Question I was one of the first dry power devices available in the US Flovent, Serevent and Advair are all available in this device

Transcription

1 What Device am I Class Side Effects History Potpourri Monitoring Tools WHAT KIND OF DEVICE AM I? I was one of the first dry power devices available in the US Flovent, Serevent and Advair are all available in this device 1

2 What is Diskus DISKUS Diskus DPI: Multidose (60 doses) Delivers about 90% of labeled dose at wide range of flow rates Desirable for pts who have fluctuating flow rates with variation of ds. Counter Advantage: if you forget to put lever back you meet resistance Use: click, click, breath in strong, steady and as deeply as possible, close to reset This devices is available in Breo, Incruse and Anora 2

3 What is Ellipta 3

4 FLUTICASONE FUROATE (ARNUITY ELLIPTA) Indication: > 12 years Dosing: 1 inhalation daily 100mcg BID vs. 200mcg QD no change in FEV1 Half life: 24 hours following oral inhalation FLUTICASONE FUROATE AND VILANTEROL(BREO ELLIPTA) Indication: Adults with COPD or Asthma Dosing: 1 inhalation daily 110/25 200/25 Indication: COPD Dosing: 1 inhalation daily 62.5 mcg MOA: inhibits acetylcholine at M3 receptor in bronchial smooth muscle 4

5 Combivent was the first of this device It is also known softmist inhaler What is respimat TIOTROPIUM (SPIRIVA ) RESPIMAT Approval based on result of 12 studies (n=5000) Non inferior to LABAs & superior to placebo in the maintenance tx of asthma when added to ICS Showed decreased asthma exacerbations when added to ICS alone or in combo with LABAs No difference in asthma symptom free days between the 2 groups Tiotropium + ICS showed improvement in morning PEF but not evening PEF or FEV1 compared to LABA + ICS LABA + ICS had decrease use of rescue inhalers vs. tiotropuim + ICS Limitations: some studies used 5 mcg per day where was approved for 2.5 mcg/day, variability in baseline asthma therapies 5

6 SPIRIVA 6 YEARS AND OLDER Phase II and Phase III UniTinA asthma clinical development program 6,000 patients from more than 150 sites worldwide 804 children (6 11 years) Concomitant tx with ICS or ICS + 1 or more controller medication Dose: 1.25mcg 2 puffs once daily TIOTROPIUM (SPIRIVA ) RESPIMAT Long acting inhaled anticholinergic Approved for asthma for ages >6 years 1.25mcg/actuation 2 puffs once daily Peak effect in 3 hours, duration 24 hours OLODATEROL (STRIVERDI RESPIMAT) Long acting Beta2 Agonist Approved COPD 2.5 mcg/actuation 2 inhalations once daily 6

7 TIOTRIPIUM/OLODATEROL (STIOLOTO RESPIMAT) LAMA/LABA Combo Approved COPD 2.5/2.5 mcg actuation 2 inhalations once daily SOFT MIST INHALERS Respimat (Spiriva, Combivent, Striverdi, STIOLTO) RESPIMAT 7

8 The First Dry powder rescue inhaler (Proair) came in this device ArmonAir is also available in this device What is RespiClick CL ICK ArmonAir RespiClick ARMONAIR RESPICLICK Fluticasone Propionate 55mcg, 113mcg, & 232mcg Approved for 12 years and older Not interchangable with Flovent HFA or Diskus Dose: 1 inhalation two times daily Most Common ADRs: nasopharyngitis, headache, cough, oral candidiasis, & URI 8

9 This medication is now available in a new device called the redihaler, which is a breath activated aerosol What is Qvar (beclamethasone) CLASS SIDE EFFECTS 9

