the acute & maintenance treatment of asthma via ......the acute & maintenance treatment of...
TRANSCRIPT
The Acute & Maintenance
Treatment of Asthma via
Aerosolized Medications
Douglas S. Gardenhire, EdD, RRT-NPS, FAARC
Associate Professor and Chairman
Department of Respiratory Therapy
Objectives
Define Asthma.
Determine aerosolized agents used to treat acute
asthma.
Determine aerosolized agents used to maintain
asthma control.
Utilize guidelines to treat acute asthma.
Utilize guidelines to maintain asthma control.
Definition of Asthma
Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation. It
is defined by the history of respiratory
symptoms such as wheeze, shortness of breath,
chest tightness and cough that vary over time
and in intensity, together with variable
expiratory airflow limitation.
GINA, 2016
Question 1
Is Racemic Epinephrine or Epinephrine
available over-the counter to treat asthma?
Yes
No
Short-Acting b Adrenergic Agents
(SABA) Ultra Short-acting
Epinephrine
Racemic Epinephrine
Question 2
Does Step 1 in GINA and NAEPP guidelines
recommend a SABA for the treatment of
asthma?
Yes
No
Short-Acting b Adrenergic Agents
(SABA) Short-acting
Albuterol
Levalbuterol
Use in Asthma
a – agonists are not routinely used for treatment of
asthma
Epi v. Terbutabline, No difference detected (n=38)
Adoun, M et al. J Crit Care, Vol 19, No 2 (June), 2004:
pp 99-102
SABA main bronchodilator of choice (NAEPP, 2007)
Use as needed
Regularly scheduled use is not recommended
Use of at least 1 week decreases tolerance, associated
with poor disease control. Salpeter, Ann Intern Med.
2004;140:802-813
Downregulation
From Gardenhire, DS Rau’s Respiratory Care Pharmacology, 2016 Mosby, St. Louis, MO
GINA <5 years old
GINA 6-11 years old
GINA 12 years old- Adult
Question 3
Corticosteroids assist beta agonists in working
better?
Yes
No
Upregulation
Corticosteroids
Increase the proportion of beta receptors on the cell
membrane
Increase affinity of beta receptors
Inhibit the release of inflammatory mediators
Corticosteroids
From Gardenhire, DS Rau’s Respiratory Care Pharmacology, 2016 Mosby, St. Louis, MO
GINA <5 years old
GINA 6-11 years old
GINA 12 years old- Adult
Long-Acting b Adrenergic Agents
(LABA)
Salmeterol
DPI
50mcg/actuation
4 years old +
Black Box Warning
Problems with Long-term
Bronchodilators SMART Chest 2006
Led to regulatory warning
Salapeter et al. Annu Intern Med 2006
Long-acting Beta2 agonists increases the risk of asthma hospitalizations and deaths compared to placebo
Nelson et al. Chest 2006 Increase in death rate while using salmeterol
Mann et al. Chest 2003
Increased exacerbations in patients receiving Formoterol
Use in Asthma
Addition of Salmeterol or Formoterol for uncontrolled
asthma when not controlled on low/med-dose
ICS…Reduce exacerbations/use of SABA (Greenstone
et al. Cochrane Database Syst Rev 2005)
Should not be used as monotherapy
Daily use should not exceed
100 mcg salmeterol
24 mcg formoterol
Consideration for increasing ICS before adding LABA
(NAEPP, 2007)
GINA <5 years old
GINA 6-11 years old
GINA 12 years old- Adult
Fixed Drug Combinations
From Gardenhire, DS Rau’s Respiratory Care Pharmacology, 2016 Mosby, St. Louis, MO
Question 4
As a respiratory care practitioner do you see the
use of anticholinergics such as ipratropium
bromide used regularly in your daily practice?
Yes
No
Question 5
Are anticholinergics regularly used in the
treatment of asthma?
Yes
No
Anticholinergic Agents
Ipratropium Bromide
Tiotropium Bromide
1.25 mcg via Respimat
Complementary Effect
From Gardenhire, DS Rau’s Respiratory Care Pharmacology, 2016, Mosby, St. Louis, MO
GINA 12 years old- Adult
Use in Asthma
Not superior to beta agonists (NAEPP, 2007;
GINA, 2016)
Asthmatic patients treated with Beta blockers
Alternative to theophylline
Acute, severe exacerbations not responding to
beta agonists (Weber. Ann Allergy, 1990)
Cont.
Ipratropium added lowered hospitalization rate of children with acute moderate to severe asthma (Qureshi et al. N Engl J Med 1998)
Adding multiple doses of ipratropium to beta agonist
Improved lung function
Avoided hospital admission (1 in 11)
(Plotnick & Ducharme, Br Med J 1998)
Cont.
Add-on tiotropium by mist inhaler improves lung function and increases the time to severe exacerbation (Rodrigo GJ et al. Chest2015;147:388-96)
In patients selected for uncontrolled symptoms and persistent airflow limitation despite moderate-high dose ICS and LABA, add-on tiotropium, improved lung function and increased time to first exacerbation. (KerstjensHA et al. Engl J Med 2012;367:1198-207)
Adding multiple doses of ipratropium to beta
Xanthines
Theophylline
Aminophylline
Oxtriphylline
Dyphylline
Use in asthma
Small therapeutic index
Less asthma control than ICS (Dahl et al. Respir Med
2002)
Non-preferred alternative, cost consideration for
inhaled meds (NAEPP, 2007, GINA 2016)
IV aminophylline and theophylline should not be used
in the management of exacerbations (Nair P et al.
Cochrane Database Syst Rev 2012;12:CD002742)
Theophylline does not improve outcomes compared
with SABA alone. Nair P et al.Cochrane Database Syst
Rev 2012;12:CD002742)
Mast Cell Stabilizer and
Leukotriene Modifiers
From Gardenhire, DS Rau’s Respiratory Care Pharmacology, 2016 Mosby, St. Louis, MO
Use in asthma
Cromolyn has favorable safety profile but low efficacy
(Guevara JP et al. Cochrane Database Syst Rev
2006:CD003558)
Leukotriene receptor antagonists (LTRA) are less effective
than ICS (Chauhan BF et al. Cochrane Database Syst Rev
2012;5:CD002314)
Limited evidence for LTRAs in acute asthma. Small studies
have demonstrated improvement (Ramsay CF et al. Thorax
2011;66:7-11)
Regular treatment with LTRA in young children modestly
reduced symptoms and need for oral corticosteroids
(Bisgaard H et al. Am J Respir Crit Care Med 2005;171:315-
22)
Monoclonal Antibodies
Omalizumab (Xolair)
Anti-IgE
12 years and older
Positive skin test to aeroallergen
Mepolizumab (Nucala)
Interleukin-5 antagonist
12years and older
Eosinophilic phenotype
Reslizumab (Cinqair)
Interleukin-5 antagonist
18 years and older
Eosinophilic phenotype
GINA <5 years old
GINA 6-11 years old
GINA 12 years old- Adult
Treatment of
Exacerbation
GINA 2016
GINA 2016
Summary SABA first line agents
Corticosteroids first agent to consider in uncontrolled asthma
LABA are effective, work best with corticosteroids
Xanthines have unwanted side effects
Cormolyn and Antileukotriens are safe, but not always effective
Ipratropium can be considered but not routine
Tiotropium add-on treatment only
Each patient is different, EDUCATE!
Questions, Comments,
Happy Thoughts?
@RTPharmacology