Download Pharmaceutical Care III Fall 2007

Pharmaceutical Care III
Management of Asthma
Angela Singh, PharmD
Assistant Professor of Pharmacy Practice
Florida A&M University College of Pharmacy
Overview of Asthma
• Inflammatory disease characterized by
hyperresponsiveness of the airways.
• Inflammatory mediators include
prostaglandins, histamine and leukotrienes.
• Inflammation results in bronchial smooth
muscle spasms, vascular congestion, increased
vascular permeability, mucous production and
impaired ciliary function.
Case
• Chief Complaint
– I have become increasingly short of breath
over the past few weeks.
• HPI
– B.W is a 20 year-old woman who attends the
university, majoring in business. She comes to
the clinic today because she has noticed that
she has been using her albuterol inhaler more
frequently (3 to 4 times a week) and has also
been experiencing symptoms at night more
frequently (3 times/month).
Case
• SH
– Denies any use of tobacco, consumes 10-12 drinks per week,
usually on the weekends, drinks one Coke daily and denies any
use of illicit drugs.
• PE
– Occasional expiratory wheezes bilaterally
• Diagnostic Tests
– Peak expiratory flow variability is 25% and her FEV1 is 85%.
Current Medications
• Albuterol inhaler 2 puffs q 4 hours as needed
for shortness of breath and/or wheezing.
• Ortho Novum as directed monthly.
• Propranolol 40 mg twice daily
• St. John’s Wort 300 mg three times daily.
Categories of Asthma
• Extrinsic/Allergic
• Intrinsic
Etiology
• Innate Immunity
• Genetics
• Environmental Factors
Pathophysiology
• Acute Inflammation
– Early response
– Delayed Response
• Chronic Inflammation
• Bronchoconstriction
• Airway
Hyperresponsiveness
• Airway Edema
Key Symptoms of Asthma
• Wheezing
• History of any of the
following
– Cough
– Recurrent wheeze
– Recurrent difficulty in
breathing
– Recurrent chest
tightness
• Symptoms occur or worsen
at night, awakening the
patient
• Symptoms occur or worsen in
the presence of
– Exercise
– Viral infection
– Inhalant allergens
– Irritants
– Changes in weather
– Strong emotional
expression
– Menstrual Cycles
Co-Morbid Conditions that may
Worsen Asthma
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•
•
•
•
GERD
Obesity
Obstructive Sleep Apnea (OSA)
Rhinitis
Stess/Depression
Diagnosis
• Medical History
• Physical Examination
• Spirometry
– Forced Vital Capacity (FVC)
– Forced Expiratory Volume in one second (FEV1)
– FEV1 / FVC ratio
Diagnostic Tests
• FEV1/FVC ratio
• Peak Flow Meters
• Bronchoprovocation Test
Peak Flow Meters
Complications
• Acute
• Chronic
Asthma Severity Classification
Classification
Mild
Intermittent
Mild
Persistent
Moderate
Persistent
Severe
Persistent
Frequency of
Symptoms
< 2 days/week
> 2 days/week
Daily
Continual
Night Time
Symptoms
<2
nights/month
>2
nights/month
> 1 night/week
Frequent
Peak Expiratory
Flow Variability
< 20%
20-30%
> 30%
> 30%
Forced
Expiratory
Volume in 1
second
> 80 %
> 80%
60% to
80%
< 60%
Case
• Based on her presentation how would you
classify her asthma?
Treatment Goals
• Prevent chronic and troublesome symptoms
• Require infrequent use of inhaled SABA (< 2 times per week) for quick
relief of symptoms (not including prevention of exercise-induced
bronchospasm (EIB))
Non-Pharmacological Approaches
• Immunizations
– Influenza vaccine
– Doesn’t prevent asthma exacerbations during flu
season
• Allergen avoidance
• Tobacco smoke, dust mites, animal dander, cockroach,
pollen, mold, exercise
• Education of the parents and the child.
Education
• Basic facts about asthma
• Role of Medications
• Patient Skills
– Taking medications correctly
– Identifying and avoid environmental exposures
– Self Monitoring
– Asthma Action Plan
How to administer an inhaler…
• Take off the cap and shake the
inhaler
• Breath out all the way
• Hold your inhaler one of the
following ways
– Hold inhaler 1 to 2 inches in
front of your mouth
(about the width of two
fingers)
– Use a spacer/ holding
chamber.
These come in many shapes
and can be useful to any
patient.
– Put the inhaler in your
mouth.
• Breathe in slowly
• As you start breathing in slowly
through your mouth, press down
on the inhaler one time (If you
use a holding chamber, first press
down on the inhaler. Within 5
seconds, begin to breathe in
slowly.
