Respiratory

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2 Drug Combination Inhalers

Advair: fluticasone (steroid) + salmeterol (LABA). AVL: MDI, diskus.


Anoro Ellipta: umeclidinium (LAMA) + vilanterol (LABA). AVL: DPI.
Breo Ellipta: fluticasone (steroid) + vilanterol (LABA). AVL: DPI.
Combivent Respimat: ipratropium (SAMA) + salbutamol (SABA). AVL: Soft mist inhaler, nebules.
Duaklir Genuair: aclidinium (LAMA) + formoterol (LABA). AVL: DPI.
Duovent: ipratropium (SAMA) + fenoterol (SABA).
Inspiolto Respimat: tiotropium (LAMA) + olodaterol (LABA). AVL: Soft mist inhaler.
Symbicort Turbuhaler: budesonide (steroid) + formoterol (LABA). AVL: DPI.
Ultibro Breezhaler : glycopyrronium (LAMA) + indacaterol (LABA). AVL: DPI (white+yellow).
Zenhale: mometasone (steroid) + formoterol (LABA).

 

Anticholinergics (Inhaled)

AE: Dry mouth, metallic taste, glaucoma if used on eye, urinary retention. Possible increased risk of cardiovascular events. CI: <18yo. OTH: Used for COPD more than asthma.
Short Acting Muscarinic Antagonists (SAMAs)

ipratropium=Atrovent: AVL: MDI, nebules. IND: COPD. Sometimes used if tachycardia from SABA. MOA: Short-acting muscarinic antagonist (SAMA). EVD: Slower onset than SABA but longer duration of action. PK: Onset=15-30 min. Duration=3-8h. DOS: MDI (20ug/puff): 2-4 puffs q6-8h. Max=12 puffs/d. Nebules: 250–500 µg TID–QID.
Long Acting Muscarinic Antagonist (LAMAs)

aclidinium=Tudorza: AVL: DPI. IND: COPD. DOS: DPI (400ug/actuation): 1 actuation BID.


glycopyrronium=Seebri Breezhaler: AVL: DPI. IND: COPD. PK: Rapid Onset LAMA. DOS: DPI (50ug/cap): 1 cap inhaled once/d.

tiotropium=Spiriva: AVL: DPI (Insert pill) and Respimat Soft Mist Inhaler (SMI). DI: Other anticholinergics. PK: Duration=24h. DOS: DPI (18ug/cap): 1 cap inhaled once/d. SMI (2.5ug/actuation): 2 actuations once/d. Max=4 puffs/d. OTH: Not for acute relief.


umeclidinium=Incruse Ellipta: AVL: DPI. IND: COPD. DOS: DPI (62.5 µg/actuation): 1 actuation once/d.


 

Antihistamines (Intranasal)

levocabastine: EVD: Effective for sneezing, itching, runny nose, inflammation. PK: Onset <15min. DOS: 1 spray in each nostril BID-QID.


 

Antihistamines (Oral)

IND: Allergic rhinitis (sneezing, itching, runny nose, itchy eyes, inflammation). MOA: Competitive antagonist for H1 receptor. Also changes 3 dimensional configuration of the receptor which decreases the affinity for histamine. EVD: Increased efficacy if taken before allergen exposure. Less effective for most allergic rhinitis symptoms vs intranasal corticosteroids. PRG: Safe. LAC: Safe. OTH: Compared to 2nd gen, 1st gen have shorter duration of action, more toxicity, less selective for H1 receptor, and is more lipophilic. 1st gen can cross BBB while 2nd can't.


FIRST GENERATION
brompheniramine: AVL:Only avail in combination products. DOS: 4mg q4-6h. Ped (6-11yo): 2mg q4-6h.


chlorpheniramine: DOS: 4mg q4-6h. Ped: 0.35mg/kg/d divided q4-6h.


cyproheptadine: AE: Stimulates appetite. DOS: Adult max=0.5mg/kg*d Ped: max=0.25mg/kg/d. OTH:


diphenhydramine=Benadryl: AVL: PO (tabs or liquid), IV, IM. IND: Allergies, naus, vom. AE: Const, sedation, confusion, dizziness, paradoxical excitement in children, dry mouth, blurred vision, urinary retention. DI: Sedatives (ex. alcohol), anticholinergic agents (scopolamine). DOS: Adult: 25-50mg q4-6h prn. Max=300mg/d. Ped: 2-5yo: max=37.5mg/d. 6-11yo: max= 150mg/d.


