A Visual Approach to Simplifying Respiratory Drug Regimens Stephanie Cheng, PharmD, MPH, BCGP October 23, 2017 Learning Objectives • Be able to list at least 3 major adverse effects of inhaled medications • Be able to visually separate the different inhaled medications into their proper classifications • Be able to identify duplicate therapies in a patient’s respiratory medication regimen • Be able to state the risk and rational of using or not using corticosteroids in the hospice population • Be able to list the steps to appropriately manage dyspnea in a hospice patient Inhaled Respiratory Drugs 3 Main Categories Beta 2 Agonists • Binds to beta-2 receptors • Relaxation of smooth muscles in the lung Can be mixed Can be mixed • Dilation and opening of airways and matched and matched in various in various Muscarinic Antagonists combinations combinations • Inhibits acetylcholine in bronchial smooth muscle • Bronchodilation Corticosteroids • Inhibits the inflammatory response 1
Adverse Effects of Inhaled Medications Drug Category Adverse Effects Tachycardia (up to 200 beats/minute), arrhythmias, nervousness, headache, tremor, Beta 2 agonists dry mouth, palpitation, nausea, dizziness, sleeplessness, hypertension or hypotension Muscarinic Dizziness, headache, dry mouth, dyspepsia, antagonists nausea, UTI, urinary retention, constipation Increase risk of upper respiratory tract Corticosteroids infections, headache, pharyngitis Dosage Forms • Handheld Inhaler – Metered dose inhaler (MDI) Handheld inhalers Handheld inhalers – Dry powder inhaler (DPI) • Require adequate inhalation force • Require adequate inhalation force – Aerolizers • Require coordination to use • Require coordination to use – HandiHaler • Are generally more expensive • Are generally more expensive – Twisthaler compared to the nebulized solution compared to the nebulized solution – Flexhaler • Nebulized solution • Oral tablet (Albuterol tablet, corticosteroid: prednisone) • Beta 2 agonists and muscarinic antagonists – Short-acting and long-acting formulations Respiratory Medications NOT in Combination Corticosteroids Corticosteroids Beta 2 Agonists Beta 2 Agonists End in End in End in End in -terol -terol -sone or -nide -sone or -nide • • Handheld Inhaler Handheld Inhaler • Handheld Inhaler • Handheld Inhaler - - Beclomethasone (Qvar) Beclomethasone (Qvar) - - Short Acting Short Acting - - Budesonide (Pulmicort Flexhaler) Budesonide (Pulmicort Flexhaler) • • Albuterol HFA (Ventolin HFA, Proair HFA, Proventil Albuterol HFA (Ventolin HFA, Proair HFA, Proventil - - Ciclesonide (Alvesco) Ciclesonide (Alvesco) HFA) HFA) - - • • Levalbuterol HFA (Xopenex HFA) Levalbuterol HFA (Xopenex HFA) Fluticasone (Flovent HFA/Diskus) Fluticasone (Flovent HFA/Diskus) - - Long acting Long acting - - Mometasone (Asmanex Twisthaler) Mometasone (Asmanex Twisthaler) • • Formoterol (Foradil Aerolizer) Formoterol (Foradil Aerolizer) • • Nebulized solution Nebulized solution • • Indacaterol (Arcapta Neohaler) Indacaterol (Arcapta Neohaler) - - Budesonide (Pulmicort Respules) Budesonide (Pulmicort Respules) • • Olodaterol (Striverdi Respimat) Olodaterol (Striverdi Respimat) • • Oral – Prednisone Oral – Prednisone • • Salmeterol (Serevent Diskus) Salmeterol (Serevent Diskus) • Nebulized solution • Nebulized solution Muscarinic Antagonists Muscarinic Antagonists - - End in End in Short Acting Short Acting -ium -ium • • Handheld Inhaler Handheld Inhaler • • Albuterol (AccuNeb) Albuterol (AccuNeb) • • Levalbuterol (Xopenex) Levalbuterol (Xopenex) - - Short Acting Short Acting - - Long Acting Long Acting • • Ipratropium HFA (Atrovent HFA) Ipratropium HFA (Atrovent HFA) • • Arformoterol (Brovana) Arformoterol (Brovana) - - Long Acting Long Acting • • Formoterol (Perforomist) Formoterol (Perforomist) • • Aclidinium (Turdorza Pressair) Aclidinium (Turdorza Pressair) • • Tiotropium (Spiriva Tiotropium (Spiriva • Oral - Albuterol • Oral - Albuterol Handihaler/Respimat) Handihaler/Respimat) • • Umeclidinium (Incruse Ellipta) Umeclidinium (Incruse Ellipta) • • Nebulized solution - Ipratropium Nebulized solution - Ipratropium 2
