BDTM8-Asthma and COPD_KEC DRUG COMMONG DOSE

ASTHMA AND COPD

1. Basic Drug Therapeutics Module
8 – Asthma and COPD

2. Learning Objectives
1.Understand the etiology and symptoms of asthma
and COPD, and appreciate their differences
2.Understand the mechanisms of action, efficacies and
side effects of different drugs used in the
management of asthma and COPD
3.Understand the differences between medications for
rescue versus control
4.Understand the differences among various inhaler
devices
5.Able to counsel patients on the correct techniques in
using of MDI, turbuhaler, and space chamber

3. 3
What is known about asthma?
•A heterogenous disease, usually characterized by chronic airway
inflammation
•Can be controlled but not cured
•Symptoms:
–wheezing, shortness of breath, chest tightness, cough
–vary over time, frequency and intensity
–caused by:
•Narrowing of airways
•Airway wall thickening
•Increased mucus
GINA 2017

4. 4
Normal & Asthmatic Bronchiole

5. Goals of Asthma Management
•Minimize AE and clinic visit
•Need little or no reliever medication
Control of
symptoms
•No missed school or work
•No sleep disturbance
•Have productive, physically active lives
Normal
activity
•No or minimal side effects from
medications
Optimal
therapy
•Prevent complications and asthma
mortality
Prevent
exacerbation

6. Non-pharmacotherapy
Avoidance of triggers
Weight reduction if obese
Minimize stress

7. Asthma Triggers
•Dust mites, cockroaches, molds, irritants
(cigarette smoke, perfumes)
Allergens
•Bad weather: thunderstorm, high humidity,
cold air, exercise, strong emotions
Physical
triggers
•Influenza (Flu), cold,
sinus infections
Infections
•Aspirin, food additives
Pharmacologic
agents/food
From Centers for Disease Control and Prevention. Available from
http://www.cdc.gov/asthma/triggers.html

8. Pharmacotherapy
2 general classes:
•Reliever
•To treat acute symptoms and exacerbations
•Controller
•To achieve and maintain control of persistent
asthma

9. Pharmacotherapy
Reliever
1.Short-acting beta agonist (SABA)
2.Short-acting muscarinic antagonist (SAMA)
3. Oral or IV Corticosteroid

10. Pharmacotherapy
Reliever
1.Short-acting Beta agonists (SABAs)
–To relief acute symptoms and prevent exercise-induced
bronchospasm
–Regular use indicates poor control of asthma
–Common side effects
•Tremor , Headache, Palpitations
•Electrolytes disturbances: Hypokalemia,
Hypomagnesemia
•More in PO and IV administration

11. Inhaled Short-acting Beta agonists
•Nebulized solution
(2.5mg/2.5ml)
•MDI (100mcg/puff)
Salbutamol
(Ventolin)
•Turbuhaler (0.5mg/puff)
Terbutaline
(Bricanyl)

12. Oral/IV Beta agonists
•Salbutamol
–Tablet 4mg
–Syrup 2mg/5ml
–Injection 1mg/ml
•Terbutaline
–Sustained release tablets (Bricanyl Durule) 5mg, 7.5mg
–Injection 0.5mg/ml
•Uses
–When inhalation not suitable

13. Pharmacotherapy
•Nebulized solution (0.25mg/ml)
•MDI puff (20mcg/puff)
•For acute asthma exacerbation
requiring emergency treatment
•Side effects
•Dry mouth, Headache, Bitter taste
Ipratropium
(Atrovent)
Reliever
2.Short-acting muscarinic antagonist (SAMA)

14. Pharmacotherapy
Reliever
3.Oral or IV Corticosteroids
–To gain rapid control of asthma
–Oral prednisolone
•adults 1mg/kg/day, up to 50mg, for 5 – 7 days
•children 1 – 2 mg/kg/day, up to 40mg, for 3 – 5 days
•may continue the use of inhaled corticosteroids
•tapering not needed if < 2 weeks
•morning dosing preferred

