Asthma Medications and Devices

Krista D. Capehart, PharmD, MSPharm, AE-CAssistant Professor of Pharmacy Practice

University of Charleston School of Pharmacy

Objectives

• Identify quick relief and controller medications for asthma.

• Discuss the different delivery devices for inhaled asthma medications.

• Demonstrate how to assist in administering asthma medications.

Quick Relief Medications

• Medications that are used to help relieve symptoms of an asthma attack

• Albuterol is one of the most commonly used quick-relief medications that works to relax the airways and make it easier to breath

• Can start to work in 5-15 minutes after use for symptoms

Bronchodilators – Beta 2 Agonists – Nebulized: every 4-6 hours as needed*

Albuterol (pre-mixed) Ventolin, Proventil, Accuneb

0.63mg/3mL unit dose vial1.25mg/3mL unit dose vial2.5mg/3mL unit dose vial

Albuterol (concentrate) 2.5mg/0.5mL – must be mixed with saline or another solution

Levalbuterol Xopenex 0.31mg/3mL unit dose vial0.63mg/3mL unit dose vial1.25mg/3mL unit dose vial

Levalbuterol (concentrate) 1.25/0.5mL – must be mixed with saline or another solution

* Per NHLBI:EPR3 Guidelines for “Home” management of asthma exacerbations – Up to two nebulized treatments 20 minutes apart may be administered, assessing condition throughout both treatments to determine if emergency transport/emergency department treatment is necessary.

Bronchodilators – Beta 2 Agonists – Metered Dose Inhalers (MDIs) every 4-6

hours as needed*Albuterol Ventolin HFA, Proventil

HFA, ProAir HFA2-6 puffs per dose (always use a spacer)

Levalbuterol Xopenex HFA 2-6 puffs per dose (always use a spacer)

Pirbutrol Maxair 2-6 inhalations per dose (breath activated – do not use spacer)

* Per NHLBI:EPR3 Guidelines for “Home” management of asthma exacerbations – Up to two treatments 20 minutes apart may be administered, assessing condition throughout both treatments to determine if emergency transport/emergency department treatment is necessary.

Bronchodilators – Anti-cholinergics – Metered Dose Inhalers (MDIs) every 4-6 hours as needed – Not for use

alone in asthma

Ipratropium bromide Atrovent HFA 4-8 puffs every 20 minutes as needed up to 3 hours for exacerbation

* Per NHLBI:EPR3 Guidelines for “Home” management of asthma exacerbations – Up to two nebulized treatments 20 minutes apart may be administered, assessing condition throughout both treatments to determine if emergency transport/emergency department treatment is necessary.

Errors in inhaler use

• Requires coordination & skill for MDI• In a study that examined inhaler (MDI &

DPI) use over 1 month, half made at least one error & 76% using MDI made an error

• Critical errors resulted in almost no drug being administered and those occurred in 11% of those using DPI & 28% in those using MDI

Spacer Devices

• Advantages– Reduces need for

patient coordination– Reduces pharyngeal

deposition

• Disadvantages– Inhalation can be more

complex for some patients– Can reduce dose available

if not used properly– More expensive than MDI

alone– Less portable than MDI

alone– Integral actuation devices

may alter aerosol properties

Ensure that each student has a Personal Written Asthma Action Plan

Ensure that each student has a Personal Written Asthma Action Plan

Management of Asthma Exacerbations: School Treatment (Per National Asthma Education Prevention Program)

• The following slides are the suggested Emergency Nursing Protocol for Students with Asthma Symptoms who don’t have a personal asthma action plan.

• A student with asthma symptoms should be placed in an area where he/she can be closely observed. Never send a student to the health room alone or leave a student alone. Limit moving a student who is in severe distress. Go to the student instead.

Management of Asthma Exacerbations: School Treatment (Per National Asthma Education Prevention Program)

Management of Asthma Exacerbations: School Treatment (Per National Asthma Education Prevention Program)

Management of Asthma Exacerbations: School Treatment (Per National Asthma Education Prevention Program)

Long-acting Controller Medications

• These are medications that are taken daily to help prevent symptoms of asthma by decreasing inflammation and will NOT treat an asthma attack

• Inhaled corticosteroids like fluticasone (Flovent®) and budesonide (Pulmicort®) and oral medications like montelukast (Singulair®) and zafirlukast (Accolate®) are the drugs that used most often to prevent symptoms of asthma

• Must be taken as prescribed even if you are not having symptoms every day

Routine Maintenance Inhaled Medications “Controller medications” Dosages listed are from NHLBI EPR3

