Asthma & COPD Treatment / Pharmacology (Inhaler Progression)

welcome to another MedCram lecture
we’re going to talk about inhalers so what’s the quick and dirty on inhalers
well here we’ve got a bronchus which is the airway that you breathe through and
in the middle of that is smooth muscle which limits the aperture or the lumen
of that bronchus if the smooth muscle contracts the lumen
gets smaller and so there’s two major receptors that we see on the smooth
muscle we have a orange receptor here which we’re going to call the muscarinic
receptor so that’s going to be an M and there’s another receptor in this case
we’ll call it the blue receptor which is the beta receptor so those are the two
major receptors now the thing that you should know is that muscarinic receptors
are actually going to cause smooth muscle contraction and so what we want
to do in this situation is we want to make sure that we are inhibiting that so
we want to make sure that there’s a big X that we have inhibitors of that
muscarinic receptor on the beta side however we want to make sure that that
gets excited or activated because the beta receptor actually relaxes that
smooth muscle and so that’s going to cause relaxation so once you know about
these two receptors and you know that you want to block the muscarinic and
excite the beta to cause bronchodilation then you’re there now the only other one
that you should know is the inhaled corticosteroid which will say here is a
I see s and that basically goes everywhere there is no real receptor but
what it does is it reduces inflammation okay so the three types of drugs that
you can use for bronchi are muscarinic antagonists beta agonists and inhaled
corticosteroids so why is that important well you’ll be able to identify these
different types of drugs based on what they end with so muscarinic always end
in I um so what are examples tiotropium if Petro priam Umatilla d neum these are
all muscarinic antagonists they all end in I um
now there is another one that you should know that has been added to that
category called glycol pie relate so you can also put late-1800s now on the
beta-agonist side all of these and in O L so you’ll know for Mathura salmeterol
albuterol all those things end in O L now how do you know whether it’s an
inhaled corticosteroid you’ll know that because it ends in O and E or own like
fluticasone mometasone etc so once you know those three then you’ll be able to
put those together so we have the muscarinic antagonists we have the beta
agonists and we have the inhaled corticosteroids so how are we going to
use these in terms of the actual clinical outcomes let’s take a look at
that okay so let’s go ahead and put those
medications into the right place in terms of this there are two types of
beta agonists there’s something called a short-acting beta agonist which I will
call a Saba okay so what does this represent this
represents like proair this looks like ventolin albuterol basically okay
now the other one that we’re going to do are the long-acting beta agonists so
that’s laba L a B a then we’re going to go
ahead and look at the long-acting muscarinic antagonists okay and then
finally we’re going to go ahead and look at the inhaled corticosteroids so for
those who don’t remember remember this that these are the ones that end in O
and E these are the ones that end in O L and these are the ones that end in I um
remember glycol pie relate is also an category so it’s I um all and own so why
do I put this into this three chambered box here with the Saba this is how we’re
going to look at the treatment of C o P D and asthma okay so as you can see if
we take a look at asthma first asthma is gonna go in this direction whereas COPD
is gonna go in this direction so the first thing that we would do in asthma
is we would add an inhaled corticosteroid and then we would ask the
question is the patient using a short-acting beta X if the answer is
somewhere between one and two times per week then we’re fine with where we are
at one medication however if the patient is using the short-acting beta-2 agonist
as a rescue inhaler three or more times per week in asthma then the inhaled
corticosteroid is not enough then what we need to do is add a long-acting beta
agonist at that point we ask the question again is the patient using a
short-acting beta-2 agonist or albuterol three or more times per week if the
answer is yes that means the patient is not well controlled and we will add not
just an inhaled corticosteroid and a long-acting beta agonist but we’ll at
that point add a long-acting muscarinic antagonist at any point if we ask this
question is the patient using a short-acting beta agonist and the answer
is no zero times per week that means the patient is so well controlled they don’t
have to use the rescue inhaler that means we can drop the long-acting
muscarinic antagonists if we’re on that or if we’re just on the inhaled
corticosteroid and the long-acting beta agonist then we can drop the long-acting
beta agonists and just keep on the inhaled corticosteroid so what we’re
seeing here is a ramping up or a ramping down depending on the answer to the
question how often is this short-acting BAE
the agonist being used notice that for asthma you will never use a long-acting
beta agonist without using an inhaled corticosteroid first okay now let’s go
to the other side COPD if you have COPD the first medication that I would add is
a long-acting muscarinic antagonist so tiotropium or you Mackall edenia or
glycol pie relate and then I would ask the question is the patient using the
short-acting beta agonist if the answer is yes three times or more per week then
I would add the long-acting beta agonists notice that the last thing I’m
going to use in a patient with COPD is an inhaled corticosteroid so this is
very important you’ll see that a long-acting muscarinic Intag and this is
one of the first things that we’ll use in a patient with COPD but we’re always
asking the question and you should see here very clearly that everybody who has
a lung disease either asthma or COPD here is gonna get a short-acting beta
agonist as a rescue inhaler like they carry it with them wherever they go
okay now as you can see at some point you’re going to be having combination of
medications the drug companies are not stupid they’ll know that usually one
medications not enough and so what you’ll see for COPD is you’ll see these
lamma lamma combinations and you see that all the time so if you pick up an
inhaler and it’s a combination of a medication you can simply look on there
and see if they have a combination of I um medication and an OLE medication for
instance one medication has Volant all and you met LaDainian that would be a
llama lab a combination because you know this chart you’ll know that that
medication is a medication that’s going to be used for COPD let me give you
another one let’s go from the asthma side you know that on the asthma side
people will be combining inhaled corticosteroids and long-acting beta
agonists so if you see something like fluticasone and salmeterol that
combination goes together and that’s forms advair for instance and that would
be a inhaled in a lab a combination now you can get
l’abbé by itself you can by cell meter all or for morale by itself but that is
becoming more and more rare because as you can see based on how I have things
set up that if you’re on a lab ah you’re either going to be coupling it with an
inhaled corticosteroid when you’re treating asthma or you’re gonna be
coupling it with a long-acting muscarinic antagonist if you’re treating
COPD now as you can probably imagine it’s not going to be long before and
they have already started working on this all three of these medications in
one so you can now look up basically any inhaler look at the contents of the
inhaler in terms of the medications and you should be able to very quickly tell
first of all what type of a medication it is and what it should be used for and
now with your patients you’ll be able to see whether or not you need to escalate
therapy or de-escalate therapy the one thing that I will say is in the case of
asthma if I am going down I go to an inhaled corticosteroid and that doesn’t
work I will add a long-acting beta agonist
but there are exceptions to this for instance if I have a patient who has
atrial fibrillation and I’m worried that I’m gonna speed up their heart rate very
quickly instead of adding a long-acting beta agonist which could speed up their
heart I may decide to increase the dose of the inhaled corticosteroid from a low
potency to a medium or even to a high potency medication alternatively I could
also add a leukotriene receptor antagonist and I didn’t put that in here
but I’ll just put it up here in the corner leukotrienes
receptor antagonist and that’s the type for okay so these are other things that
you can think about but this is the general modality that you’ll see in the
treatment between asthma and COPD thanks for joining us