Asthma Medications For Treatment and Prevention of Attacks | Steven Ma, PharmD | RxEconsult
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Review of Asthma Medications For Treatment and Prevention of Attacks Category: Chronic obstructive pulmonary disease (COPD) and Asthma by - June 17, 2014 | Views: 26489 | Likes: 0 | Comment: 0  

Asthma medications for attack treatment and prevention

What is asthma?

Asthma is a chronic inflammatory disease that affects the airways of the lungs. The airways of the lungs can become inflamed and narrowed which prevents normal breathing. A patient can present with symptoms of shortness of breath, chest tightness, and coughing. There is no cure for asthma. Asthma medications relieve symptoms by opening airways and preventing asthma attacks.

How is asthma classified?

Asthma can be categorized into different levels of severity. A patient is categorized into different levels based on their severity of asthma symptoms and lung function. Lung function is usually measured by a test called forced expiratory volume in 1 second (FEV1). This test measures the amount of forced air a person can blow out in one second. Improvements in FEV1 can be a sign of improved lung function. Drug treatments are based on the patient's severity and step in therapy. The different categories of severity are intermittent, mild, moderate, and severe asthma. Some drug classes that are used in the treatment of asthma include short-acting beta agonist (SABA), inhaled corticosteroids (ICS), long-acting beta agonist (LABA), and leukotrienes inhibitors.

Asthma Medications for Treatment and Prevention of Symptoms

Short-acting Beta agonists (SABA) are used as rescue medications for asthma. They have a very quick onset and immediately open the airways and relieve symptoms during an acute attack. Short-acting beta agonist stimulate beta-2 receptors (a receptor in the lungs that regulates dilation or restriction of the airways) allowing the airways to open up. Some side effects of this medication class include throat irritation, headache, cough, upper respiratory infections, viral respiratory infections, pharyngitis, nausea, and vomiting. Some drug interactions with albuterol include beta blockers, diuretics, and monoamine oxidase (MAO) inhibitors. Beta blockers can restrict the airways of the lungs which works directly opposite to beta agonist, diuretics used with albuterol can potentially lead to increased risk of hypokalemia (low potassium), and MAO inhibitors combined with albuterol may potentiate risk of cardiovascular effects.

Ventolin HFA (albuterol)

The usual dosing for Ventolin is 1 to 2 inhalations every 4 to 6 hours. One advantage Ventolin HFA may have over the other inhalers is that there is a dose counter on the inhaler. The dose counter will allow the patient to know if there is still medicine in the inhaler. In clinical trials, the average onset time for a 15% increase in FEV1 with Ventolin was 5.4 minutes and the average peak time was 56 minutes. Placebo had an average change in FEV1 of about 0-4%.

Proventil HFA (albuterol)

The usual dosing for Proventil is 1 to 2 inhalations every 4 to 6 hours. In clinical trials, the average onset time for a 15% increase in FEV1 with Proventil was 6 minutes and the average peak time was 50 to 55 minutes.

Proair HFA (albuterol)

The usual dosing for Proair is 1 to 2 inhalations every 4 to 6 hours. In clinical trials, the average onset time for a 15% increase in FEV1 with Proair was 8.2 minutes and the average peak time was 47 minutes. Placebo had an average change in FEV1 of about -2 to 2%.

Xopenex HFA (levalbuterol)

The usual dosing for Xopenex is 1 to 2 inhalations every 4 to 6 hours. In clinical trials, the average onset time for a 15% increase in FEV1 with Xopenex was 5.5 to 10.2 minutes and the average peak time was 76 to 78 minutes. Placebo had an average change in FEV1 of about 3-14%.

Inhaled Corticosteroids (ICS) are a second step in therapy if short-acting beta agonists are not sufficient to control asthma attacks. Corticosteroids have anti-inflammatory effects and are used to decrease inflammation in the lungs. They do not work immediately to relieve asthma symptoms. It takes about 1 to 2 weeks to see the effects of corticosteroids. Low dose corticosteroids are used in mild asthma, medium doses are used in moderate or severe asthma, and high doses are used in severe asthma. Some side effects include headache, upper respiratory infection, rhinitis allergic, pharyngitis, throat irritation, cough, oral candidiasis, nasal congestion, and back pain.

Qvar 40 mcg, 80 mcg (beclomethasone)

The usual starting dose is Qvar 40 or 80 mcg 1 to 2 inhalations twice daily. Highest recommended dose is 320 mcg twice daily. In clinical trials, patients had significant improvements in pulmonary function with Qvar treatment compared to placebo. Qvar 40 mcg twice daily produced an AM PEF average change of 28 L/min, Qvar 80 mcg twice daily produced an AM PEF average change of 30 L/min, and placebo produced an AM PEF average change of 4 L/min. Drug interactions with beclomethasone include glycerol phenybutyrate and testosterone. Interaction with glycerol phenybutyrate can increase risk of high ammonia levels in the body and interaction with testosterone can increase risk of edema (swelling).

