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598 SECTION 5 Problems of Oxygenation: Ventilation TABLE 29-7 DRUG THERAPY Asthma and Chronic Obstructive Pulmonary Disease DRUG ROUTE OF ADMINISTRATION SIDE EFFECTS (SE) COMMENTS* Antiinflammatory Agents Corticosteroids hydrocortisone (Solu-Cortef) methylprednisolone (Medrol, Solu-Medrol) prednisone IV Oral, IV Oral With long-term use: cushingoid appearance, skin changes (acne, striae, bruising), osteoporosis, increased appetite, obesity, peptic ulcer, hypertension, hypokalemia, cataracts, menstrual irregularities, muscle weakness, immunosuppression, catabolism. With short-term use (e.g., <2 wk): sleep disturbances, increased appetite. Alternate-day therapy minimizes SE. Oral dose should be taken in morning with food or milk. When given in high doses, observe for epigastric distress. Long-term corticosteroid therapy requires supplementation with vitamin D and calcium to prevent osteoporosis. Discontinue gradually over time to prevent adrenal insufficiency. If during tapering symptoms recur, health care provider should be notified. fluticasone (Flovent HFA, Flovent Diskus) MDI, DPI Oral candidiasis (thrush), hoarseness, irritated throat, headache, sinus infection, upper respiratory infection. Not recommended for acute asthma attack. Rinse mouth with water or mouthwash after use to prevent oral fungal infections. Use of spacer device with MDI may decrease incidence of oral candidiasis. With inhaled corticosteroids, may not see effects until after at least 2 wk of regular treatment. beclomethasone (Qvar) MDI Oral candidiasis, hoarseness, irritated throat, dry mouth, cough, few systemic effects except for headache. Same as fluticasone except less oral candidiasis because of very small particle size which is deposited deeper in the airways. budesonide (Pulmicort Turbuhaler) DPI Same as above. mometasone (Asmanex Twisthaler) DPI Same as above. ciclesonide (Alvesco) MDI Headache, nasopharyngitis. Oral candidiasis and other localized oropharyngeal effects (e.g., hoarseness). Fewer SE than other ICSs because of small particle size with minimal activation in oropharynx. Anticholinergics Short-Acting ipratropium (Atrovent HFA) Nebulizer, MDI Drying of oral mucosa, cough, flushing of skin, bad taste. Alternating schedules of β-adrenergic agonists and atropine administration may be helpful in some patients. Temporary blurred vision if sprayed in eyes. Use cautiously in patients with narrow-angle glaucoma or prostatic enlargement. Ongoing review to determine if this class of anticholinergics places patients at risk for cardiovascular events, including strokes. Long-Acting tiotropium (Spiriva HandiHaler) DPI Dry mouth, upper respiratory infection. Blurred vision if powder comes in contact with eyes. Must discontinue use of ipratropium while on tiotropium. Patient must use short-acting β-adrenergic agonists for quick-relief medication. See above related to class risk. Anti-IgE omalizumab (Xolair) Subcutaneous injection Injection site reaction (e.g., bruising, redness, warmth, pain). Only for moderate to severe persistent allergic asthma with symptoms not adequately controlled by ICS. Not for acute bronchospasm. Administer only under direct medical supervision and observe patient for a minimum of 2 hr following administration as anaphylaxis has been reported with use. BP, Blood pressure; CNS, central nervous system; DPI, dry powder inhaler; GI, gastrointestinal; HFA, hydrofluoroalkane (propellant); ICSs, inhaled corticosteroids; IV, intravenous; MDI, metered-dose inhaler. *For patient instructions in English and Spanish for the devices, see www.chestnet.org/patients/guides/inhaledDevices.php. †FDA is continuing to review clinical trial data to assess mood and behavioral adverse events related to drugs that act through the leukotriene pathway, and further updated information can be found at www.fda.gov/medwatch.

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  • 598 SECTION 5 Problems of Oxygenation: Ventilation

    TABLE 29-7 DRUG THERAPYAsthma and Chronic Obstructive Pulmonary Disease

    DRUGROUTE OF ADMINISTRATION SIDE EFFECTS (SE) COMMENTS*

    Antiinflammatory AgentsCorticosteroidshydrocortisone (Solu-Cortef)methylprednisolone

    (Medrol, Solu-Medrol)prednisone

    IVOral, IV

    Oral

    With long-term use: cushingoid appearance, skin changes (acne, striae, bruising), osteoporosis, increased appetite, obesity, peptic ulcer, hypertension, hypokalemia, cataracts, menstrual irregularities, muscle weakness, immunosuppression, catabolism.