10 You should always rinse gargle and spit when using this class of medications to avoid thrush and dysphonia What are Inhaled Corticosteroids Generic Brand Dose/Actuation Notes Fluticasone propionate Flovent HFA - 44, 110, 220 mcg Diskus - 100, 250, 500 mcg HFA, Diskus DPI Approved >4 Fluticasone furoate Arnuity 100mcg 200mcg Ellipta DPI Approved >12 Beclomethasone dipropionate QVAR 40 mcg 80 mcg redihaler Flunisolide Aerospan 80 mcg HFA MDI w/ build in spacer approved >6 Budesonide Pulmicort Flexhaler - 90, 180 mcg Neb. Sol , 05 mg Mometasone furoate Azmanex Twisthaler - 110, 220 mcg HFA 100, 200 mcg Ciclesonide Alvesco 80 mcg 160mcg Flexhaler - DPI Only available product for nebulizer Once daily dosing Twisthaler DPI - >4 HFA - >12 MDI Approved >12 10

11 This class of medication is known for the side effects CAN T SEE, CAN T PEE, CAN T SPIT, CAN T HAVE A BOWEL MOVEMENT What are anticholinergics 11

12 This class of medication must be given under medical supervision due to the risk of anaphylaxis What are monoclonal antibodies OMALIZUMAB (XOLAIR ) EPR-3: recommended for step 5 and 6 care in patients who have allergies and who are inadequately controlled by highdose ICS & LABA Recombinant Anti-IgE monoclonal antibody MOA: binds free IgE and IgE mast cells which leads to decrease in the release of mediators in response to allergen exposure Approved in ages >6 y.o. with allergic asthma and IgE level of IU/ml Subcutaneous injection q 2-4 wks depending on baseline IgE levels and pts wt Anaphylaxis has occurred: administered under medical supervision 12

13 MEPOLIZUMAB (NUCALA ) GINA recommends as add on for those not controlled with step 4 therapy Anti interleukin 5, monoclonal antibody MOA: still not fully understood Inhibits IL 5 signaling, reducing production and survival of eosinophils Approved Nov as add on therapy for maintenance tx of severe asthma in patients >12 y.o. who have eosinophilic phenotype 100 mg q 4 weeks: Subq in upper arm, thigh, or abdomen Hypersensitivity reactions may occur Herpes zoster outbreaks have been reported; consider herpes zoster vaccine prior to initiation N Engl J Med Sep 25;371(13): doi: /NEJMoa Epub 2014 Sep 8. RESLIZUMAB (CINQAIR ) GINA recommends as add on for those not controlled in step 4 therapy Anti interleukin 5, monoclonal antibody MOA: Same as mepolizumab Approved for add on, maintenance therapy of severe asthma in patients who are >18 y.o. who have eosinophilic phenotype 3 mg/kg IV infusion over minutes under supervision Anaphylaxis 0.3% The infamous SMART trial gave this class of medications a black box warning of increased risk of asthma related deaths 13

14 What are Long Acting Bronchodialators LONG ACTING BETA 2 AGONISTS: THERAPEUTIC ISSUES: SMART (Serevent Multi center Asthma Research Trial) Compared to placebo: Serevent MAY be associated with increased risk of respiratory related deaths/resp. related life threatening experiences (More prominent in African Americans) (Steroids under utilized in SMART trial) Salmeterol should not be instituted in patients with severely worsening or acutely deteriorating asthma. And should not be used as monotherapy ADDITIONAL BLACK BOX WARNING LABAs approved for asthma, salmeterol (Serevent) and formoterol (Foradil), will be changed to require that the drugs always be used in combination with an asthma controller medication such as an inhaled corticosteroid, according to the FDA. Other new items to be required on the products' labels include: LABAs should only be used long term in patients with asthma not adequately controlled with inhaled steroids or other controller medications. The agents should be used for the shortest time possible to achieve symptom control. Once patients are no longer experiencing symptoms, LABAs should be discontinued if possible with patients maintained on controller medications alone. Children and adolescents needing a LABA should use a combination product that also contains an inhaled steroid to ensure compliance with both medications. 14

15 LABA Indications: adjunctive therapy for moderate severe persistent asthma and EIB: min before exercise; no repeat for 12 hours Products: Indacterol (Arcapta Neohaler) 5 min onset Formoterol (Foradil ) DPI (Perforomist Neb) 5 minute onset Salmeterol (Serevent ) 30 minute onset Arformoterol (Brovana ) Indicated for COPD only 10 minute onset Neb 15 30mcg BID Olodaterol (Striverdi Respimat) 5 minute onset ADRs: headache, palpitations, tremor, nausea and vomiting Postmarketing reports of neuropsychiatric events have been reported in this class of medications What are Leukotriene Receptor Antagonists 15

