Respiratory illness treatment

drugs commonly used for asthma/copd management

1. R x Respiratory illnesses Dr. Kamal Kishore M.D.(Ayu)

2. Contents Drugs used for cough Drugs used for Asthma/COPD Protocols for asthma management Protocols for COPD management Antimicrobials for Respiratory infections

3. Drugs used for cough

4. DRUGS FOR COUGH Pharyngeal demulscents Demulscent – to caress soothingly Increases flow of saliva Reduces afferent impulses from irritated mucosa EXAMPLE- Glycerine. Menthol, liquorice, honey, lozenges

5. DRUGS FOR COUGH Expectorants – Secretion enhancers Potassium citrate Potassium iodide Guaifenesin (200 mg ) Vasaka Ammonium Chloride

6. DRUGS FOR COUGH Expectorants – Mucolytics Acetyl Cysteine – Po 200-600mg e.g. mucinac tab. Ambroxol – po 30/75mg e.g . mucolite tab BromHexine (derivative of alkaloid Vascine from adhatoda vasica ) po 4/8mg e.g. bromex tab/syrup

7. DRUGS FOR COUGH Anti- tussives Opiods Anti-tussive Non Opiods Anti-tussive Anti-histaminic Anti-tussive Codeine (Methyl morphine) (depresses cough centre) (Produces addiction & constipation) Dextromethorphan (depresses cough centre) (no addiction & constipation) Chlorpheniramine Diphenhydramine Promethazine (produces CNS depression/sedation)

8. DRUGS FOR COUGH Productive cough formula PRODUCTIVE COUGH = EXPECTORANT (SEC. ENHANCERS & MUCOLYTIC) + BRONCHODILATOR Guaifenesin + Ambroxol + Terbutaline (Sec. enhancer) (Mucolytic) (Bronchodilator-SABA) Guaifenesin + Ambroxol + Levosalbutamol (Sec. enhancer) (Mucolytic) (Bronchodilator- SABA) ( Only SABA bronchodilators are used in combination therapies for productive cough )

9. DRUGS FOR COUGH Dry cough formula DRY COUGH = ANTITUSSIVE + SEDATIVE ANTI-HISTAMINIC Dextromethorphan + Chlorpheniramine + Phenyl ephrine (Antitussive) (Anti-Histaminic) (Sympathomimetic bronchodilator) Dextromethorphan + Chlorpheniramine (Antitussive) (Anti-Histaminic)

10. Drugs used for Asthma/COPD

11. ANS = PNS + SNS PNS (rest digest) constricts bronchioles through Ach SNS (Flight Fight) Dilates Bronchioles through Adr . NorAdr .

12. Inhalers Metered Dose Inhalers MDI Dry Powder Inhalers DPI Nebulizers NEB Also called as pMDI i.e. pressurised MDI Have propulsion system e.g. hydroflouroalkanes Can be used with a spacer device Medicines is packed in capsules known as Rotacaps / Transcaps Allows larger dose administration of medicines Suitable for kids Medicines are packed in respules Needs a Nebulizer machine for dispensing the medicine.

13. Bronchodilators – Sympathomimetics - SABA & LABA Sympathomimetics/B-Sympathomimetics/B-Agonists Mimics Sympathetic nervous system thereby dilates bronchioles Two types Short acting b agonists (SABA) Long acting B agonist (LABA)

14. Broncho di lators SABA Albuterol /Salbutamol Terbutaline PO - 2/4/8 mg INJ (IV/IM/SC) – 0.25/0.5mg/ml INH – 50/100/120 mcg/puff PO – 2.5/5 mg INJ - 0.25/0.5 mg/ml INH – 250/500mcg/puff

15. Broncho di lators LABA Salmeterol Formoterol INH – 25/50 mcg/puff INH – 16/12/24 mcg/puff LABA are not preferred as monotherapy LABA are most effective on combination with ICS

16. Bronchodilators – paraSympatholytics - SAMA & LAMA paraSympatholytics /Anti cholinergic/Anti muscarinic anti to paraSympathetic nervous system thereby dilates bronchioles Two types Short acting anti muscarinic agents (Sama) Long acting anti muscarinic agents ( LAma )

