Guavez, Richelle Ann E.

BS Pharmacy 2-1

An 8-year-old boy is brought to your office because of a chronic cough. His mother says that
he coughs frequently throughout the day and will have symptoms 2 or 3 nights a month as
well. This has been a problem on and off for approximately a year, but seems to be worse in
the spring and fall. He also coughs more when he is riding his bike or playing soccer. He has
been treated twice in the past year for “bronchitis” with antibiotics and cough suppressants
but he never seems to clear up completely. His examination is normal except for his lungs,
which reveal expiratory wheezing. You diagnose him with asthma and prescribe an albuterol
inhaler.

 What is the mechanism of action of albuterol?

The bronchial smooth muscle is relaxed by albuterol through its action on beta-
2 adrenergic receptors. Moreover, it prevents cells, especially mast cells, from
releasing acute hypersensitivity mediators. Albuterol also influences beta-1
adrenergic receptors, but this effect is negligible and has no impact on heart
rate. Albuterol was demonstrated to reduce uterine contractions in at least one
particular investigation that used immunoliposomes to deliver it to oxytocin
receptors. Nonetheless, albuterol is not recognized as a tocolytic.

 What are the most common side effects of albuterol?

Tremors are among the most often mentioned albuterol adverse effects.
Hypersensitivity responses and tachycardia are other adverse effects.

More common side effects of Albuterol

 Shakiness in the legs, arms, hands, or feet
 trembling or shaking of the hands or feet
 chest pain, fast or pounding heartbeats;
 upset stomach, vomiting;
  painful urination;
 dizziness;
 feeling nervous;
 headache, back pain, body aches; or
 cough, sore throat, sinus pain, runny or stuffy nose.

 What medications can be used to provide long-term control of the asthma symptoms?
Inhaled corticosteroids - These medications include fluticasone propionate
(Flovent HFA, Flovent Diskus, Xhance), budesonide (Pulmicort Flexhaler,
Pulmicort Respules, Rhinocort), ciclesonide (Alvesco), beclomethasone (Qvar
Redihaler), mometasone (Asmanex HFA, Asmanex Twisthaler) and fluticasone
furoate (Arnuity Ellipta).

Before these medications provide their full benefit, you may need to utilize
them for a few days or weeks. In contrast to oral corticosteroids, there is a
relatively minimal chance of significant side effects with inhaled
corticosteroids.

Leukotriene modifiers - These oral medications — including montelukast

(Singulair), zafirlukast (Accolate) and zileuton (Zyflo) — help relieve asthma
symptoms.

Montelukast has been connected to psychological side effects such agitation,

hostility, hallucinations, depression, and suicide thoughts. In the event that you
encounter any of these responses, get medical help right away.

Combination inhalers - These medications — such as fluticasone-salmeterol

(Advair HFA, Airduo Digihaler, others), budesonide-formoterol (Symbicort),
formoterol-mometasone (Dulera) and fluticasone furoate-vilanterol (Breo
Ellipta) — contain a long-acting beta agonist along with a corticosteroid.
 Theophylline - Theophylline (Theo-24, Elixophyllin, Theochron) is used to
relax the muscles that surround the airways, aiding in maintaining the airways'
openness. In addition to requiring routine blood testing, it is not as frequently
used as other asthma drugs.

Long-Acting Beta2-Agonists – When someone has asthma, their bronchial

muscles tend to constrict and narrow their airways, which is how medications
of the beta2-agonist class function.

Cromolyn Sodium and Nedocromil – These anti-inflammatory drugs, which

are only moderately effective, are no longer frequently used in the long-term
treatment of mild to moderate asthma in children.

 What are possible diagnostic tests to perform to confirm asthma condition in patients?
Spirometry – When a patient is 5 years old or older, this is the primary test
that clinicians typically employ to diagnose asthma. To assist evaluate how
well your lungs are operating (pulmonary function), you take a deep breath and
aggressively breathe out (exhale) through a tube linked to a spirometer. This
keeps track of both how quickly and how much air you exhale (volume). Your
airways may have become narrowed by asthma if certain measurements are
lower than normal for a person your age. Your doctor could instruct you to
breath an asthma medication to open airways after obtaining measures of your
lungs, and then repeat the test. If your symptoms significantly improve after
taking the medication, you might have asthma.

Challenge test – Your doctor may attempt to cause asthma symptoms by

having you inhale a substance, such as methacholine, that causes the airways to
narrow in people with asthma if your spirometer results are normal or close to
normal. If you appear to have asthma provoked by exercise (exercise-induced
asthma), you may be asked to conduct physical activity to check whether it
prompts symptoms. You will need to retake the spirometry test following either
action. You most likely don't have asthma if your spirometry results stay
normal. But if your measurements have fallen significantly, it's possible you
do.

Lung tests in children – Children under the age of five rarely undergo lung
exams by doctors. Instead, a child's signs and symptoms, medical history, and
physical examination are typically used to make a diagnosis. Due to the wide
variety of illnesses that can mimic the symptoms of asthma in young children,
diagnosing asthma in this age range can be particularly challenging. If your
child's doctor suspects asthma, the doctor may prescribe a bronchodilator—aa
drug that opens the airways. After using the bronchodilator, if your child's
symptoms and signs get better, they might have asthma.

Exhaled nitric oxide test – Nitric oxide gas in your breath is measured using a
device that you breathe into through a tube. Although the body naturally
produces nitric oxide, excessive amounts in the breath can indicate asthma
since they indicate that your airways are irritated.

Sputum eosinophils – This examination looks for certain white blood cells
(eosinophils) in the saliva and mucus (sputum) you cough up. When symptoms
start to appear, eosinophils are already present, and they become apparent when
stained with a rose-colored dye.

Allergy testing – Skin testing or blood tests can be used to diagnose allergies.
They inform you if you are allergic to dust, mold, pollen, or animals. In the
event that allergic triggers are found, your doctor might advise allergy shots.

Provocative testing for exercise and cold-induced asthma – Your doctor will
do these tests before and after you engage in strenuous exercise or take
 numerous deep breaths of icy air, and they will measure your airway
obstruction.

Additional tests: Ruling out conditions other than asthma

 X-ray or computerized tomography (CT) imaging of your chest
 CT scans of your sinuses
 Blood tests
 Gastroesophageal reflux assessment
 Examination of the phlegm in your lungs (sputum induction and
examination) for signs of a viral or bacterial infection

References:

Johnson DB, Merrell BJ, & Bounds CG. (2022). Albuterol. In: StatPearls. Treasure Island (FL):
StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482272/
Drugs.com. (n.d.). Albuterol Side Effects: Common, Severe, Long Term.
https://www.drugs.com/sfx/albuterol-side-effects.html
Drugs.com. (n.d.). Albuterol Inhaler: Uses, Dosage &Amp; Side Effects.
https://www.drugs.com/albuterol.html
Mayo Clinic. (2022, January 6). Asthma: Steps in Testing and Diagnosis.
https://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma/art-20045198
Mayo Clinic. (2022, March 5). Asthma - Diagnosis and Treatment - Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/asthma/diagnosis-treatment/drc-20369660
HealthyChildren.org. (n.d.). Asthma Medicines: Long-term Control.
https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/
Asthma-Medicines-Long-term-Control.aspx