Pulmicort 90 mcg, 180 mcg (budesonide)

The usual starting dose is Pulmicort 90 or 180 mcg 1 to 2 inhalations twice daily. Maximum dose should not exceed 720 mcg twice daily. In clinical trials, patients treated with Pulmicort 180 mcg 2 inhalation twice daily had an average increase in FEV of 0.28 liters as compared to 0.10 liters for placebo. Drugs that are strong cytochrome P450 (enzymes in the liver) inhibitors or inducers should not be combined with budesonide. Inhibitors may increase the effects of budesonide while inducers can decrease its effects. Some drugs that are cytochrome P450 inhibitors include ritonavir, cimetidine, ketoconazole, fluconazole, and omeprazole. Some drugs that are cytochrome P450 inducers include carbamazepine, rifampin, and phenytoin.

Asmanex Twisthaler 110 mcg, 220 mcg (mometasone)

The usual starting dose of Asmanex 110 mcg or 220 mcg is 1 to 2 inhalations once daily in the evening. Maximum daily dose is 880 mcg. In clinical trials, patients treated with Asmanex 440 mcg had a 14% FEV1 increase while placebo had a 2.5% FEV1 increase. In another study, Asmanex 440 mcg demonstrated a 16% FEV1 increase while placebo had a 5.5% FEV1 increase. Drugs that are strong cytochrome P450 (enzymes in the liver) inhibitors or inducers should be combined with mometasone. Inhibitors may increase the effects of mometasone while inducers can decrease its effects.

Flovent 44 mcg, 110 mcg, 220 mcg (fluticasone)

The usual starting dose for Flovent 44, 110, 220 mcg is 1 to 2 inhalations twice daily. Maximum dose is 880 mcg twice daily. In clinical trials, patients treated with Flovent 88 mcg, 220 mcg, and 440 mcg showed a range of 9 to 11.2% increase in FEV1 compared to 3.4% increase for placebo. Drugs that are strong cytochrome P450 inhibitors or inducers should be avoided when taking fluticasone. Inhibitors may increase the effects of fluticasone while inducers can decrease its effects

Alvesco 80 mcg, 160 mcg (ciclesonide)

The usual starting dose for 80 or 160 mcg is 1 to 2 inhalations twice daily. The highest recommended dose is 320 mcg twice daily. In comparison to placebo, average increases in FEV1 were 0.12 liters or 5% for Alvesco 160 mcg once daily, 0.24 liters or 10.4% for Alvesco 80 mcg twice daily, and 0.13 liters or 5% for Alvesco 80 mcg twice daily followed by Alvesco 160 mcg once daily. Drug interactions with ciclesonide include glycerol phenybutyrate and testosterone. Interaction with glycerol phenybutyrate can increase ammonia levels in the body and interaction with testosterone can cause increased risk of edema (swelling).

Long-acting Beta agonists (LABA) should never be used alone for the treatment of asthma. They are used in combination with an inhaled corticosteroid. Some studies show that using long-acting beta agonist by themselves can increase the risk of severe asthma symptoms. Long-acting beta agonists work in the same way as short-acting beta agonist, but has an extended duration of action. This class of drug is used to control and prevent asthma attacks minimizing the use for short-acting beta agonist. Some side effects include upper respiratory tract infection, pharyngitis, oral candidiasis, bronchitis, cough, headaches, nausea and vomiting. Some drug interactions of this class include beta blockers, diuretics, and monoamine oxidase (MAO) inhibitors. Beta blockers can restrict airways in the lungs which reduces the effect of beta agonist, diuretic use can increase risk of hypokalemia (low potassium), and MAO inhibitors may increase risk of cardiovascular effects. In addition, drugs that are strong cytochrome P450 (enzymes in the liver) inhibitors or inducers should be avoided since inhibitors may increase the effects of corticosteroids while inducers can decrease its effects.

Advair Diskus 100 mcg/50 mcg, 250 mcg/50 mcg, 500 mcg/50 mcg (fluticasone/salmeterol)

The usual dose of Advair Diskus is two inhalation twice daily. The strength used depends on the severity of the asthma. In one clinical trial, the average increase in FEV1 was 0.51 liters or 25% for Advair Diskus 100 mcg/50 mcg and 0.01 liters or 1% for placebo. In another clinical trial, Advair Diskus 250 mcg/50 mcg had an average increase in FEV1 of 0.48 liters or 23% while placebo had a decrease in FEV1 of 0.11 liters or 5%.

