Asthma: Oral Steroids: (for severely uncontrolled
asthma)
bronchial hyper-responsiveness and
underlying inflammation
chronic inflammatory disorder of the
airways
Having patients demonstrate correct
technique is often a good idea
Wheezing, breathlessness, chest
tightness, coughing; often at night or
early in the morning
Common Triggers: Allergens, Drugs
(NSAIDs, ASA, non-selective BBs),
Cold air or humid hot air, smoke,
chemicals, Respiratory Infections.
Inhaled steroids are the preferred
controller (sometimes with LABA).
Inhaled rapid-acting beta agonist
preferred reliever for acute
bronchospasm and prevention of EIB
(Exercise-Induced Bronchospasm).
SABA: (For Rescue PRN)
albuterol (ProAir, Proventil,
Ventolin)
levalbuterol (Xopenex)
If using SABA > 2 days/week then
increase maintenance therapy
LABA: (***BBW to only used with steroids,
not monotherapy b/c increased risk of
death)
Once asthma is controlled, assess for
stepdown therapy (removal of LABA)
without loss of asthma control.
salmeterol + fluticasone (Advair Diskus
or HFA)
fomoterol + budesonide (Symbicort)
Inhaled Corticosteroids: (1st line therapy)
beclamethasone (QVAR): ** preferred in
pregnancy
budesonide (Pulmicort)
fluticasone (Flovent)
mometasone (Asmanex)
SE: Oral Candidiasis (Thrush),
dysphonia, cough. **Prevent thrush
with spacer or rinsing mouth with warm
water and spit after use
Cortisone, hydrocortisone (Solu-
Cortef), methylprednisolone (Medrol,
Medrol Dosepak, Solu-Medrol),
Prednisone, Prednisolone (Millipred,
Orapred, Prelone), triamcinolone
(Kenalog), dexamethasone (Decadron),
betamethasone
If on it more than 10-14 days,
requires a taper
Long-Term SE: Cushing Syndrome,
Immunosuppression, Acne,
Insomnia/Nervousness, Hypokalemia,
Amenorrhea, Osteoporosis, Weight Gain,
Diabetes, GI Bleed etc..
Methylprednisolone 4mg =
Prednisone/Prednisolone 5mg =
0.75mg Dexamethasone
Leukotriene Receptor Antagonist:
montelukast (Singulair):
10mg QD, 1-5 yrs. old (4mg),
5-14yrs. old (5mg)
can cause headache and
neuropsychiatric behavior
For EIB, only works in 50% of
patients, take 2 hours before
exercise
has phenyalanine in it for a
sweetener so dont use in PKU
Theophylline:
not the most effective and has many
drug interactions/side effects
Therapeutic range: 5-15 mcg/ml
SE: nausea, loose stools
Aminophylline to Theophylline
multiple by 0.8
Theophylline to Aminophylline
divide by 0.8
Omalizumab (Xolair):
For severe, allergic asthma. Inhibits
IgE binding on mast cells and
basophils
Should always be given in the
doctors office
can cause Anaphylaxis
[36] ASTHMA
Oral Steroid Dose Equivalents
Betamethasone0.6 mg
1. Chronic inflammation of the lungs in which the airways are reversibly narrowed
Dexamethasone0.75 mg
2. S/S: wheezing, breathlessness, chest tightness, coughing Methylpred/Triamcinolone 4 mg
3. Common triggers: Prednisone/Prednisolone5 mg
Hydrocortisone20 mg
a. Allergens - airborne pollens, host dust mites, animal
Cortisone25 mg
dander, cockroaches, fungal spores
b. Drugs ASA, NSAIDs, sulfites, BB
c. Environmental cold air, fog, ozone, sulfur dioxide,
nitrogen dioxide, tobacco, wood smoke
d. Exercise cold air or humid, hot air
e. Occupational bakers (flour dust), farmers (hay mold),
spice, enzyme workers; painters, chemical workers,
plastics rubber, wood workers
f. Resp infxn RSV, rhinovirus, influenza, parainfluenza,
mycoplasma pneumonia

Exercise Induced Bronchospasms (EIB)

1. Pretreat before exercise with short acting B2 agonist, LTA, mast cell stablizers
2. SABA DOC ; taken right before exercise, lasts 2-3 hrs
3. LABA longer duration, take 15 mins before (formoterol), 30 mins before (salmeterol)
LABAs should not be used as monotherapy in pts with asthma
4. Montelukast take 2 hrs before, lasts up to 24 hrs; but only works in 50% of pts
5. Cromolyn (Intal) give 10-15 mins before; not as effective as SABAs