–IV Hydrocortisone or Methylprednisolone in emergency
GINA 2017

15. Pharmacotherapy
Controller
1.Corticosteroid
2.Long acting beta agonist (LABA)
3.Leukotriene receptor antagonist (LTRA)
4.Methyl Xanthines
5.Tiotropium mist inhaler

16. Controller
1. Inhaled corticosteroids (ICS)
- First line for persistent asthma
•Act locally in lungs
•Lower systemic absorption  lower side effects
•May take up to 1 – 2 weeks to see full benefit
•RINSE MOUTH with water after inhalations
•Use corticosteroid inhaler as SCHEDULED, not as
needed
Pharmacotherapy

17. Possible side effects:
–Local:
•Oral candidiasis, Hoarseness
–Systemic:
•Cushing effects, Skin thinning, ↑ ease of skin bruising,
Osteoporosis, Cataracts, Glucose intolerance,
Hypertension, Myopathy, Euphoria, Depression,
Growth retardation
Inhaled Corticosteroids

18. Inhaled Corticosteroids
•Becotide 50 mcg/puff
•Becloforte 250 mcg/puff
Beclomethasone
Dipropionate
•Pulmicort 200mcg/puff
Budesonide
•Alvesco 80,160mcg/puff Ciclesonide
•Flixotide 50, 125, 250 mcg/puff
Fluticasone
Propionate

19. Pharmacotherapy
Controller
2. Long acting beta agonist
•Not for acute symptoms
•Not to be used as monotherapy for long term control
•Increase risk of asthma-related death with
inappropriate use as only medication for asthma
•Black Box warning by FDA on all preparations
containing a LABA
•Example : Salmeterol (Serevent)

20. LONG-Acting Beta-agonist +
ICS Combinations
•SereTIDE (+ Fluticasone propionate) Salmeterol
•Symbicort (+ Budesonide)
•Vannair (+ Budesonide)
•Flutiform (+ Fluticasone propionate)
Formoterol
•Relvar Ellipta (+ Fluticasone furoate) Vilanterol

21. Controller
3. Leukotriene receptor antagonist
•Option for patients with both asthma and allergic
rhinitis, or if patient will not use ICS
•Well tolerated in general
•Precautions : eosinophilia, vasculitis,
neuropsychiatric events
•Example: Montelukast


Pharmacotherapy

22. Pharmacotherapy
Controller
4. Methylxanthines (Aminophylline/Theophylline)
•Less efficacious option, adjunctive therapy with ICS
•Side effects occur more commonly
•Examples
•Theophylline (Syrup, Sustained release tablets)
•Aminophylline (Injection)

23. Methylxanthines
•Possible Side effects
–At high levels:
•Nausea, Vomiting , CNS stimulation, Headache,
Tachycardia, Seizures
–At usual levels:
•Insomnia, GI upset, Increased hyperactivity in some
children, Difficult urination in BPH

24. Other controllers option
•Tiotropium mist inhaler (Spirvia)
–Long acting muscarinic antagonist
–Recommended by GINA 2018 as add on therapy for adults
or adolescent with history of exacerbation
–Not indicated in children < 12 years old
–Not yet indicated in HADF for asthma

25. Chronic Obstructive Pulmonary
Disease (COPD)

26. What is COPD?
•Chronic Obstructive Pulmonary Disease
•characterized by persistent airflow limitation usually
progressive and associated with an enhanced
chronic inflammatory response in the airways and
the lung to noxious particles or gases

27. COPD ASTHMA
COPD vs. Asthma
•Onset in mid-life
•Productive cough, dyspnea on
exertion
•Symptoms slowly progressive
•History of tobacco smoking or
exposures to other type of
smoke
•Largely irreversible airflow
limitation
© 2014 Global Initiative for Chronic Obstructive Lung Disease
•Onset often in childhood
•Dry cough, often at night/early
morning
•Symptoms vary over time, often
related to trigger
•Allergy, irritants and/or eczema
•Largely reversible airflow
limitation
Asthma COPD Overlap Syndrome (ACOS) - shares features
with both asthma and COPD.

