Bronchial
Asthma
& Inhalation Therapy
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Bronchial
Asthma
One of the
commonest chronic diseases
Inhalation Therapy :
A Major Landmark
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Bronchial Asthma
Chronic disorder
with intermittent episodes of bronchospasm
- Dyspnoea
- Wheeze
- Cough
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Aetiology
* Heredity
* Allergy
* Drugs
* Psychological
* Infections
* Cold
* Exercise
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Types of Bronchial
Asthma
* Extrinsic
Asthma
* Intrinsic Asthma
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Important
Lung Function Tests
- FEV1
- PEFR
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Clinical
Features
- Dyspnoea
- Cough
- Wheezing
Status
Asthmaticus
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Principles
of Management of Asthma
* Control
symptoms
* Maintain normal pulmonary function
* Avoid triggers
* Prevent / manage exacerbations
* Avoid adverse effects of drug therapy
* Patient education
* Reduce mortality
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Management
of Asthma
1. Prevention
2. Immunotherapy
3. Drug Therapy
- inhalation
- oral
- parental
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Drug Therapy
of Bronchial Asthma
- Important Agents
Beta-2
agonists
adrenaline (subcutaneous)salbutamol (oral/inhaled)
salmeterol (inhaled)
terbutaline (oral/inhaled)
Methylxanthines
theophylline (oral/IM)
aminophylline (IV)
Anticholinergics
Ipratropium (inhaled)
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Corticosteroids
hydrocortisone (IV)
prednisolone (oral)
beclomethasone (inhaled)
budesonide (inhaled)
Mast
Cell Stabilisers
Ketotifen (oral)
Sodium cromoglycate (inhaled)
Nedocromil (inhaled)
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Inhalation
Therapy
* Direct drug
delivery to respiratory tract
* Major milestone in asthma therapy
* First line of treatment today
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Types
of Inhalation Therapy
Metered
dose inhalers - MDI
* Most widely used form of inhalation therapy
* Drug delivery as aerosol
* Needs coordination between actuation and inhalation
Rotahalers
* Involve inhalation of dry powder
* For patients who cannot coordinate actuation & inhalation
* Unsuited for breathless patient
* Require good inspiratory flow rate
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Types
of Inhalation Therapy (contd.)
Nebulisers
* Normal breathing is adequate
* Expensive
* Regular maintenance required
* Risk of transmitting air-borne infections
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Advantages
of Inhalation Therapy
* Drug delivery
directly to desired site
* Greater efficacy
* Lower doses - better tolerability
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Metered
Dose Inhalers (MDIs)
Meters, aersolises and delivers drug
* Based
on principle of propellant system
* Drug-propellant mixture in a cannister
* On actuation, drug released as an aerosol
* Inhalation must be coordinated with aerosol release
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Proper
Inhalation Technique is Necessary!
* High aerosol
cloud velocity - 100 k. m.p.h.