17. Broncho di lators SAmA Ipratropium bromide INH MDI/DPI 40/80 mcg/puff Respules 250/500 mcg/ml

18. Broncho di lators lAmA Tiotropium bromide INH – MDI/DPI – 9/18mcg/puff

19. Bronchodilators – methyl xanthines Causes inhibition of phosphodiesterase leading to increase in c AMP thereby causing short acting bronhcodilation Not very popular in use due to toxicity (arrythmias & seizures) Methyl xanthines are plant metabolites – caffeine, theophylline and theobromine Theophylline group Aminophylline Etophylline Theophylline Doxophylline Acebrophylline

20. Broncho di lators M E xa Aminophylline Doxophylline Theophylline Acebrophylline PO – 100/125/300 mg INJ – 250mg/2ml IV PO – 400/800 mg PO – 100/300mg PO – 100/200mg

21. Broncho di lators c Ombinat ion LABA + LAMA SABA + SAMA Salbutamol (SABA) + Ipratropium bromide (SAMA) Formoterol (LABA) + Triotropium bromide (LAMA)

22. Broncho di lators c Ombinat ion SABA + MEXA Salbutamol (SABA) + Theophylline (MEXA) Terbutaline (SABA) + Doxophylline (MEXA)

23. Broncho di lators c Ombinat ion MEXA + MEXA Etophylline (MEXA) + Theophylline (MEXA) DERIPHYLLIN

24. ANS = PNS + SNS PNS (rest digest) constricts bronchioles through Ach SNS (Flight Fight) Dilates Bronchioles through Adr . NorAdr .

25. I nhaled corticosteroids (ICS) Beclomethasone Budesonide INH – MDI – 50/100/200/250 mcg/puff DPI – 100/200/400 mcg/cap INH – MDI – 100/200/400 mcg/puff DPI – 100/200/400 mcg/cap Respules – 0.25/0.5/1mg/2ml

26. I nhaled corticosteroids (ICS) Fluticasone Triamcinolone acetonide INH – MDI – 25/50/125 mcg/puff DPI – 50/100/250 mcg/cap INH – MDI – 100mcg/puff

27. Broncho di lators c Ombinat ion ICS + LABA Budesonide (ICS) + Formoterol (LABA ) Fluticasone (ICS) + Salmeterol (LABA)

28. ANS = PNS + SNS PNS (rest digest) constricts bronchioles through Ach SNS (Flight Fight) Dilates Bronchioles through Adr . NorAdr .

29. Leukotriene antagonists Montelukast Zafirlukast PO – 10mg PO – 20mg

30. M ast cell stabilizers Sodium cromoglicate INH - 5mg/puff

31. Anti I g E Antibody Omalizumab INJ – 150mg/1.2ml SC

32. protocols for Asthma management

33. Controller medicine Reliever medicine

34. protocols for COPD management

35. Antimicrobials for respiratory infection

36. Acute bacterial rhinosinusitis (ABRS) First line antimicrobials (5-7 days) Amoxicillin-clavulanate 500mg/125mg PO tid or 1gm/125mg PO BD Moxifloxacin 400mg PO od Doxycycline 100mg PO bid Second line antimicrobials (7-10 days) Amoxicillin–clavulanate 2000mg/125mg PO bid Levofloxacin 500mg po OD Pharyngitis (GAS-pharyngitis) Benzathine penicillin G 1.2 million units IM for single dose Penicillin V 500mg Po BID Amoxicillin 500mg PO Tid Cefadroxil 500mg PO BID Azithromycin 500mg po OD on DAy1 f/b 250mg Po od from 2 nd – 5 th day

37. Acute bronchitis No antimicrobial required, only cough managment Influenza Oseltamivir 75mg Po BID for 5 days Zanamivir 10mg inhalations BID for 5 days Pneumonia For previously healthy patients / no use of antimicrobials within previous 3 months For patients with co morbidities / use of antimicrobials within previous 3 months MACROLIDE/DOXYCYCLINE Azithromycin 500mg OD on first day f/b 250mg OD for next 4 days Clarithromycin 500mg bd Doxycycline 100mg BID B-LACTAM + MACROLIDE/DOXYCYCLINE RESPIRATORY FLUOROQUINOLONES B LACTAM = Amoxicillin 2000mg/125mg BID or Cefpodoxime 200mg BID or Cefuroxime 500mg BID MACROLIDE = Azithromycin 500mg OD on first day f/b 250mg OD for next 4 days RESP. FLUOROQUINOLONES = Levofloxacin 750mg OD, Moxifloxacin 400mg daily, Gemifloxacin 320mg BID

38. THANK YOU KEEP BREATHING