28. Goals for treatment of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease © 2017 Global Initiative for Chronic Obstructive Lung Disease

29. Non-Pharmacotherapy
Quit smoking
–Most important in COPD!!
–Can improve symptoms:
breathlessness, wheezing and coughing
–Reduce the risk of COPD flare-ups
–Slow the progress of the disease

30. © 2017 Global Initiative for Chronic Obstructive Lung Disease

31. Short-acting Bronchodilators
SABA: Salbutamol
SAMA: Ipratropium

Uses:
•Primary therapy for patient category
A, as needed symptom relief
•As “rescue” medication for all GOLD
patients
•SABA preferred for more rapid onset
of activity



© 2017 Global Initiative for Chronic Obstructive Lung Disease

32. Long-acting Bronchodilators
LABA: Salmeterol, Indacaterol, Olodaterol
LAMA: Tiotropium, Glycopyrronium

•May be used as monotherapy (in contrast to
asthma tx)
•Uses
•Patient with more symptoms (Group B)
or above
•For patients desiring less frequent
dosing
© 2017 Global Initiative for Chronic Obstructive Lung Disease

33. Bronchodilators Combination (LABA + LAMA)
Ultibro : Indacaterol + Glycopyrronium
Anoro Ellipta: Vilanterol + Umeclidinium
Spiolto: Olodaterol + Tiotropium

•Patients with persistent exacerbations
should consider dual therapy:
(LABA + LAMA) or (LABA + ICS).
•ICS ↑risk for pneumonia in some
patients, LABA + LAMA is preferred


© 2017 Global Initiative for Chronic Obstructive Lung Disease

34. Inhaled Corticosteroids (ICS)
In patients who develop further exacerbations on
LABA/LAMA therapy, may

•Escalate to LABA + LAMA + ICS
or
•Switch to LABA + ICS
•NOT as monotherapy

• Examples of combination products:

oFluticasone propionate/salmeterol (Seretide)
oBudesonide/formoterol (Symbicort, Vannair)

© 2017 Global Initiative for Chronic Obstructive Lung Disease

35. Phosphodiesterase - 4 Inhibitors
•Roflumilast (Daxas)
•Once daily oral medication
•Reduce inflammation. No direct bronchodilator activity
•For patients treated with LABA + LAMA + ICS still have
exacerbations
•Side effects
–N&D, reduced appetite, abdominal pain, headache
–Occur early during treatment, reversible and
diminish over time with continued treatment
–Avoid in underweight patients
•Not to be given together with theophylline

© 2017 Global Initiative for Chronic Obstructive Lung Disease

36. Use of Inhaled Medications

37. Characteristics of Inhaled Medications
Delivers medication directly to the airways
Minimizes systemic side effects
Faster onset of action
•Appropriate technique is important !!
•Regular assessment of inhaler technique to ensure
adequate delivery

38. Oral dose
Circulation
l
Lung
Inhaled
Dose
Systemic
bioavailability
Lung
Circulation

39. Factors Affecting Delivery to the Lungs
•Willingness
•Coordination ability
•Inspiratory flow rate
Patient
•Affect lung deposition
•Particle size (ideal :1-5um)
•Particle velocity, not too fast
Aerosol
characteristics
•Nebulizers
•Metered Dose inhalers (MDIs)
•Dry-powder inhalers (DPIs)
Device

40. Nebulizer
Device that changes medication solution to a mist.
Can be administer by tightly fitting mask or
mouthpiece (children who can breath thru mouth)
--- Use slow tidal breathing, occasional deep breaths
Blow-by administration of nebulized medications is not
recommended because it reduces the amount of
medication the patient inhales

41. •Easy to teach and use by any age
•Patient coordination not required
Advantages
•Less portable than inhalers and require power source
•Delivery may take 5 to 10 minutes or longer
•Issue on infection control
Disadvantages
Nebulizer