Symbicort 80 mcg/4.5mcg, 160 mcg/4.5mcg (budesonide/ formoterol)

The usual dose of Symbicort is two inhalation twice daily. The strength used depends on asthma severity. In clinical trials, the average increase in PEF was 9.3% for Symbicort 160 mcg/4.5 mcg while placebo had a decrease in PEF of about 5%.

Dulera 100 mcg/5mcg, 200 mcg/5mcg (mometasone/formoterol)

The usual dose of Dulera is two inhalations twice daily. The strength used depends on asthma severity. In clinical trials, the average increase in FEV1 was 0.13 liters or 5.28% for Dulera 100 mcg/5mcg, the average increase in FEV1 was 0.19 liters or 8.5% for Dulera 200 mcg/5mcg, and the average decrease in FEV1 was 0.05 liters or 2.2% for placebo.

Leukotriene inhibitors can be used as alternative asthma medications to inhaled corticosteroids. Leukotriene is produced and released by the body's immune system during inflammation. In asthma, the overproduction of leukotrienes can lead to inflammation of the airways. Leukotrienes inhibitors can prevent the production or activity of leukotrienes. Some side effects include upper respiratory infection, fever, headache, pharyngitis, cough, abdominal pain, diarrhea, sinusitis, nausea and vomiting.

Singulair 10 mg (montelukast)

The usual dose of Singulair is 10 mg orally once daily in the evening. In clinical trials, Singular 10 mg produced an average increase in FEV1 of 0.32 liters or 13% compared to an increase in FEV1 of 0.10 liters or 4.2% for placebo. Some drug that  interaction with montelukast include gemfibrozil, rifampin, and phenytoin. Gemfibrozil can increase the concentration of montelukast in the blood while rifampin and phenytoin can decrease the concentration of montelukast in the blood.

Accolate 10 mg, 20 mg (zafirlukast)

The usual dose of Accolate is 20 mg orally twice daily taken 1 hour before or 2 hours after meals. In clinical trials, Accolate 20 mg taken twice daily demonstrated an increase in FEV1 of 0.15 liters while placebo demonstrated an increase in FEV1 of 0.05 liters. Drugs that can decrease the effect of zafirlukast include theophylline and erythromycin. Zafirlukast increases the risk of bleeding from warfarin. Zafirlukast use with aspirin may increase the risk of side effects.

Zyflo CR 600 mg (zileuton)

The usual dose of Zyflo is 1200 mg (2 tablets) orally twice daily after morning and evening meals. In clinical trials, two Zyflo 600 mg tablets given   twice daily (2400 mg) produced an increase in FEV1 of 0.39 liters while placebo produced an increase in FEV1 of 0.27 liters. Zyflo may increase theophylline toxicity and combining it with pimozide can cause cardiotoxicity (QT prolongation, torsades de pointes, cardiac arrest). Zileuton can increase the effects of beta blockers and increase the risk of bleeding from warfarin.

Anti-IgE Modulator

Xolair (omalizumab) is an anti-IgE antibody that binds to and blocks immunoglobulin E receptors which contributes to allergic responses. The recommended dosing is Xolair 150 mg to 375 mg injection every 2 to 4 weeks. By blocking this receptor, the drug is able to reduce the inflammatory response in asthma. In a clinical trial studying the efficacy of Xolair, 546 asthmatic patients on a steroid treatment were randomly given Xolair or placebo every 2 to 4 weeks. At the end of 16 weeks with the same dose of steroids 14.6% of patients on Xolair had worsening of asthmatic symptoms compared to 23.3% of patients on placebo. At the end of a second 16-week therapy with a decreased dose of steroids 21.3% of patients on Xolair plus a low dose inhaled steroid had worsening asthma symptoms compared to 32.3% of patients on placebo plus a low dose inhaled steroid. Side effects include joint pain, fatigue, leg or arm pain, dizziness, fracture, ear ache, and inflammation of the skin. There are currently no known drug interactions with omalizumab.

Other Medications for Treatment and Prevention of Asthma Attacks

These asthma medications are used as alternatives to the therapies mentioned above. They can be added on to common asthma treatments and can potentially help improve lung function or reduce asthma attacks.

Cromolyn is a mast cell stabilizer. Mast cell when activated release histamine and other mediators in response to allergies.

Theophylline is a phosphodiesterase inhibitor which blocks cAMP & cGMP (chemicals that relax smooth muscles) from degrading. Through this mechanism, theophylline is able to relax smooth muscles and open up the airways in the lungs.

References

National Heart, Lung, and Blood Institute: Guidelines for the Diagnosis and Management of Asthma (EPR-3)

Dipiro, Joseph T. "Chapter 33 Asthma." Pharmacotherapy. a Pathophysiologic Approach. New York: McGraw-Hill Education, 2012. Print.

Prescribing information for each medication.



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