INHALED MEDICATIONS AND DRUGS FOR ASTHMA AND COPD

DR. VISHNU SHARMA .M. PROFESSOR AND HEAD DEPT OF PULMONARY MEDICINE A. J. INSTITUTE OF MEDICAL SCIENCES MANGALORE

WHY INHALED MEDICATION

ORAL
Large dosage used Greater side effects Slow onset of action Not useful in acute symptoms

Inhaled
Small amount of dosage used Lesser side effects Fast onset of action (e.g. bronchodilators) Useful in acute symptoms

Devices
MDI

DPI
NEBULIZER

The Best route for Asthma and COPD Medication is the

Inhaled Route
The same holds true for

ACUTE ASTHMA ATTACK and AECOPD

Why Nebulisation
Immediate relief is required which can be achieved only from inhalation therapy. Patient is critical hence unable to co-ordinate with inhaled devices.

Nebulisation is the best resort to give optimal dose and targeted drug delivery

Nebulizer
Fill volume-2 to 4ml
Time 8-10mt End point-Spluttering sound O2 flow rate 6-8li/mt

Instructions to the Patient

Sit upright Take normal steady breaths Breath hold if possible for 5-8 seconds Not to talk during the nebulisation

Mask / Mouth piece

Mask for those who cant co-operate

Mouthpieces less chance to eye irritation

Precautions
Aseptic precautions to prevent infection
Proper disinfection Hand hygiene

Respule/Respiratory solution
Respule -ready to use
Respiratory solution needs to be diluted Respule cost is more

 RESPIRATORY SOLUTION

RESPULE

Metered dose inhaler

Quick to use
Compact

Disadvantage

Technique is difficult

Why use a Spacer ?

Ensures correct use of an MDI by correcting co-ordination problems. Reduces incidence of throat infections with inhaled steroid

As good as nebuliser for acute exacerbations ( with MDI )

Then do we need nebulizers ?

YES

Acute severe asthma with impending respiratory failure Intensive care / Hospital / Clinic / Ambulances

Dry powder inhaler

Easy

to use

Compact

More oropharyngeal deposition

Which inhalation Device?

Inhalers

MDI

DPI

Nebuliser
(acute severe episodes only)

When you can not use a DPI?

Patient not able to inhale-Child below 3, or Elderly

Use:

MDI + Spacer

MDI + Spacer + Baby Mask

Disadvantages OF Inhaled medications

Needs patient co-operation
Technique should be correct Oropharyngeal deposition Irritation to eye with nebulization

Inhalation Drugs in Asthma and COPD

Beta 2 agonists Anti cholinergics

Gluco-corticosteroids

Long acting beta agonists

Salmeterol Formoterol

Indacaterol
Arfomoterol Bambuterol

Formetrol
Rapid onset of action Short duration of side effect Response increase with dose No cumulative side effect.

Salmetrol
Slower onset
Long duration of side effect No such effect Cumulative side effect

ADVERSE EFFECTS
Uncommon with

inhalation

Tremor,

dyspnoea, weakness, headache

arrhythmias

Palpitations, tachycardia, Tolerance

Hypokalemia with high doses

PRECAUTIONS
Use

with cautions in patients with diabetes, hypertension

Severe

paradoxical bronchoconstriction

Administered

cautiously in cardiac patients

DRUG INTERACTIONS
Combination

of salmeterol - fluticasone & formoterol-budesonide have synergistic action

Increased

risk of hypokalemia with high dose of corticosteroid with 2 agonists

Anticholinergic drugs
Ipratropium bromide is a quaternary ammonium derivative of atropine.

Tiotropium bromide the most recently developed, has a longer duration of action.

Advantages
Minor side effects

Used in COPD

Disadvantages
Slow onset of action Less effective than 2 agonist

No anti-inflammatory action

Inhaled corticosteroids
High topical low systemic activity

Suppress bronchial inflammation, increase peak expiratory flow rate

Mechanism of action
Modulation of cytokine and chemokine production Inhibition of eicosanoid synthesis Inhibition of accumulation of leucocytes in the lungs Decreased vascular permeability

Methods of administration
MDIs

DPIs
Nebulization

Equivalent dosages

Equivalent dosages
200mg beclomethasone 200mcg budesonide

80mcg ciclesomide 100mcg fluticasone

200mcg mometasone

Preparations
Beclomethasone Budesonide

Fluticasone
Ciclesonide Mometasone

LOCAL Adverse effects

Hoarseness- steroid induced myopathy

Dysphonia
Oropharyngeal candidiasis

Systemic Adverse effects

Mood changes
Osteoporosis Bruising, hyperglycemia HPA suppression

Adverse effects- concerns

HPA suppression- dosages above 1500mcg of beclomethasone Children 400mcg beclomethasone

Children with asthma even though there may be prepubertal growth delay, they tend to catch up later Thinning of skin and striae especially elderly

Interactions
ICS+LABA
Potentiate each other Equivalent to double the dosage of steroid

THANK YOU