42. Metered-dose Inhalers (MDI)
•Administered as aerosol with pressurized
propellant
•Shake before use
•Actuation independent of inhalation

43. •More portable than nebulizer and fast
•Can use with ventilator or tracheostomy
Advantages

•Coordination of inhalation required with actuation of
inhaler
•Maybe difficult for kids and elderly
Disadvantages
Metered-dose Inhalers (MDI)

44. Considerations for MDI
•Large particles with high velocity
More oropharyngeal deposition, less inspired
•Inhale slowly to minimize particle deposition
in mouth
•Deep breath, rather than force of spray is the
key to deliver drug into lungs!

45. Propellants CFC vs. HFA
•CFC (chlorofluorocarbons)
–used in most MDI in early days
–harmful to ozone layer and environment
–Banned by FDA in 2008

•HFA (hydrofluoroalkane)
Replaces CFC, may taste and feel different
Softer, finer mist actually easier to breathe into lungs
No change in dose delivered

46. Cleaning of MDI
•Once a week to prevent MDI from clogging
1.Remove the canister. (NEVER put canister in water!)
2.Run warm water through the top of the case for about 30 sec
3.Shake to remove excess water
4.Allow to air dry on clean towel.
5.Replace canister and press the canister once to clear out any
remaining moisture.
6.The device is ready for use

47. Inhalation Accessory Devices
•Spacers/Valved Holding Chambers (VHC)
•Optimize the use of MDI
•Helps coordinate actuation with inhalation
•Extend the mouth piece of the inhaler
•Slow the aerosol velocity
•Decrease drug deposition in the throat
•Minimize side effects

48. Dry Powder Inhalers (DPI)
Medication administered as powder in capsule
or blister that is punctured
Actuation dependent on inspiration
Cannot use with ventilator, tracheostomy
Smaller particles with slower velocity
Do not use with spacer

49. Considerations on using DPI
•Do not need to coordinate inhalation and
actuation
•No propellant – no priming, no shaking
•Need high inspiratory flow, breathe in deeply
and as hard as possible
•Low inspiratory flow rates may have trouble
triggering device
– Children, elderly, severe COPD

50. Patient Considerations in
Product Selection
•Physical limitations
–Vision, tremor, arthritis
•Ability to understand multiple inhaler techniques
– MDI vs. DPI
•Patients with severe airflow obstruction
–Certain DPIs may not be effective
•Education is the key
•Teach back and observation during counseling

51. References
1.Global Initiative for Asthma. Global Strategy for Asthma Management and
Prevention, 2018. Available from: www.ginasthma.org
2.Global Initiative for Asthma (GINA). 2015 Asthma, COPD and Asthma-COPD Overlap
Syndrome (ACOS). Based on the Global Strategy for Asthma Management and
Prevention and the Global Strategy for the Diagnosis, Management, and Prevention
of Chronic Obstructive Pulmonary Disease. 2015.
3.The Global Strategy for the Diagnosis, Management and Prevention of COPD, Global
Initiative for Chronic Obstructive Lung Disease (GOLD) 2018. Available
from: http://goldcopd.org
4.NHLBI. National Heart, Lung, and Blood Advisory Council Asthma Expert Working
Group. Draft Needs Assessment Report for Potential Update of the Expert Panel
Report-3.2014.
5.BTS/SIGN British Guideline on the Management of Asthma, October 2014. Available
from : www.brit-thoracic.org.uk/document-library/clinical-
information/asthma/btssign-asthma-guideline-2014/
6.American Thoracic Society. Diagnosis and Management of Stable Chronic
Obstructive Pulmonary Disease: 2011 Available from :
www.thoracic.org/statements.
7.World Health Organization. Chronic respiratory diseases. 2009. Available from:
www.who.int/respiratory/copd/burden/en/index.html.
8.Centers for Disease Control and Prevention. Common asthma triggers. Available
from www.cdc.gov/asthma/triggers.html

52. Thank you