Respiratory Medications NOT in Combination Beta 2 agonists Muscarinic antagonists Corticosteroids Short acting Long acting Short acting Long acting Beclomethasone Formoterol Albuterol Aclidinium (Qvar) (Foradil Aerolizer) HFA (Turdorza (Ventolin HFA, Indacaterol Pressair) Budesonide Proair HFA, (Arcapta (Pulmicort Flexhaler) Proventil HFA) Neohaler) Tiotropium Olodaterol (Spiriva Ipratropium Handheld Ciclesonide Handihaler, (Striverdi Inhaler HFA (Alvesco) Respimat) Spiriva (MDI or DPI) (Atrovent HFA) Respimat) Levalbuterol Fluticasone HFA Salmeterol (Flovent HFA, Flovent (Xopenex (Serevent Diskus) Diskus) Umeclidinium HFA) (Incruse Ellipta) Mometasone (Asmanex Twisthaler) Albuterol Arformoterol Nebulized Budesonide (AccuNeb) (Brovana) Ipratropium Solution (Pulmicort Respules) Formoterol Levalbuterol (Xopenex) (Perforomist) Oral Prednisone Albuterol Respiratory Medications in Combination Beta 2 Agonist + Muscarinic Antagonists • Short Acting – PRN or Routine Use – Handheld Inhaler – Albuterol/Ipratropium (Combivent Respimat) – Nebulized solution – Albuterol/Ipratropium (DuoNeb) • Long acting – Routine Use Only – Vilanterol/Umeclidinium (Anoro Ellipta) – Olodaterol/Tiotropium (Stiolto Respimat) All All long-acting long-acting Corticosteroid + Beta 2 Agonist inhalers are inhalers are • Long acting – Routine Use Only handheld handheld – Budesonide/formoterol (Symbicort) inhalers inhalers – Fluticasone/salmeterol (Advair HFA, Advair Diskus) – Fluticasone/vilanterol (Breo Ellipta) – Mometasone/formoterol (Dulera) Respiratory Medications in Combination Muscarinic Corticosteroids Beta 2 Agonist Antagonists Short-Acting – PRN or Routine Use Albuterol / Ipratropium Handheld Inhaler (MDI) (Combivent Respimat) Nebulized Albuterol / Ipratropium Solution (Duoneb) Long-Acting – Routine Use Only Vilanterol / Umeclidinium (Anoro Ellipta) Olodaterol / Tiotropium (Stiolto Respimat) Budesonide / Formoterol Handheld (Symbicort) Device (MDI or DPI) Fluticasone / Salmeterol (Advair HFA, Advair Diskus) Fluticasone / Vilanterol (Breo Ellipta) Mometasone / Formoterol (Dulera) 3
Approach to a Patient’s Inhaled Medications 1) Separate the PRN orders from Routine orders a) For PRN therapy , the patient should only be on a regimen that contains one beta 2 agonist and/or one muscarinic antagonist. Corticosteroids and long acting beta 2 agonists and Corticosteroids and long acting beta 2 agonists and muscarinic antagonists should NOT be used on a PRN muscarinic antagonists should NOT be used on a PRN basis. basis. b) For Routine therapy , the patient does not have to have something from all 3 categories, but if they are on something, they should only have one of that type of medication on board. 2) See if there are any duplicate therapies 3) Discontinue any duplicate therapies 4) Are there any medications you can consolidate? Patient Case #1 • Terminal Diagnosis – COPD • Medication List – Proair HFA (albuterol) – 2 puffs q4-6 hours PRN – Combivent Respimat (albuterol/ipratropium) – 1 puff q4 hours PRN – Spiriva Handihaler (tiotropium) – 1 cap inhaled once daily – Xopenex (levalbuterol) – 3mL vial via neb four times a day – Advair (fluticasone/salmeterol) – 1 inhalation BID – Duoneb (albuterol/ipratropium) – 3mL vial via neb four times a day – Prednisone 10mg PO daily – Duoneb (albuterol/ipratropium) – 3mL vial via neb q4-6 hours PRN Patient Case #1 – Step 1 Separate PRN orders from Routine orders Separate PRN orders from Routine orders • Proair HFA (albuterol) – 2 puffs q4-6 hours PRN • Combivent Respimat (albuterol/ipratropium) – 1 puff q4 hours PRN • Spiriva Handihaler (tiotropium) – 1 cap inhaled once daily • Xopenex (levalbuterol) – 3mL vial via neb four times a day • Advair (fluticasone/salmeterol) – 1 inhalation BID • Duoneb (albuterol/ipratropium) – 3mL vial via neb four times a day • Prednisone 10mg PO daily • Duoneb (albuterol/ipratropium) – 3mL vial via neb q4-6 hours PRN 4
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