16 HISTORY One of the most prominent ancient forms of drug delivery dating back to at least 1100 BC was smoking this through pipes and incense What is Opium 16

17 First invented in 1852, this was the first of this type of inhaler What is DPI or dry powder inhaler This propellant was replaced by HFAs 17

18 CFCs This medication was first marketed in Europe in 1972 and the US in 1982 but has never gone generic and has a current new device of a breath activated aerosol What is Beclamethasone (Qvar) 18

19 This product dating back to at least 600 BC and became a preferred therapeutic option for patients with lung ailments in the 21 st century contained stramonium and sometimes herbs such as tea leaves, kola nuts lobelia and belladona leaves What are Asthma Cigarettes POTPOURRI 19

20 This Fun Camp for Kids with Asthma will be held July 8 13 th 2018 What is Camp Huff N Puff 20

21 CAMP HUFF N PUFF This is the #1 INTERVENTION that all health care professionals can provide and is suggested by the guidelines to prevent asthma related deaths What is Education 21

22 THE INTERVENTION OF AN INHALER Artist: Bryan Matthew Boutwell Instead of coming out with the generic we all waited for, this device contains fluticasone and shas just slightly different dosages than the approved cousins which also come in a discus and HFA What is AirDuo RespiClick 22

23 AIRDUO RESPICLICK Fluticasone Propionate/Salmeterol 55/14mcg, 113/14mcg, & 232/14mcg Approved for 12 years and older Not interchangable with Advair HFA or Diskus Dose: 1 inhalation two times daily Most Common ADRs: nasopharyngitis, headache, cough, oral candidiasis, & back pain (incidence 3%) Before stepping up therapy, the guidelines recommend you always do this first What is check inhaler technique 23

24 ALWAYS CHECK INHALER TECHNIQUE FIRST This medication is the first LABA/LAMA/ICS combo What is Trelegy Ellipta 24

25 TRELEGY ELLIPTA Fluticasone/Umelidinium/Vilanterol( 100/62.5/25 mcg) One inhalation once daily Approved COPD MONITORING AND INHALATION DELIVERY TOOLS This helps enhance aerosol delivery and decreases need of coordination when using metered dose inhalers (MDIs) 25

26 What is Valved Holding Chamber or Spacer This tool is often used in combination with an asthma action plan to help patient determine zones What is peak flow meter 26

27 This device helps educate patient on the optimum inspiratory flow rate of different devices What is The In Check Dial OPTIMUM INSPIRATORY FLOW Delivery to lungs is dependent on inspiratory airflow and medication device resistance Inspiratory flow requirements may vary between devices 27

28 INSPIRATORY FLOW RANGES Device Inspiratory Flow Ranges Diskus L/min Flexhaler60-90 L/min Autohaler L/min HFA MDI L/min Aerolizer L/min Twisthaler L/min Handihaler L/min Optimal Rates: MDI 30 L/min DPI 60 L/min Require Additional Adaptors This Hand Held electric monitor quickly allows you to measure a patients degree of obstruction and PEF and may be used by the patient at home What is FEV1 monitor 28

29 MONITORING FEV1 FEV1 = Forced Expiratory Volume in 1 second (L) Normal = % predicted Reduced FEV1 indicates airflow obstruction Low FEV1 is associated with increased risk of severe exacerbation Not as sensitive as for assessing asthma control FEV1/FVC, but more sensitive than PEF TARGET INHALATION TIME BASED ON FEV1 Optimal Inspiratory Flow Rates: DPI = 60L/min = 1L/1 second MDI = 30L/min = 1L/2 seconds Target Inhalation Time DPI = FEV1 x 1 second MDI = FEV1 x 2 seconds What is our volunteer s target inhalation time for an MDI? For a DPI? This tools measures humidity 29

30 Hygrometer 30