• Keep breathing in slowly, as
deeply as you can.
• Hold your breath
• Hold your breath as you count to
10 slowly, if you can.
• Wait about 1 minute between
puffs.
Tips for Using an Inhaler
•
•
•
•
•
Rinse mouth with water or mouth wash after using corticosteroid
medication to prevent hoarseness and fungal infections in the mouth
and throat.
If you are taking more than one inhaled medication, it is important to
take them in the correct order. Bronchodilating medications are usually
taken first to open the airways and allow other types of medications to
be more effectively inhaled into the lungs. Corticosteroids and cromolyn
are inhaled after bronchodilating drugs.
Avoid the use of over-the-counter inhalers. Most of these contain
epinephrine, which is effective for only a short time and may cause
rebound bronchospasm (making it more difficult to breathe).
Take only the recommended number of puffs prescribed by your
provider; over-use or incorrect use can be dangerous.
Notify your doctor if any of the following occur:
– You do not get relief from your metered dose inhaler
– You have increasing shortness of breath despite use of inhalers
– You are experiencing weakness, increased heart rate, shakiness,
insomnia, nervousness, headaches, nausea or vomiting
CFC vs HFA Inhalers
• Due to the Clean Air Act Chlorofluorocarbon
(CFC) inhalers are being phased out of the
market and replaced with hydrofluroalkane
(HFA) inhalers.
• These inhalers require different instructions
for priming, storage and use.
Pharmacologial Approaches
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•
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•
Beta Agonists
Corticosteroids
Leukotriene Modifiers
Mast Cell Stabilizers
Theophylline
Monoclonal Antibodies
Short Acting Beta Agonists (SABA)
Used for the Prevention and TREATMENT of Bronchospasms
Brand Name
Generic Name
Formulations
Comments
Xopenex®
Xopenex HFA®
Pregnancy Category C
Levalbuterol
Nebulizing Solution
Oral Aerosol
Store at room
temperature. Protect from
light. Contains 200
actuations. Vials should
be used within two weeks
after opening protective
pouch.
Proventil HFA ®, Proair
HFA ®, AccuNeb®
Ventolin HFA®
Combivent® (combination
product), VoSpire ER®
Pregnancy Category C
Albuterol
Oral Aerosol
Nebulizer Solution
Tablet
Extended Release Tablet
Syrup
Store at room
temperature, each inhaler
contains 200 actuations,
Use nebulizing solution
within one week of
opening foil pouch.
Maxair ®
Pregnancy Category C
Pirbuterol
Oral Aerosol
Autohaler
Contains 400 inhalations,
Store at room temperature
Alupent®
Pregnancy Category C
Metaproterenol
Oral Aerosol
Nebulizer
Syrup
Tablet
Store in a tight, light
resistant container.
Contains 200 actuations.
Do not use if solution is
brown or contains a
precipitate.
Long Acting Beta Agonists (LABA)
Used for the PREVENTION of bronchospasms
Brand Name
Generic Name
Dosage Forms
Comments
Foradil®
Perforomist ®
Symbicort ®
(combination product)
Pregnancy Category C
Formoterol
Aerosol Powder
Nebulizing Solution
Store Foradil®
in refrigerator prior to
dispensing, after
dispensing store at room
temperature. Remove
capsules from blister
pack immediately before
using. Use within 4
months of purchase.
Serevent Diskus®
Advair HFA ®
(combination product)
Pregnancy Category C
Salmeterol
Aerosol Powder
Store at room
temperature away from
direct light or heat.
Stable for 6 weeks after
removal from foil pouch.
Not for the use of acute
control of
bronchospasms. Major
substrate 3A4.
Beta Agonists
• Side Effects
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Tachycardia
Insomnia
Nervousness
Hypokalemia
Hyperglycemia
Diarrhea
Dry Mouth
Tremors
• Drug Interactions
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–
–
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MAOIs
Sympathomimetic Agents
Beta Blockers
P450 3A4 Inhibitors &
Inducers
• Salmeterol
– Caffeine
– Yohimbine
Spacing Devices
Corticosteroids
Generic Name
Brand Name
Formulations
Beclomethasone
Pregnancy Category C
QVAR ®
Oral Aerosol
100 Actuations
Traimcinolone
Pregnancy Category C
Azmacort ®,
Oral Aerosol
240 actuations
Flunisolide
Pregnancy Category C
Aerobid ® Aerospan HFA
Oral Aerosol
100 actuations
Fluticasone
Pregnancy Category C
Flovent HFA ®
Flovent Diskus ®
Advair ®
Oral Aerosol
120 actuations
Mometasone
Pregnancy Category C
Asmanex ®
Aerosol Powder
200 Actuations
Budesonide
Pregnancy Category B
Pulmicort Flexhaler ®
Pulmicort Respules ®
Symbicort ®
Aerosol Powder
120 Actuations
Nebulizer
Corticosteroids
• Oral Agents
– Prednisone
– Methylprednisilone
– Prednisilone
• Adverse Effects
– Oral candidiasis
– Hoarseness
– May slow bone growth in
children.