Guidelines for ages 5- 11 year old unless otherwise noted

Beclomethasone HFA 40 or 80mcg/puff

QVAR Low dose: 80-160mcg total per day to be divided and given every 12 hoursMedium dose: >160mcg-320mcg total per day to be divided and given every 12 hours High dose: >320mcg total per day to be divided and given every 12 hours

Budesonide DPI 90mcg, 180mcg, or

Pulmicort Flexhaler Low dose: 180-400mcg total per day to be divided and given every 12 hoursMedium dose: > 400-800mcg total per day to be divided and given every 12 hoursHigh dose: >800mcg total per day to be divided and given every 12 hours

Routine Maintenance Inhaled Medications “Controller medications” Dosages listed are from NHLBI EPR3 Guidelines for

ages 5- 11 year old unless otherwise noted

Budesonide inhalation suspension for nebulization 0.25mg/2ml,0.5mg/2ml, and 1mg/2mL

Pulmicort Respules Low dose: 0.5mg total per day to be given in one or two treatmentsMedium dose: 1mg total per day to be given in one or two treatmentsHigh dose: 2mg total per day to be given in two treatments

Mometasone DPI110mcg/puff, 220mcg/puff

Asmanex Twisthaler 1 puff in the evening

Routine Maintenance Inhaled Medications “Controller medications” Dosages listed are from NHLBI EPR3 Guidelines for ages 5-11 year

old unless otherwise notedFluticasone HFA 44mcg, 110mcg, 220mcg/puff Fluticasone DPI 50mcg, 100mcg, or 250mcg per inhalation

Flovent HFA Flovent Diskus

Low dose:88-176mcg total per day to be divided and given every 12 hoursMedium dose: > 176-352mcg total per day to be divided and given every 12 hoursHigh dose: >352mcg total per day to be divided and given every 12 hoursLow dose: 100-200mcg total per day to be divided and given every 12 hoursMedium dose: > 200-400mcg total per day to be divided and given every 12 hoursHigh dose: >400mcg total per day to be divided and given every 12 hours

Combination Medications Inhaled – Beta2 Agonist and Corticosteroid

Fluticasone/Salmeterol DPI 100mcg-50mcg

Advair Diskus 1 inhalation twice daily (12 hours apart)

Fluticasone/Salmeterol HFA45mcg-21mcg115mcg-21mcg230mcg-21mcg

Advair HFA Not approved for children <12 years

Budesonide/formoterol HFA80mcg-4.5mcg

Symbicort HFA 2 puffs twice daily (12 hours apart)

Long Acting Beta 2 Bronchodilators – not recommended for use alone in asthma without an

inhaled corticosteroid

Salmeterol DPI 50mcg/inhalation

Serevent Diskus 1 inhalation every 12 hours

Formoterol DPI 12mcg/single use capsule for inhalation

Foradil Inhale the contents of one capsule every 12 hours

Oral Medications• Oral Corticosteroids

Methylprednisolone 2, 4, 8, 16, 32mg tablets

Medrol 0.25-2mg/kg daily in single morning or every other day as needed for control

Prednisolone 5mg tablets5mg/5mL liquid15mg/5ml10mg ODT (Oral disintegrating tablet)15mg ODT30mg ODT

Prelone, PediapredPrelone, OrapredOrapred ODT

0.25-2mg/kg daily in single morning or every other day as needed for control

Prednisone 1, 2.5, 5, 10, 20, 50mg tablets5mg/mL5mg/5mL

0.25-2mg/kg daily in single morning or every other day as needed for control

Leukotriene Receptor Antagonist (LTRAs)

Montelukast 4mg or 5mg chewable tablet, 10mg tablet

Singulair 5mg at bedtime (6-14 years of age)

Zafirlukast 10mg, 20mg

Accolate 10mg twice daily (7-11 years of age)

Food and Drug Administration (FDA) Decision

• March 31, 2005 – FDA rules that manufacturers needed to phase out production and sale of CFC MDI by December 31, 2008

• Manufacturers began to develop HFA MDI for both “quick relief” medications (albuterol and levalbuterol) and for “long-term controller” medications (inhaled corticosteroids)

Differences between CFC and HFA MDIs

Component CFC HFADose delivery from near empty container

Variable Consistent

Variable ambient temperature

Variable Consistent (-20C)

Force of spray More forceful Softer

Mist Temperature Colder Warmer

Mist Volume Higher Lower

Taste Different Different

Breath-holding < important with CFC > Important with HFA

Priming General guidelines for all Very specific to product

Cleaning Periodic cleaning necessary

Stressed as REGULAR cleaning necessary

Hess DR, Myers TR, Rau JL. A Guide to Aerosol Delivery Devices. Access at http://www/AARC.org/aerosol_delivery on July 25, 2008.