Pregnancy
1. Albuterol is the preferred SABA
2. Budesonide is the preferred ICS

Drugs used for asthma exacerbations Asthma maintenance therapy

SABA1. Inhaled steroids
IV steroids2. LT antagonists
Anticholinergics3. Theophylline
LABA
Cromolyn
Omalizumab (Xolair)

BETA 2 AGONISTS
Epinephrine (Primatene Agents should not be S/E: tremor, shakiness, lightheadedness,
Mist) Metaproterenol used due to non-beta cough, palpitations, HYPOK,
(Alupent) 2 selective Hyperglycemia, tachycardia
Albuterol (Ventolin 1-2 inhalations Q4-6
HFA, Proventil HFA, (MDI) Shake well before use. Prime prior to use
ProAir HFA, and again if
AccuNeb) >2 wks breathe in deeply & slowly
Levalbuterol (Xopenex, 1-2 inhalations Q4-6 HFA inhalers have softer, less forceful
Xopenex HFA) (MDI) sprays (CFC inhalers have been d/c due
R isomer of albuterol to environmental concerns)
Pirbuterol (Maxair
Autohaler) If using SABA >2days/wk, need to inc
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LABA
Salmeterol (Serevent 1 inh BID, except HFA BBW: asthma related deaths. Do not
Diskus) Salmeterol + is 2 inh BID use LABA as monotherapy
fluticasone (Advair
Diskus)
Formoterol (Foradil) Foradil-1 cap via aerolizer
Formoterol + BID
budesonide ; do not swallow
(Symbicort) capsule. Symbicort
MAST CELL STABLIZERS prevents mast cell release of histamine &
LT by inhibiting degranulation after contact with allergens/antigens
Cromolyn sodium (Intal) S/E: unpleasant taste, cough, nausea
OTC cromolyn nasal spray- for nasal allergies
(NasalCrom)

CORTICOSTEROIDS
Beclomethasone HFA (QVAR HFA) solution,
do not shake
Budesonide (Pulmicort Flexhaler,
Pulmicort Respules) Budesonide +
formoterol (Symbicort HFA) 2 inh BID
Ciclesonide (Alvesco) do not have to shake before
use
Flunisolide HFA (Aerospan HFA)
Fluticasone (Flovent HFA, Flovent
Diskus) Fluticasone + salmeterol
(Advair Diskus, Advair HFA) Advair
Diskus 1 inh BID Advair HFA 2 inh
Mometasone (Asmanex Twisthaler)
Mometasone + formoterol (Dulera) 2 inh BID
Triamcinolone (Azmacort)
S/E: dysphonia, oral candidiasis, cough,
horseness, URI, hyperglycemia, inc risk of fx
and pneumonia (with high dose long term)
st
ICS are 1 line for long term control of all ages
with asthma Systemic steroids have rapid onset
of action and are used as pulse therapy for
up to 15 days after asthma attack
Advair diskus breathe in quickly
& deeply Pulmicort Respules for
ages 1 to 8
Advair Diskus for ages > 4
Advair HFA, Symbicort HFA, Dulera for ages > 12

LEUKOTRIENE MODIFYING AGENTS - edema, constriction &

inflammation
Zalfirlukast 20 mg BID (empty Caution: neuropsychiatric events have
(Accolate) LTE4 stomach) For > 5 yo been rpt
antagonist
Montelukast 10 mg QD in evening
(Singulair) 6mths-5 yrs = 4 mg, 5-14 S/E: HA, dizziness, abd pain, LFTs, URI,
LTD4 + E4
Zileuton antagonist
(Zyflo CR) yo=5mg
1200 mg BID pharyngitis, sinusitis, churg strauss
5-LOX inhibitor that Not recom for children syndrome (rare)
inh LT formation The granules can be mixed with 1 teaspoonful (5
mL) of baby formula / breast

THEOPHYLLINE blocks PDE causing cAMP which releases Epi.

