The main medications used to treat chronic asthma are easiest to remember using the following mnemonic. I like lazy Saturdays. I stands for inhaled corticosteroids because I comes first to help you remember that they are the first line of treatment in asthma. Like is for leukotriene modifiers. Lazy is for long-acting beta-2 agonists because these are used even on a lazy day.
Saturdays is for short-acting beta-2 agonists. because on Saturday, college football players may need a short-activated two agonists. Let's dive into each of these further.
Inhale corticosteroids are kind of a big deal in the world of asthma, as they are considered the key controller medications that work by reducing inflammation specifically in the lungs. They do this by binding onto glucocorticoid receptors, which go on to inhibit the transcription of inflammatory genes such as cytokines as well as activation, which can cause inflammation. of eosinophils and the release of inflammatory mediators. Cytokines are like your messenger proteins that alert other immune system cells to the site of inflammation. Eosinophils are a type of white blood cell that can cause inflammation and swelling.
The inflammatory mediators, like leukotrienes, histamine, or prostaglandins, directly lead to the symptoms of inflammation. By inhibiting them, this reduces the hyperinflammatory cascade that leads to bronchial hyperreactivity, swelling, and mucus production. This makes it easier to breathe and prevents future asthma attacks. Inhale corticosteroids are the preferred medication for controlling asthma over the long term since hyperinflammation is the main cause of asthma. Examples include budesonide, beclomethazone, glutacazone, mometazone, and cloclosanide.
Steroids, often in the suffix onard or asone, some are too... prednisone or cortisone. Luckily, inhaled corticosteroids work locally and have relatively few side effects compared to oral corticosteroids. The common side effects of inhaled corticosteroids can be remembered using the mnemonic HOCUS.
H stands for hoarseness, O stands for oral thrush or candidiasis, so be sure to counsel your patients to rinse their mouth and throat with warm water and spit to prevent this from occurring. C is for cough, U is for upper respiratory tract infections, which is rare and often occurs with high doses or long-term use. And finally, S is for sore throat. Beta-2 agonists are bronchodilators that work to relax the smooth muscle bands that tighten around the airways that are divided into two forms, short-acting and long-acting beta-2 agonists.
These forms differ by their duration of action, with short-acting beta-2 agonists Working rapidly within five minutes to reverse bronchoconstriction and relieve or stop asthma symptoms Which makes them a great rescue inhaler Long-acting beta-2 agonist helps keeps the airways open for 12 hours or longer and are used on a daily basis to prevent asthma attacks Beta-2 agonist work by binding onto beta-2 receptors located on the smooth muscles of airways in the lungs Beta-2 receptors are commonly located on the lungs, while beta-1 receptors are commonly located on cardiac muscles. You can remember this by remembering that we have two lungs for beta-2 receptors and one heart for beta-1 receptors. Activation of beta-2 receptors causes an increase in cyclic AMP, which leads to a decrease in calcium release, since calcium plays a big role in contraction.
a decrease in calcium leads to a decrease in contraction of airway smooth muscles, which leads to bronchodilation. Beta-2 agonists can cause some unwanted side effects with the heart at high doses, such as increased heart rate, palpitations, increased blood pressure, and anxiety. You can remember this as the beta symbol often looks like a heart turned sideways.
Other side effects include tremors, hyperglycemia, hypokalemia, and cough. It is important to monitor how often patients are using their rescue inhaler, as frequent use can indicate that their asthma is not under control. Other things to monitor include blood pressure, heart rate, blood glucose, and potassium. Also, since this class of medications work quickly, they are often used prior to exercise or in exercise-induced asthma.
They can be taken 5 to 15 minutes before exercise and last 2 to 3 hours. Remember back to how the college football player may need this on his sidelines on a Saturday game? Next, we have long acting beta 2 agonists, which work exactly like short acting beta 2 agonists. except that it lasts longer with a duration of action of 12 hours and are used with a twice daily dosing regimen. Examples include salmeterol and formoterol.
You can remember this because they contain words similar to metro in their names. Metro trains run long distances, so these are long-acting beta-2 agonists. Because they have no anti-inflammatory action, these medications should not be used alone in asthma due to increased risk of asthma related deaths.