    With short-term use (e.g.,

  • 599CHAPTER 29 Obstructive Pulmonary Diseases

    DRUGROUTE OF ADMINISTRATION SIDE EFFECTS (SE) COMMENTS*

    Leukotriene ModifiersLeukotriene Receptor Blocker Not for acute asthma attacks.zafirlukast (Accolate) Oral tablets Headache, dizziness; nausea, vomiting,

    diarrhea, fatigue, abdominal pain.Take at least 1 hr before or 2 hr after meals.

    Affects metabolism of erythromycin and theoph-ylline. Not to be used to treat acute asthma episodes.

    montelukast (Singulair) Oral tablets, chewable tablets, oral granules

    Well tolerated. Not to be used to treat acute asthma episodes.

    Leukotriene Inhibitorzileuton (Zyflo CR) Oral tablets Liver enzymes; dyspepsia, pain,

    headache.Monitor liver enzymes. May interfere with

    metabolism of warfarin (Coumadin) and theophylline. Not to be used to treat acute asthma episodes.

    2-Adrenergic AgonistsInhaled: Short-Acting (SABA)albuterol (Proventil HFA,

    Ventolin HFA, ProAir HFA, AccuNeb, VoSpire ER [oral only])

    Nebulizer, MDI, oral tablets including extended release

    Note: Oral tablets not for acute use, only long acting

    Tachycardia, BP changes, nervousness, palpitations, muscle tremors, nausea, vomiting, vertigo, insomnia, dry mouth, headache, hypokalemia.

    Use with caution in patients with cardiac disorders as -agonists may cause BP and heart rate, CNS stimulation/excitation, and risk of dysrhythmias. Has rapid onset of action (1-3 min). Duration of action is 4-8 hr.

    levalbuterol (Xopenex, Xopenex HFA)

    Nebulizer, MDI Tachycardia, nervousness, tremor (less than albuterol).

    Too frequent use can result in loss of effectiveness.

    pirbuterol (Maxair Autohaler) MDI Same as albuterol but cardiac effects are less.

    Inhaled: Long-Acting (LABA) In asthma: Should never be used as monotherapy. Should be used in combination with inhaled steroids.

    In COPD: Can be used as monotherapy. Not used for rapid relief of dyspnea.

    salmeterol (Serevent) DPI Headache, throat dryness, tremor, dizziness, pharyngitis.

    Not to exceed two puffs q12hr. Not to be used for acute exacerbations. Has a counter.

    formoterol (Foradil Aerolizer, Perforomist)

    DPI, nebulizerPerforomist is for

    nebulizer

    Angina, tachycardia, nervousness, headache, tremor, dizziness.

    Can affect blood glucose levels. Should be used with caution in patients with diabetes.

    arformoterol (Brovana) Nebulizer See formoterol. See formoterol. For chronic COPD use.

    MethylxanthinesIV agent: aminophylline

    (second-line therapy)Oral: theophylline

    Oral tablets, IV, elixir, sustained-release tablets

    Tachycardia, BP changes, dysrhythmias, anorexia, nausea, vomiting, nervousness, irritability, headache, muscle twitching, flushing, epigastric pain, diarrhea, insomnia, palpitations.

    Wide variety of response to drug metabolism exists. Half-life is by smoking and by heart failure and liver disease. Cimetidine, cipro-floxacin, erythromycin, and other drugs may rapidly theophylline levels. Taking drug with food or antacids may help GI effects. Patient must be encouraged to take drugs even when feeling well.

    Combination Agents Also see each component of medications for SE.ipratropium and albuterol

    (Combivent, DuoNeb)MDI, Nebulizer Chest pain, pharyngitis, diarrhea, nausea. Patients must be careful not to overuse. Must take

    as prescribed.fluticasone/salmeterol

    (Advair Diskus or HFA)DPI, MDI Headache, pharyngitis, oral candidiasis. See salmeterol and fluticasone. Has a counter.

    Comes in three different strengths.budesonide/formoterol

    (Symbicort)MDI Dysrhythmias, hypertension, paradoxic

    bronchospasm.See budesonide and formoterol. Has a counter.

    mometsone furoate/formoterol fumarate (Dulera)

    MDI Nasopharyngitis, sinusitis, headache

    TABLE 29-7 DRUG THERAPYcontdAsthma and Chronic Obstructive Pulmonary Disease


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