABAs)
 Pirbuterol.
Dosing and Uses:
Autohaler: 1-2 actuations q4-6hr PRN,
no more than 12 actuations/day.
 Levalbuterol.
Dosing and Uses:
Neb Solution: 1.25-2.5 mg q20min for 3
doses, then 1.25-5 mg q1-4hr PRN.
MDI: 4-8 puffs q20min for up to 4 hr,
then q1-4hr PRN.
 Anticholinergic
Agent
Ipratropium
Dosing and Uses:
Inhaler: 8 actuations q20 min PRN for up
to 3 hr.
Nebulizer: 500 mcg q20 min for 3 doses;
then PRN.
 Systemic
steroids. In acute asthma
exacerbation, early use of systemic
corticosteroids
often
aborts
the
exacerbation, decreases the need for
hospitalization, prevents relapse, and
speeds recovery.
 Prednisone.
Dosing and Uses: 40-60 mg q 6 h or q 8
h for 48 h,
then 60–80 mg/day 40–60 mg
IV has no advantage over oral
administration if GI function is normal.
 Systemic
steroids.
 Prednisolone.
Dosing and Uses: 5-60 mg PO qDay
 Methylprednisolone.
Dosing and Uses: 2-60 mg/day divided
QD/QID PO.
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Long-term control medications
include
Inhaled corticosteroids (ICSs),
Mast cell stabilizers,
Long-acting beta agonists (LABAs),
Combination inhaled corticosteroids and
long-acting beta agonists,
Methylxanthines,
Leukotriene antagonists,
Immunomodulators.

Inhaled corticosteroids are indicated
for long-term suppression, control, and
reversal of inflammation and symptoms.
 Ciclesonide
Receiving Bronchodilators or Inhaled
Corticosteroids: 80 mcg inhaled PO
BID initially; may increase to 160 mcg
BID.
Receiving Oral Corticosteroids: 80
mcg inhaled PO BID initially; may
increase to 320 mcg BID.
 Inhaled
corticosteroids
Beclomethasone.
Dosing and Uses:
40-80 mcg inhaled PO BID if never used
corticosteroid inhalers before;
40-160 mcg inhaled PO BID if used
corticosteroids inhalers before;
320 mcg inhaled PO BID highest
recommended dose.
 Inhaled
corticosteroids
 Fluticasone inhaled.
It is available as a metered-dose inhaler
aerosolized product (HFA) or DPI (Diskus).
Dosing and Uses.
 Flovent HFA inhaler: Initial 88 mcg (2
puffs) inhaled PO BID; may increases to
max 440 mcg inhaled PO BID.
 Flovent Diskus: Initial 100 mcg inhaled PO
BID; may increases to max 500 mcg BID
 Inhaled
corticosteroids
 Budesonide inhaled
Dosing and Uses.
360 mcg inhaled PO BID; in some patients,
may initiate at 180 mcg BID; 720 mcg
BID maximum.
 Mometasone
Dosing and Uses.
220 mcg inhaled PO qDay/BID.
 Inhaled
corticosteroids
 Triamcinolone inhaled.
Dosing and Uses.
Inhaler: 2 puffs (150 mcg) TID/QID;
no more than 16 puffs/day. Discontinue if
inadequate relief after 3 weeks.
 Flunisolide.
Dosing and Uses.
2 actuations (160 mcg) inhaled PO BID;
may titrate upward, not to exceed 4
actuations (320 mcg) BID.
 Long-acting
β2-agonists are active for up
to 12 h and are used for moderate and
severe asthma but should never be used as
monotherapy.
 Formoterol. Dosing and Uses: 12 mcg
inhaled q12hr.
 Salmeterol. Dosing and Uses: 1 inhalation
(50 mcg) BID OR.
 Arformoterol. Dosing and Uses: 15 mcg
inhaled via nebulization BID. Not to exceed
30 mcg/day.
 Beta2-Agonist/Corticosteroid
Combinations.
 Budesonide and formoterol [Symbicort].
Budesonide 80 mcg/formoterol 4.5 mcg or
Budesonide 160 mcg/formoterol 4.5 mcg
Dosing and Uses:
Never treated with corticosteroids:
2 inhalations twice daily depending on severity
of asthma.