* Aerosol likely to hit the throat
* Smaller particles can reach the lower respiratory tract, where action
is desired
* Larger particles likely to be deposited in the throat (hence wasted)
* Coordinating inhalation with actuation increases the quantity of
drug reaching the lower respiratory tract
* Patient education improves coordination
* ‘Cold Freon’ effect
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Spacer
Devices
* Plastic
container serving as reservoir into which MDI releases drug
* Spacer slows down the aerosol and allows particles to remain suspended
in the device
* Inhalation need not be coordinated with actuation
* Useful in patients who cannot coordinate inhalation with actuation
* Helps to maximise lung delivery and minimize throat deposition
* Lower doses are effective
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Commonly
Used Agents in InhalationTherapy
Relievers
(Bronchodilators)
* Beta-2 agonists
- Salbutamol*
- Salmeterol*
- Terbutalinel
*
Methylxanthines
- Aminophylline
* Anticholinergics
- Ipratropium
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Preventers
(Antiinflammatory)
*
Corticosteroids
- Beclomethasone*
- Budesonide*
*
Mast cell stabilisers
- Sodium cromoglycate
- Nedocromil sodium
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* wil be discussed
in more detail in this presentation
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Beta
Receptor Agonists
* Stimulate
beta-2 receptors in bronchi
---> bronchodilation
* Selective beta agonists avoid cardiac adverse effects
* Short acting -- Salbutamol, terbutaline;
Long acting -- Salmeterol
* May be used alone or with other drugs e.g., steroids
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Xanthines
(e. g. Theophylline, Aminophylline)
- Phosphodiesterase
inhibition
- Adenosine receptor antagonism
- Mast cell stabilisation
- Improvement of diaphragmatic contractility
- Prostaglandin inhibition
- Alteration of intracellular Ca++ concentration
- Immunomodulation
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Corticosteroids
(e. g. beclomethasone, budesonide)
Potent anti-inflammatory
effect
* Inhibit chemical mediators
* Inhibit inflammatory cells, e. g., eosinophils
* Reduce vascular permeability
* Increase sensitivity of beta receptors
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Mast
Cell Stabilisers
(e. g. ketotifen, nedocromil)
*
Prevent release of inflammatory mediators
Anticholinergics
(e. g. ipratropium)
*
Inhibit action of acetylcholine --> bronchodilation
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Inhalation
Therapy for Asthma
(Based on NHBL guideline)
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Long-term
preventive
Daily medications
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Step
1 |
Mild
Intermittent
Asthma |
None
needed |
Inhaled
short
acting beta
agonists |
Step
2 |
Mild
Persistent
Asthma |
Low
dose inhaled
steroids or
cromoglycate |
Short
acting
inhaled beta
agonist |
Step
3 |
Moderate
Persistent
Asthma |
Higher
dose of inhaled steroids
or low/medium dose of steroid
plus a long actingbeta agonist or
medium dose steroidsplus nedocromil |
Short
acting
inhaled beta
agonists |
Step
4 |
Severe
Persistent
Asthma |
Treatment
as for Step 3 plus use oral steroids |
Short-acting
inhaledbeta agonists |
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Salbutamol
First line
anti-asthmatic therapy
* Quick onset; short duration of action
* Suited for intermittent attacks and as rescue medication
Actions
* Selective beta-2 agonist
* Effective bronchodilation
* Avoids cardiac adverse effects
Pharmacokinetics
* Bronchodilation within 10 min
* Action lasts for 6 hours
* Only a small portion (10%) that goes into the lungs appears as free
drug in systemic circulation
* Excreted in urine (80%) and faeces (20%) within 24 hours
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Salbutamol
(contd.)
Indications
- Bronchial asthma
- Chronic bronchitis & emphysema
Dosage:
*
Prevention of asthma & relief of acute episodes
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1-2 inhalations |
3-4
times daily |
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Prevention of exercise induced asthma |
2
inhalations |
15
min before exercise |
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Total daily dose |
16-20
inhalations |
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Children |
1
inhalation |
3
- 4 times daily ( can be increased to 2) |
(for packs
providing 100 mg salbutomal (per dose)
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Salbutamol
(contd.)
Tolerability
* Well tolerated
* Smaller drug doses - avoids tremor and other side effects of oral
therapy
* Has been used throughout pregnancy without ill effects
* Excreted in breast milk - no ill effects on child
Contraindications
* Hypersensitivity
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Beclomethasone
Dipropionate
Potent Antiinflammatory
* First line corticosteroid therapy for asthma
* Controls hyper-reactivity and inflammation
* May be used alone / together with beta agonists
* Improvement in respiratory functions within a week
* Allows elimination / reduction of oral steroids
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Beclomethasone
(contd.)
Pharmacokinetics:
* Only a fraction of administered dose reaches lungs
* Rapid inactivation of swallowed drug in liver
Tolerability:
* Generally safe
* Occasionally throat irritation, dysphonia, sore throat, dryness
of mouth
* Candidal infection of throat/mouth may occur
Pregnancy
and Lactation:
* Inadequate evidence of safety in pregnancy
* Potential benefits to be weighed against hazards
* Low potential for significant levels in breast milk
Precautions:
* Caution in transfer from oral to inhaled corticosteroid
* Substitution of inhaled drug for oral corticosteroid can cause withdrawal
symptoms
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Beclomethasone
(contd.)
