Respiratory Update for SCC Nursing Faculty Respiratory Medications – Refresher and Update on Recent Changes Presented by Cynthia Fouts June, 2012
Learning Objectives: At the conclusion of viewing this presentation, the learner will be able to • classify respiratory medications. • explain the reason for MDI changes which have occurred over the past decade. • demonstrate the procedure for administration of both MDI and DPI medications. • list recently discontinued respiratory medications
As of June, 2012, there are 93 FDA approved drugs for use to treat respiratory ailments. This presentation will cover 12 medications which have been approved in the last decade. It will also discuss new delivery methods for previously approved medications and medications used in different therapeutic applications.
Respiratory Medication Classifications • Antihistamines • Antitussives • Bronchodilators • Inhaled Corticosteroids • Decongestants • Mucolytics • Non-steroidal antiasthma agents There are other respiratory medications but most fall within these categories.
Antihistamines • block histamine; decrease inflammation and reduce secretions • 2nd generation – cause less drowsiness than the 1st generation antihistamines • also have anti-cholinergic effect – cause dry mouth
Antitussives • suppress the cough reflex at the medulla oblongata; narcotics may depress respiratory drive • benzonatate – narcotic • butamirate citrate – non-narcotic • codeine – narcotic • dextromethorphan – non-narcotic • hydrocodone – narcotic • important - ensure the patient don’t suffer from pooling of secretions if cough is suppressed.
Bronchodilators • dilate the airways by releasing constriction of the muscles surrounding them • 3 different classifications • Xanthines • Sympathomimetics (Adrenergic) • Parasympatholytic (Anticholinergics)
Bronchodilator - Xanthines • stimulate the CNS thus stimulating respiration, dilating coronary and pulmonary arteries, and act as a diuretic. • Theophylline, Aminophylline, Caffeine • 2nd or 3rd line agent in treating COPD and asthma • useful in treating Apnea of Prematurity
Bronchodilator - Sympathomimetics • mimic the effect of the sympathetic nervous system to dilate the bronchi and increase the rate and depth of respiration • most are beta2 specific – increase concentration of cellular cAMP • short-acting and long-acting beta agonists (SABA, LABA) • albuterol, bitolterol, salbutamol, terbutaline, racemicephiniphrine, levalbuterol
Bronchodilator - Anticholinergics • blocks effects of acetylcholine at the cholinergic receptors on bronchial smooth muscle • Ipratroprium bromide and tiotropium bromide • specifically approved for COPD but may be used in treatment of asthma also. • studies have shown additive effect when used in conjunction with beta agonists.
Inhaled Corticosteroids • decrease inflammatory response within the airways • when inhaled, systemic side effects are diminished • long-term use in treatment of COPD and Asthma • always rinse the mouth after inhalation of a steroid to reduce incidence of oral thrush • Flunisolide, fluticasone, budesonide, mometasone, ciclesonide NOT FOR EMERGENCY USE – DO NOT USE DURING AN ACUTE ASTHMA ATTACK.
Decongestants • decrease blood flow to upper respiratory tract and decrease excessive production of secretions • especially useful in allergic rhinitis • may be given orally or by nasal spray
Mucolytics • Acetylcysteine – decreases the viscosity of sputum by breaking the disulfide bonds which connect the mucin proteins. • Not shown to really be helpful in treating lung diseases • may be given orally as an antioxidant antidote to reduce liver injury with acetaminophen overdose
Mucolytics • Dornase alpha – a peptide mucolytic which reduces extracellular DNA and F0actin polymers • indicated in treatment of cystic fibrosis • currently being used in treatment of other pulmonary diseases although no efficacy has yet been shown
Non-steroidal Anti-asthma Agents • anti-inflammatory effect through mechanism different from corticosteroids • stop the inflammatory process • mast cell stabilizer – cromolyn sodium • antileukotrienes – accolate, singuair, zyflor • monoclonal antibodies - xolair • prophylactic management (control) of mild persistent asthma
Why are MDI’s being changed? The Montreal Protocol is an international treaty intended to eliminate the use of substances that contribute to destroying the ozone layer, including CFCs (chlorofluocarbons). The most commonly used inhalers were changed over to the new HFA propellant or remade as dry powder inhalers (DPI). In switching to the new HFA format, it was discovered that dose delivery is actually enhanced with delivery by HFA as opposed to CFC – a win-win situation!
Comparison of dose delivery between CFC inhalers, HFA inhalers, and DPIs.
The following is a list of inhalers to be discontinued along with the corresponding date nedocromil , June 14, 2010 metaproterenol , June 14, 2010 triamcinolone , December 31, 2010 cromolyn , December 31, 2010 (available as nebulized solution) flunisolide , June 30, 2011 combivent, December 31, 2013 (replaced with CombiventRespimat) pirbuterol , December 31, 2013
Now for a look at the new respiratory medications introduced within the past decade.