– Cushing’s Effects
– Osteoporosis
– Hypertension
– Cataracts
– Glucose Intolerance
– Skin Thinning
– Depression
• Comments
– Use SPACERS to minimize
local and systemic adverse
effects.
– RINSE MOUTH with water
after inhalations to prevent
thrush infections.
– Use steroid inhalers as
scheduled not as needed.
– Consider calcium and
Vitamin D
supplementation.
– Pulmicort Respules is the
only nebulized approved
steroid.
Corticosteroids: Drug Interactions
• Anti-diabetic agents
• 3A4 Inhibitors & Inducers
– Flunisolide, Fluticasone, Mometasone,
Budesonide
Mast Cell Stabilizer
Brand Name
Generic Name
Formulations
Intal
Cromolyn
Sodium
Oral Aerosol
200 actuations
Nebulizing
Solution
Mast Cell Stabilizers
• Adverse Effects
– Unpleasant taste
– Cough
• Drug Interactions
– No significant drug
interactions
• Comments
– Slow onset: may take 4-8
weeks for expected effect.
– Alternative to steroids in
children.
– Not for rapid relief.
Theophyilline ( Theodur, Uniphyl,
Theo-24)
• Dose 10 mg/kg/day given BID-TID with a
maximum dose of 900 mg daily.
• Therapeutic Levels
– 5-15 mcg/mL
• Formulations
– Controlled Release Tablet (Uniphyl)
– Extended Release Capsule (Theo-24)
– Elixir (Elixophyllin)
• Side Effects
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Nausea
Vomiting
Nervousness
Tremors
Insomnia
Headache
Arrhythmia
Seizures
Theophylline cont.
• Drug Interactions
– 3A4 and 1A2 Inhibitors &
Inducers
– Caffeine
• Comments
– Beneficial for night
symptoms.
– Not for acute relief.
Leukotriene Modifiers
Generic Name
Brand Name
Formulation
Montelukast
Singulair
Tablets
Chewable Tablets
Granules
Zafirlukast
Accolate
Tablets
Leukotriene Modifiers
• Drug Interactions
– Montelukast
• Inhibitors & Inducers of
2C9 & 3A4.
– Zafirlukast
• Inhibits 2C9, 3A4
• Inhibitors & Inducers of
2C9 (it is a major
substrate).
• Adverse effects
– Hepatotoxicity
• Liver function tests at
baseline, every month x
3 months for one year
– Headache
– GI Upset
Zileuton (Zyflo®)
• Inhibits the production of
leukotrienes.
• Available as an extended
release tablet
• Useful in mild persistent
asthma and in combination
with corticosteroids in
moderate persistent asthma.
• Used in pateints > 12 years of
age.
• Adverse Effects
– Elevated liver enzymes.
– Monitor hepatic enzymes
• Drug Interactions
– Zileuton is a 1A2 and 3A4
inhibitor.
Omalizumab ( Xolair)
• Monoclonal antibody that
acts by inhibiting IgE
binding to mast cells and
basophils.
• Administered
subcutaneously every 2-4
weeks
• Must be refrigerated.
• Helpful in moderate to
severe persistent allergyrelated asthma.
• Use in > 12 years old
• Second line therapy
• Very expensive
Omalizumab (Xolair)
• Drug Interactions
– No significant drug
interactions
• Adverse Effects
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Injection site reaction
Urticaria
Thrombocytopenia
Anaphylaxis
Case
• Based on her medication profile are there any
medications that may be interfering with the efficacy of
albuterol? Are there any drug interactions within her
profile?
Stepwise Approach to Asthma
• Intermittent = Step 1
• Mild = Step 2
• Moderate = Step 3 or Step 4
• Severe = Step 5 or Step 6
Stepwise Approach of Management of Asthma
Management of Exacerbations
• Assess Severity
• Initial treatment
– Short acting beta agonist
• Good Response
• Incomplete Response
• Poor Response
Questions
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Angela Singh
[email protected]
599-3359
Office # 345