Theophylline (IR-
Elixophyllin, ER- TheoCap,
Theo 24, Theochron)
Therapeutic range = 5-15 S/E: nausea, HA, tachy,
mcg/mL insomnia, tremor,
nervousness
Signs of tox: persistent
vomiting, vent tachy, seizures Avoid excessive amts of caffeine
 Page 4 of
102
st
Has 1 order kinetics followed by theophylline levels: (3A4 Theophylline will Lithium
MM inhibitors)

Drugs that theophylline theophylline levels : 3A4

levels (1A2 inhibition) OC, inducers, levothyroxinem
zafirlukast, acyclovir, charbroiled foods
Omalizumab (Xolair) used in moderate to severe asthma (step 5-6 of guideline)
for pts with allergies
1. Drug should always be given in the Dr. office. (BBW: anaphylaxis)
2. S/E: HA, inj site rxns, URI, sinusitis
Chapter 36: Asthma [36]
Chronic inflammatory disorder of the airways involving many cells - mast cells,
eosinophils, neutrophils, T lymphocytes, macrophages, and epithelial cells
Classic Symptoms = wheezing, breathlessness, chest tightness, and coughing
Common Triggers
Allergens
Drugs - ASA, NSAIDs, sulfites, BBs
Environmental - cold air, fog, ozone sulfur dioxide, nitrogen dioxide, tobacco
smoke, wood smoke
Exercise - cold air or hot humid air
Occupational - bakers, farmers, spice/enzyme workers, paint, chemicals,
plastics, rubber, wood
Respiratory Infections
Special Populations
EIB - pretreat w/ SABA (DOC) or LABA or montelukast.
SABA to be taken right before exercise, lasts 2-3 hours
IF longer duration is needed, take LABA 15-30 mins before
Montelukast must be taken 2 hrs before exercise, lasts up to 24hrs - but
only works in 50%
Pregnancy - Albuterol is preferred SABA, budesonide is preferred ICS
Monitor closely as it can get worse - proper treatment is very important to
ensure good O2

Drug Therapy
SABAs - Pirbuterol (Maxair), Levalbuterol (Xoponex), Albuterol (VoSpire ER,
AccuNeb)
Shake first, then prime if first time or >2weeks
B2 selective
HFA inhalers clog easier, and have a softer warmer spray
If using SABA > 2 days/week, then must increase
maintenance therapy
LABAs - salmeterol and formoterol
BBW - increased risk of asthma related deaths, do
not use as monotherapy in persistent asthma
(should be on long term control therapy)
Mast Cell Stabilizers - inhibit degranulation to prevent release of histamine
and leukotrienes
CS - inhibit inflammatory response and depress migration of PMN leukocytes
and fibroblasts
Inhaled
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102

Beclomethasone HFA (Qvar), Budesonide (Pulmicort), Ciclesonide

(Alvesco), Fluticasone (Flovent), Mometasone (Asmanex)
SE - increased risk of fractures and pneumonia with long term HD
therapy, oral thrush, hyperglycemia, URTIs
Pulmicort Respules - indicated for 1-8yo
Advair Diskus - 50 mcg salmeterol + 100/250/500 mcg fluticasone - for ages 4+
The rest are for ages > 12
Oral
Cortisone, HC (Cortef oral or Solu-CORTEF inj),
Methylprednisolone (Medrol, Solu- Medrol, etc),
Prednisone (Rayos ER tabs), Prednisolone
(Orapred, Pediapred, Veripred, Prelone, Flo-
Pred), Triamcinolone (Kenalog, Trivaris,
Aristospan - all inj)
Cortisone is a prodrug for cortisol, prednisone is a prodrug for prednisolone.
For acute exacerbations and very severe dz (Step 6).
CI - live vaccines, systemic fungal infections, varicella
SE -
Short Term (<1month) - increased appetite/wt gain, fluid retention,
emotional instability, insomnia, GI upset. With high doses may
have increased BP and BG.`
Long Term - HPA suppression, cushings, growth retardation,
osteoporosis/fractures, pancreatitis, psych disturbances, Na/H20
retention/HTN, hypokalemia, hyperG/DM, impaired wound healing,
dermal thinning/bruising, inhibition of monocyte/leuko funct,
glaucoma, cataracts, moon facies, central redistribution of fat,
increased wt/appetite, hirsutism, acne, hyperpigmentation,
insomnia, nervousness, amenorrhea, peptic ulcers, abd distention,
N/v, muscle wasting
0rj2039i49023i4293i4932i420934i90i2340923i4903i40923i94
Leukotriene Modifiers - help to decrease airway edema, constriction and
inflammation
Zafirlukast (Accolate) - antagonist at LTD4 and LTE4
Children 5-11 yo take 10 mg BID, for 12 and up take 20 mg BID on empty stomach\
Zafirlukast may be lowered w/ eryth, theo, and food - take 1hr before or
2 hours after meals
May increase levels of warfarin
Montelukast - antagonist at LTD4 only
Children 1-5yo take 4 mg QD, 5-14yo take 5 mg QD, 14+ take 10 mg
QD
Take in the evening
Oral Granules - must be given within 15 mins of opening, do not mix with any
liquids other than breast milk of baby formula - or use cold/room temp food
Substrate of 3A4 and 2C9
Can be taken for EIB - take at least 2 hours before exercise (DNE 1
dose/24h)
Zileuton (Zyflo and Zyflo CR) - 5-lipooxygenase inhibitor which inhibits LT
formation
NOT recommended for children
Zyflo 600 mg QID or Zyflo CR 1200 mg BID - take within 1hr or
 Page 6 of
102