Alvesco (ciclesonide) • Approved January, 2008 • Prophylactic maintenance treatment of asthma • Prodrug delivered via metered dose inhaler (MDI) • 12 time greater affinity for glucocorticoid receptors than dexamethasone. • 80 mcg or 160 mcg
Arcapta (indacaterolmaleate inhalation powder • approved July, 2011 • long-acting beta2-adrenergic agonist (LABA) • once daily inhalation of one 75 mg. capsule • correct administration - dry powder inhaler taken via the neohalerusing the same technique as the spirivahandihaler.
Brovana (arformoteroltartrate) • approved October, 2006 • selective beta2-adrenergic bronchodilator • long-term twice-daily maintenance therapy for COPD • 156 mcg administered twice a day by nebulizer
Daliresp (roflumilast) • approved February, 2011 • selective phosphodiesterate 4 (PDE4) inhibitor • reduces release of inflammation mediators • useful in treatment of COPD • 500 mcg tablet taken orally daily, with or without food
Dulera (mometasone furoate + formoterolfumarate dihydrate) • approved June, 2010 • for treatment of asthma • combination therapy of corticosteroid plus LABA • Dosage dependent on previous therapy • 100 mcg/5 mcg up to 800 mcg/20 mcg BID by inhalation from MDI
Dymista (azelastine hydrochloride and fluticasone proprionate) • approved May, 2012 • treatment for seasonal allergic rhinitis • combination therapy of antihistamine and corticosteroid • sprayed suspension for intranasal administration • one spray per nostril twice daily • prime spray prior to initial use and if not used for 14 days.
Patanase (olopatadine hydrochloride) • approved April, 2008 • treatment of seasonal allergic rhinitis • antihistamine • metered-dose manual spray pump for intranasal administration • two sprays per nostril twice daily • prime prior to initial use and if not used for more than 7 days
Pulmozyme (dornasealfa) • approved March, 1998 • mucolytic • Although this drug was approved prior to 10 years ago, it has seen an increase in usage lately as a mucolytic for COPD patients. • Efficacy has not been shown in any trials for COPD therapy
Qnasl (beclomethasonedipropionate) • approved March, 2012 • treatment of seasonal and perennial allergic rhinitis • anti-inflammatory steroid • non-aqueous nasal spray solution for intranasal inhalation • 80 mcg/spray administered as two sprays in each nostril once daily (total of 320 mcg/day)
Spiriva (tiotropium bromide) • approved February, 2004 • treatment of bronchospasm associated with COPD • anticholinergic • 18 mcg supplied in a gelatin capsule administered via the HandiHaler; one capsule daily • http://www.youtube.com/watch?v=bXHHFmZ_DRI&feature=related
Spiriva (tiotropium bromide) • 2.5 mcg supplied in the Respimat inhaler; 2 puffs daily • used with caution in patients with known cardiac rhythm disorders • http://www.youtube.com/watch?v=cIYKXuIWGfA&feature=related
Xolair (omalizumab) • approved June, 2003 • treatment of moderate to severe persistent asthma • binds to human immunoglobulin E (IgE) which is responsible for release of mediators of the allergic response • powder for reconstitution into solution for subcutaneous injection • 150 to 375 mg SC every 2 or 4 wks • dose and frequency determined by serum total IgE level. • limit injection site to not more than 150 mg.
Zemaira (alpha-1-proteinase inhibitor) • approved July 2003 • treatment of alpha-1-proteinase inhibitor (A1-PI) deficiency emphysema • intravenous therapy • chronic augmentation and maintenance of A1-PI deficiency and clinical evidence of emphysema
CombiventRespimat • approved March, 2012 • Combination of Albuterol and Ipratropium Bromide • Slow-moving mist • Propellant-free delivery • Only one inhalation per dose as opposed to the old MDI which requires 2 puffs per dose
The Advairdiskus is approved for treatment of both COPD and Asthma. The HFA inhaler, approved in July, 2008, is only for the treatment of Asthma. http://www.youtube.com/watch?v=_iEEVkMU1IA
Serevent is approved for the treatment of both COPD and Asthma. It is NOT designed to be a rescue inhaler used to treat an acute asthma attack. HFA inhaler approved June, 2006.
Bibliography • BoehringerIngelheim receives FDA approval for COMBIVENT RESPIMAT to treat COPD. (2011). Medical News. Retrieved from: http://news-medical.net/news/20111010/Boehringer-Ingelheim-rece-ves-FDA-apaproval-for-COMBIVENT-RESPIMAT-to-treat-COPD.aspx • Gardenhire, D. (2012). Rau’s Respiratory Care Pharmacology, 8th Ed., St. Louis: Elsevier Mosby . • Pinoynurze. (2008). Drugs Affecting the Respiratory System. Retrieved from: http://www.slideshare.net/pinoynurze2/pharmacology-respiratory-drugs-380509 • Reinventing Metered Dose Inhalers: From Poorly Efficient CFC MDIs to Highly Efficient HFA MDIs. (2003). Drug Development and Delivery (31). Retrieved from http://www.drugdeliverytech.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=53E82363413A44F6AD01FDFF8D242DFE • Respiratory Drugs (2012) MediLexicon. Retrieved from: http://medilexicon.com/drugs-list/respiratory.php