Indications:
Prophylaxis of bronchial asthma
Dosage:
Adult
& Children over 12 years.
* Starting dose, 2-4 inhalations or 4 inhalations, 3 - 4 times daily
twice daily
* Mild asthma, 200 - 600 mcg
* Moderate asthma 600 - 1000 mcg
* Severe asthma 1000 - 2000 mcg
Children
4-12 years.
1-2 inhalations 3-4 times dailyor400 mcg per day undivided doses
(for packs
providing 50 mcg, 100 mcg and 250 mcg beclomethasone per dose)
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Salmeterol
Long
acting selective Beta-2 agonist
* Bronchodilation within 10-20 minutes persisting for 12 hours
* Suitable for long term administration
* Useful in nocturnal & exercise induced asthma
* Can be used with short acting bronchodilator / steroid
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Salmeterol
(contd.)
Pharmacokinetics:
* Peak plasma concentration in 5-15 minutes
* Extensively metabolised by hydroxylation
* Eliminated within 72 hours
Tolerability:
* Well tolerated
* Adverse effects similar to salbutamol
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Salmeterol
(contd.)
Indications:
* Long term treatment of mild to severe asthma
* Nocturnal asthma and exercise induced asthma
Pharmacokinetics:
* 2 inhalations twice daily(50 - 100 mg twice daily)
(for packs
providing 25 mg salmeterol per dose)
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Budesonide
Newer corticosteroid
with specific benefits
* High ratio of topical anti-inflammatory to systemic activity
* Potential to become a first-line treatment
Pharmacokinetics:
* Extensive first-pass metabolism
Tolerability:
* Well tolerated even on long term use
* Minimum systemic adverse effects
* Local effects-hoarseness, sore throat, cough
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Budesonide
(contd.)
Indications:
* Management of adult and childhood asthma
Dosage:
* Must be individualised
* Initial recommended dose : 400 - 1600 mcg per daydivided into 2
- 4 administrations
* Maintenance dose: 200 - 400 mcg
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Salbutamol
+ Beclomethasone
Bronchodilator
+ Corticosteroid combination for Moderate to Severe asthma
* Benefits of two time-tested agents
* Patients not responding to single ingredients benefit from combination
therapy
* Compliance and convenience
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Salbutamol
+ Beclomethasone (contd.)
Indications
* Moderate to severe asthma
Warnings
and Precautions:
* Not for acute attacks but for long-term therapy
* Regular reassessment of patients advisable
Dosage:
* Adults : 2 inhalations 3 - 4 times a day
* Children : 1-2 inhalations 2-4 times daily
(for
packs providing salbutamol 100mcg and beclomethasone diproprionate
50 mcg per dose)
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Salient
Features
Salbutamol
* Salbutamol
- time tested agent
* Beta-2 stimulation - bronchodilation
* Selectively avoids cardiac adverse effects
* Quick onset, short duration
* For immediate relief form bronchospasm
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Salient
Features
Salmeterol
* Long acting
beta-2 agonist
* Convenient twice daily dosing
* Suitable for long term use, nocturnal & exercise induced asthma
* Avoids cardiac effects
* 50 mcg salmeterol similar to 200 mcg salbutmol
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Salient
Features
Beclomethasone Dipropionate
* Beclomethasone
- time tested corticosteroid
* Useful for preventing attacks
* Reduces inflammation, airway hyper-responsiveness and allergic
response
* Can be used alone or with beta-2 agonists
* Enhances response to bronchodilators
* Safer alternative to oral steroids
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Salient
Features
Budesonide
* Newer
corticosteroid
* Predominant local action
* Less systemic availability- avoids systemic adverse effects
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Salient
Features
Salbutamol + Beclomethasone
* Combination
of two time-tested agents
* For moderate to severe asthma not responding to single agents
* Convenience of fixed dose combination
* Comprehensive asthma control
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