Previously treated with corticosteroids:
budesonide 160 mcg/formoterol 4.5 mcg
2 inhalations BID.
 Beta2-Agonist/Corticosteroid
Combinations
 Fluticasone and salmeterol.
Dosing and Uses: 2 inhalations PO BID.
 Inhaled medium dose corticosteroids:
100 mcg/5 mcg – 2 inhalations PO BID;
not to exceed daily dose of 400 mcg/20 mcg.
 Inhaled
high dose corticosteroids:
200 mcg/5 mcg – 2 inhalations PO BID;
not to exceed daily dose of 800 mcg/20 mcg.
 Beta2-Agonist/Corticosteroid
Combinations
 Mometasone
and formoterol.
Dosing and Uses.
Initial dose based on asthma severity.
 Diskus: initially
1 inhalation PO BID of 50/100 or 50/250.
Not to exceed 1 inhalation PO BID of 50/500.
 Metered
dose inhaler (HFA):
2 inhalations PO BID.
Not to exceed 2 inhalations PO BID of 21/230.
 Mast
cell stabilizers are given by
inhalation prophylactically to patients with
exercise-induced
or
allergen-induced
asthma.
 Cromolyn sodium (Intal).
Dosing and Uses:
200 mg PO QID;
may double dose if effect not satisfactory
within 2-3 weeks;
not to exceed 400 mg PO QID.
 Leukotriene
modifiers are taken orally
and can be used for long-term control
and prevention of symptoms in patients
with mild persistent to severe persistent
asthma.
 Zileuton
Dosing and Uses:
Extended Release: 1200 mg PO BID, within
1 hour after morning and evening meals.
Conventional (discontinued): 600 mg PO
QID.
 Methylxanthines
are used for long-term
control as an adjunct to β2-agonists.
 Theophylline.
Dosing and Uses:
Patients not currently taking theophylline:
5-7 mg/kg IV/PO;
not to exceed 25 mg/min IV.
Maintenance: 0.4-0.6 mg/kg/hr IV infusion or
4.8-7.2 mg/kg PO (SR) q12hr to maintain levels
10-15 mg/L.
 Monoclonal
Antibody. An anti-IgE
antibody developed for use in severely
allergic patients with asthma who have
elevated IgE levels.
 Omalizumab
Dosing and Uses:
150-375 mg SC q2-4Weeks.
 Leukotriene
Receptor Antagonist
is a selective competitive inhibitor of LTD4
and LTE4 receptors. Indicated for
chronic asthma treatment and
prophylaxis
 Zafirlukast
20 mg PO BID.
 Montelukast.
10 mg tablet).
10 mg PO qEvening (use
Asthma Management
Pharmacotherapy is increased in a stepwise
fashion until the best control of impairment
and risk is achieved (step-up). Before
therapy is stepped up, adherence,
exposure to environmental factors (eg,
trigger exposure), and presence of comorbid
conditions are reviewed. These factors should
be addressed before increasing drug therapy.
Once asthma has been well controlled for
at least 3 mo, drug therapy is reduced if
possible to the minimum that maintains good
control (step-down).
Steps of Asthma Management
Step 1
(starting point for intermittent
asthma)
Preferred Treatment
Short-acting β2-agonist PRN
Steps of Asthma Management
Step II
( starting point for mild persistent
asthma)
Preferred Treatment
Low-dose inhaled corticosteroid
Alternate Treatment
Mast cell stabilizer,
leukotriene receptor antagonist, or
theophylline
Steps of Asthma Management
Step III
(starting point for moderate persistent asthma)
Preferred Treatment



Medium-dose inhaled corticosteroid or
Low-dose inhaled corticosteroid
plus
long-acting β2-agonist
Alternate Treatment
Low-dose inhaled corticosteroid
plus one of the following:
a leukotriene receptor antagonist,
theophylline
or zileuton
Steps of Asthma Management
Step IV
(starting point for severe persistent
asthma )
Preferred Treatment
 High-dose
inhaled corticosteroid
plus
long-acting β2-agonist
and
 possibly omalizumab for patients with allergies
Steps of Asthma Management
Step IV
(starting point for severe persistent
asthma )
Preferred Treatment
 High-dose
inhaled corticosteroid
plus
long-acting β2-agonist
plus
oral corticosteroid
and
 possibly omalizumab for patients with allergies