morn/evening meals
Requires monitoring of LFTs every month x3months, then every 2-
3months for 1st year
SE - HA, dizziness, abd pain, increased LFTs, URTIs, pharyngitis,
sinusitis, Churg-Strauss Syndrome (rare)

Caution - neuropsych events have been reported

Do not abruptly d/c for inhaled/oral CS
Theophylline - blocks PDE, increasing cAMP, which promotes release of
EPI = bronchodilation, diuresis, and CNS+Cardiac stimulation
Therapeutic Range - 5-15mcg/mL (peak)
Signs of Toxicity - persistent and repetitive vomiting, vTach, seizures
If using IV aminophylline, divide theo dose by 0.8 (aminophylline contains
80% theophylline)
Avoid excessive caffeine, dietary protein (esp charbroiled meat), and CHO
Has first order, then michaelis menton (saturable) pharmacokinetics (like phenytoin
and voriconazole) - small increase in dose can cause large increase in conc
DDIs - substrate of 1A2 and 3A4
Drugs that increase Theo by 1A2 inhibition -
OCPs, zafirlukast, zileuton, acyclovir,
cimetidine, cipro, ethinyl estradiol, fluvox,
isoniazid
Drugs that Increase Theo by 3A4 inhibition - amiodarone, azoles,
clarithro, cyclosporine, erythro, dilt, verap, lova, somva, atorva, PIs, etc
Dugs that increase Theo by other means - allopurinol, erythro, propranolol,
ephedrine, MTX. Also conditions - CHF, cirrhosis, hypothyroid (dec
clearance)
Drugs that Decrease Theo Levels - CBZ, phenobarb, phenytoin, primidone,
rifampin, ritonavir, tobacco/MJ smoke, StJW, tipranavir/ritonavir, thyroid horm,
high protein diet, low CHO diet, charbroiled foods
Theo will decrease lithium concentrations (by increasing renal excretion of Li)
and will decrease zafirlukast
Aticholinergics - for acute attacks (in ED)
Omalizumab (Xolair) - IgG monoclonal Ab inhibits IgE binding for mod-sev
persistent asthma in pts w/ + skin test to perennial aeroallergens and
inadequately controlled symptoms on ICS (step 5/6)
Dosed based on pretreatment IgE levels and body weight
Given SC Q2-4weeks - always given in MD office
BBW - anaphylaxis may occur up to 24hrs after dose
SE - possible malignancies

Pregnancy Cat B

***********************See Page 593 for Asthma Classification and Treatment
Chart***************************
Peak Flow Meters - measure the greatest velocity attained during a forced
expiration from fully inflated lungs. Use spirometry as well as height, age, and
gender to determine personal best.
Help to identify exacerbations sooner - using an asthma action plan
Proper technique and best effort are essential -
stand up straight, take full breath in, and blow as
hard and fast as possible. Do this 3 times total and
record the highest.
Use it every morn when you wake up, before taking any asthma meds
 Page 7 of
102

Clean at least 1x/week, do not use brushes or boiling water

Zones
Green Zone = 80-100% of personal best
Yellow Zone = 50-80% of personal best - use action plan to increase meds
Red Zone = <50% of personal best - ALERT - seek
medical attn (ER)
Spacers reduce thrush with ICS and reduce cough with some inhalers, clean at
least 1x/week
Albuterol MDI - prime if first time or if it hasnt been used in >14 days (spray 3
times)
Shake well before each spray
Hold breath as long as possible after using (up to 10s)
If multiple sprays are needed, wait 1min in between
Advair Diskus - never breathe out into the mouthpiece, most pts can taste or
feel the powder but not always. Never wash any part of the diskus (including
the mouthpiece)
Flovent HFA - prime again if not used for >7days
Clean at least 1x/week, do not take canister out to clean it - just clean
mouthpiece with water
Store with the mouthpiece down