Softer, warmer plume may cause patients to think the HFA inhalers do not work as well as the CFCs. The HFA inhalers deliver 108 mcg of albuterol sulfate, which is equivalent to 90mcg albuterol base. This is the same amount of active medication as is in the CFC

albuterol MDIs.

http://www.google.com/imgres?q=image+HFA+vs+CFC+plume&hl=en&client=firefox-a&hs=GND&sa=X&rls=org.mozilla:en-US:official&biw=1280&bih=579&tbm=isch&prmd=imvns&tbnid=ry2nJQGuKZghPM:&imgrefurl=http://www.expert-reviews.com/doi/pdf/10.1586/17476348.2.2.149&docid=q-SjR7QNpJcZOM&w=120&h=67&ei=F81wToruLMHcgQem4_EQ&zoom=1&iact=hc&dur=3717&page=1&tbnh=58&tbnw=104&start=0&ndsp=21&ved=1t:429,r:2,s:0&tx=44&ty=31&vpx=486&vpy=217&hovh=58&hovw=104 Accessed September 2011

Priming…

• Each of the HFA metered-dose inhalers must be “primed”

• What does “priming” mean?• How many times for different inhalers?!?

Examples of HFA priming guidelinesMedication When to prime # of spraysProventil HFA (albuterol)

Prior to 1st use2 wks of non-use

44

Ventolin HFA (albuterol)

Prior to 1st use2 wks of non-use

44

ProAir HFA (albuterol)

Prior to 1st use2 wks of non-use

33

Flovent HFA (fluticasone)

Prior to 1st useWith < 3 weeks of non-useWith > 3 weeks of non-use

414

QVAR (beclomethasone)

Prior to 1st useWith 10 days of non-use

22

Advair HFA (fluticasone and salmeterol)

Prior to 1st useWith 4 weeks of non-use

42

Atrovent HFA (ipratropium)

Prior to 1st useWith 3 days of non-use

22

Inhalation technique for the HFA MDIs

1. Remove mouthpiece cover and check for foreign objects.

2. Shake the inhaler well immediately before use.

3. Prime if necessary.4. Breath out normally

through the mouth, getting as much air out of the lungs as possible.

5. Place the mouthpiece between the lips and teeth.

6. Breath in slowly and press MDI canister down once at the beginning of the inhalation.

7. Hold breath as long as possible, up to 10 seconds.

8. Remove inhaler from mouth and breath out slowly

9. Wait 30-60 seconds between doses.

10. Rinse mouth and spit with ICSs.

Cleaning HFA MDIs

• All HFAs state actuator needs to be cleaned at least once a week and as needed

• Clean by removing the canister and running warm water through the top and air dry overnight if possible

Dry powder inhalation (DPI) devices

• No propellants• Built-in dose counters• Breath actuated• Formoterol – individual capsules• Diskus (salmeterol & fluticasone) – blister

strip• Budesonide and mometasone– drug

reservoir

Technique for Diskus• Diskus expires 1 month from

the day the pouch is opened• Open, Click, Inhale1. Open by placing the thumb

on the thumb grip and push away from you until the mouthpiece appears and snaps into position.

2. Hold the Diskus FLAT with the mouthpiece toward you and slide the level as far as it will go until it clicks.

3. Inhale – – Exhale fully while holding the

Diskus away from your mouth and FLAT. Never breath into the mouthpiece

– Put the mouthpiece to your lips and inhale quickly and deeply through your mouth (not nose).

– Remove the Diskus from your mouth and hold your breath for about 10 seconds. Exhale slowly.

– Rinse your mouth with water and spit after breathing in the medicine.

– Close the Diskus when you are finished.

Technique for budesonide DPI• Prime before using for the 1st time

ONLY• Hold the inhaler so that the white

part is pointing up and remove the cover by lifting up

• Hold the inhaler by the brown grip and grasp the inhaler in the middle, still holding it upright

• Twist the brown grip as far as possible to one direction then fully back again in the other direction until it stops

• The device is now primed and does NOT need to be primed again

• Load the dose– Twist the cover and lift off– Hold inhaler in upright position

and grasp brown grip– Place other hand in the middle of

the inhaler– Twist all the way in one direction

and then fully back again in the other direction until it clicks

• Keep inhaler vertical until ready to use– Exhale completely (not into the

inhaler)– Place mouthpiece in your mouth,

close lips around it, inhale deeply and forcefully through the inhaler

– Remove the inhaler from your mouth and exhale

– Replace the cover– Rinse mouth with water and spit.

