Inhalers (Asthma Treatment & COPD Treatment) Explained!

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 ICS 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 -ium so what
are examples tiotropium ipratropium Umeclidinium these are all
muscarinic antagonists they all end in -ium
now there is another one that you should know that has been added to that
category called glycopyrrolate so you can also put -late, so if you see an -ium or a -late its a muscarinic antagonist, now on the beta agonist side all of these end in -ol so you’ll know formoterol
salmeterol albuterol all those things end in -ol now how do you know whether
it’s an inhaled corticosteroid you’ll know that because it ends in -one like fluticasone or 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, LABA
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 these are
the ones that end in -one these are the ones that end in -ol and these are
the ones that end in -ium remember glycopyrrolate is also in that
category so it’s -ium -ol and -one 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 COPD 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 agonist 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 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- 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 in the lung I think beta
agonist then we can drop the long-acting beta agonist 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 the short-acting
beta-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 Umeclidinium or glycopyrrolate 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 and tagging 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
lama lama 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 -ium medication and an -ol medication for
instance one medication has vilanterol Umeclidinium and that would be
a lama laba 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 corticosteroid and a laba combination now you can get
laba by itself you can buy salmeterol or formoterol 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 laba 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 gonna 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
4 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