That is why they are often found in combination with an inhaled corticosteroid like Simbacort which contains Budesonide and Formotarol or Advair which includes Salmeterol and Fluticasone. Side effects are similar to short-acting beta-2 agonists. Remember, long-acting beta-2 agonists with inhaled corticosteroids are considered control borer medications and should be taken daily even on a lazy day to prevent asthma exacerbations.
Now that we've talked about the specific counseling points about the different types of inhaled medications, let's take a minute and review how to counsel a patient on using their meter dose inhaler using the mnemonic SPORT. S stands for shake well before each use. P stands for prime before first use by shaking well for 5 seconds and then spraying into the air 3 times. This should be repeated if the inhaler has not been used for more than 7 days.
O stands for out. Take a deep breath out. R is for rest. Rest the inhaler in the mouth and close your lips around it.
T is for take. Take a deep breath as you press all the way down on the inhaler to release the medication. And finally, T is for 10 seconds.
Hold your breath for as long as you can, up to 10 seconds. It's important to use spacers for children as it can help them ensure proper delivery of the medication. There are several different types of inhalers that deliver medications in slightly different ways, such as dry powder inhalers, respimats, acu-inhalers, and elliptas, and more. Always double-check the package inserts when educating patients on how to use their new inhaler. The next drug commonly used in asthma are leukotriene modifiers.
They are a great add-on therapy in patients with allergies since they block the action of leukotrienes. If you can recall, leukotrienes are a type of pro-inflammatory chemical that causes bronchial smooth muscle contraction, as well as recruit other pro-inflammatory mediators, such as histamine and prostaglandin, into tissues. By inhibiting leukotrienes, we can see a reduction in airway swelling, smooth muscle contraction, inflammation, and nasal congestion, often associated with allergies. Examples include montelukaz, xyferlukaz, and xylutin, which all have the suffix"-luk-"in the name.
reminding you that it is a leukotriene modifier. Clinical Pearl. This class of medications is dosed on age, not weight.
Some other side effects include headache, dizziness, abdominal pain, increased LFTs, upper respiratory tract infections, sinusitis, and pharyngitis. Behavior and mood changes are rare side effects that include aggressive behavior, agitation, hostility, depression, and or suicidal thoughts. It's an important counseling points for patients.
Though the side effects may seem like a lot, this class of medications is relatively well tolerated. Other medications that are often not used include theophylline, inhaled anticholinergics, and amaluzumab. Theophylline is an oral bronchodilator medication that you may see in the treatment of asthma. Its use has declined greatly due to the greater efficacy of inhaled corticosteroids and beta-2 agonists, as well as the numerous drug interactions and side effects associated with it, some of which include nausea, headache, tachycardia, insomnia, tremor, nervousness, arrhythmias, confusion, and seizures.
In addition, it has a narrow therapeutic index of 10 to 20 micrograms per milliliter and requires frequent lab draws to monitor drug levels. Its mechanism is not fully known, but is believed to block phosphodiesterase, resulting in bronchodilation and mild anti-inflammatory effects. Short-acting inhaled anticholinergics such as ipitropium can commonly be used with beta-2 agonists and acute asthma exacerbations. They inhibit acetylcholine from binding onto muscarinic receptors on airway smooth muscle cells, leading to bronchodilation.
They have few side effects due to the fact that they are inhaled locally and are poorly absorbed into circulation. The main side effects include dry mouth, which is common with teatropium. Long-acting inhaled anticholinergics such as teatropium provide modest improvements in asthma exacerbations and are reserved in patients with uncontrolled asthma despite being on an inhaled corticosteroid plus along acting beta-2 agonists amaluzumab is a subcutaneous injection made of igg monoclonal antibodies that inhibit ige binding onto mast cells if you can recall ige is one of the main culprits that lead to asthma symptoms Imaluzumab is indicated in patients with moderate to severe persistent allergic asthma despite being on max doses of inhaled corticosteroids and long-acting beta-2 agonists. It has a box warning for anaphylaxis and requires that it be administered in a healthcare setting where patients can be monitored. Other side effects include injection site reactions, muscle pain, dizziness, fatigue, and dermatitis.
To wrap it up, when initiating medications in a newly diagnosed asthma patient, Make sure to assess their symptoms and start them on a rescue inhaler, such as a short-acting beta-2 agonist, as needed. If their symptoms worsen, they can escalate or step up therapy using higher doses of their controller medications. Lastly, if a patient has allergies and is not responding to other therapies, they can benefit from an add-on medication, such as a leukotriene modifier. Thanks