Technique for mometasone DPI• Remove inhaler from pouch –

throw away 45 days after opening or when dose counter reads “00”

• Open the inhaler– Hold inhaler straight up with

colored portion on the bottom.– Holding the colored base twist

the cap counterclockwise to remove it. Removing cap loads the dose

• Inhale the dose– Breathe out fully– Place the inhaler in your

mouth holding it horizontally, closing your mouth firmly around the inhaler

– Take in a fast, deep breath. Do not cover the ventilation holes

– Do not breath into the inhaler. Remove the inhaler from your mouth and hold your breath for 10 seconds.

– Rinse mouth with water and spit.

Nebulizers

• Nebulizers uses ampules of medication that is put in a special cup and usually air is used to make the solution into a breathing treatment

• It usually takes about 5-10 minutes to complete a breathing treatment of 3 mL of medication.

How do we see if the medications are working?

• Peak flow meters• Spirometry

Other asthma resources for you at school

• The National Heart Lung and Blood Institute – National Asthma Education and Prevention Program has a large assortment of resources available online at http://www.nhlbi.nih.gov/health/public/lung/index.htm#schools

References• Kelly HW and SorknessCA. Asthma. In: Dipiro JT, Talber RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A

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Disease Management, 8th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2006. p. 877-918.• Global Initiative For Asthma: Global Strategy for Asthma Management and Prevention. Revised 2006.

http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60• National Heart Lung and Blood Institute. National Asthma Education and Prevention Program; Expert Pane Report 3:Guidelines for

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US:official&biw=1280&bih=579&tbm=isch&prmd=imvns&tbnid=ry2nJQGuKZghPM:&imgrefurl=http://www.expert-reviews.com/doi/pdf/10.1586/17476348.2.2.149&docid=q-SjR7QNpJcZOM&w=120&h=67&ei=F81wToruLMHcgQem4_EQ&zoom=1&iact=hc&dur=3717&page=1&tbnh=58&tbnw=104&start=0&ndsp=21&ved=1t:429,r:2,s:0&tx=44&ty=31&vpx=486&vpy=217&hovh=58&hovw=104 Accessed September 2011

• Hess DR, Myers TR, Rau JL. A Guide to Aerosol Delivery Devices. Access at http://www/AARC.org/aerosol_delivery on July 25, 2008.

• Leach CL. The CFC to HFA transition and its impact on pulmonary drug development. Resp Care 2005;50:1201-1206.• Busse WW, Brazinsky S, Jacobson K, Schmitt K, Vanden Burgt J, et al. Efficacy response of inhaled beclomethasone dipropionate

in asthma is proportional to dose, and is improved by formulation with a new propellant. J Allergy Clin Immunol 1999;104:1215-1222.

• Hess DR, Myers TR, Rau JL. A Guide to Aerosol Delivery Devices. Access at http://www/AARC.org/aerosol_delivery on July 25, 2008.

• Prescribing information for Asmanex Twisthaler 2008, Advair Diskus 2008, Spiriva 2008, Pulmicort FlexHaler 2007, Proventil HFA 2007, Ventolin HFA 2008, ProAir HFA 2006, Foradil Aerolizer 2006, QVAR 2006

• Use of Ozone Depleting Substances: Removal of Essential Use Designation; Final Rule. Federal Register April 4, 2005;70(63):17167-17192.

• Questions and answers on final rule of Albuterol MDI’s. at http://www.fda.gov/cder/mdi/mdifaqs.htm access August 8, 2008.• OptHolt T and Philibosian D. Inhalation Therapy Device Workshop. Delivered at the Association of Asthma Educators Annual

Meeting in San Francisco July 18-21, 2008.• FDA Public Health Advisory: National Transition from Chlorofluorocarbon (CFC) Propelled Albuterol Inhalers to Hydrofluroalkane

(HFA) Propelled Albuterol Inhalers. Accessed at http://www.fda.gov/cder/mdi/albuterol.htm Accessed on August 8, 2008.• http://www.nhlbi.nih.gov/health/prof/lung/asthma/sch-emer-actplan.pdf