SECOND GENERATION
cetirizine=Reactine: AVL: PO (tabs and liquid). AE: Most likely 2nd gen to cause drowsiness (dose dependent). DOS: >5yo: 5-10mg/d. 5mg/d if renal or hepatic impairment. Ped: 6-23months: 2.5mg/d. 2-5yo: 2.5-5mg/d.


desloratadine=Aerius: AVL: PO (tabs, liquid). EVD: Has evidence for nasal congestion. PK: Active metabolite of loratadine. DOS: Adult=5mg/d. Renal or Hepatic impairment=5mg q48h. Ped: 6-11mon=1mg/d. 1-5yo=1.25mg/d. 6-11yo=2.5mg/d.


fexofenadine=Allegra: EVD: Appears non-sedating even at high doses. DOS: 60mg q12h. 60mg/d if renal impairment. Ped: 6-11yo: 30mg q12h.


loratadine=Claritin: AVL: PO (tab, ped rapid dissolve tab). DOS: Adult=10mg/d. Renal or hepatic impairment=10mg q48h. Ped: <30kg=5mg/d. >30kg=10mg/d.


COMBINATIONS

dimenhydrinate=Gravol: DOS: 50-100mg q4-6h prn. OTH: Contains diphenhydramine + mild stimulant 8-chlorotheophylline.


 

β2 Agonists (Inhaled)

Short-Acting β2-Agonists (SABAs)
IND: Asthma (first line) and COPD. MOA: Stimulates β2 receptors which inhibits bronchoconstriction. AE: tremor, nervousness, increased HR, increased insulin secretion, increased glucose, decreased K. Possible increased QT. PRG: Safe. LAC: Safe. OTH: Aka rescue inhaler.


salbutamol=Ventolin: AVL: MDI, diskus, nebules. ADM:Shake MDI before use. Hold air for 10sec. PRG: Preferred SABA in P. PK: t1/2=4.5-6h. Duration=3-6h. Takes a few minutes to work. DOS: MDI100ug/puff: 1-2 puffs TID-QID prn. Max=8 puffs/d or 800ug/d. T 2 puffs 15min pre-exercise. Diskus200ug/actuation: 1 actuation TID-QID prn. Max=4 actuations/d. Nebules: 2.5–5mg QID prn.


terbutaline=Bricanyl: AVL: DPI. IND: Also used to delay labor up to 48h. DOS: DPI0.5 mg/actuation: 1 actuation q4–6h prn. Max=6 actuations/d.


Long-Acting β2-Agonists (LABAs)
MOA: Stimulates β2 receptors which inhibits bronchoconstriction. EVD: Always use as add on to corticosteroid in asthma due to increased asthma (but not COPD) deaths. AE: increased HR, nervousness thrush, URTI, hypokalemia. DOS: Used regularly (not prn).
formoterol=Foradil=Oxeze: AVL: DPI (w/ or without caps). PK: Onset=5min. Duration=12h. DOS:1 cap (12ug) BID. Max=48ug/d. OTH: Should only be used as rescue if combined with budesonide (Symbicort).


indacatrol=Onbrez: AVL: DPI. IND: COPD but not asthma. PK: Duration=24h. DOS: (75 µg/cap): 1 cap inhaled once/d.


olodaterol=Striverdi: AVL: Soft Mist Inhlaer (SMI). IND: COPD. PK:Duration=24h.


salmeterol=Serevent AVL: Diskus. PK: t1/2= 5.5h. Onset=15min. Duration=12h. DOS: Diskus and Diskhaler (50ug/actuation): 1 actuation BID. OTH:Shouldn’t be used as rescue inhaler.


vilanterol: PK: Onset=15min. Duration=24h. OTH: Avail as combo w/ fluticasone (Breo Ellipta).


 

β2 Agonists (Oral)

orciprenaline=Alupent: AVL: PO (liquid 250mL grape flavor. IND: Asthma, bronchitis, emphysema. ADM: If using an inhaler as well, taking the liquid first can open the lungs making the inhaler more effective. AE: Fine tremor, nervousness, Headache, dizziness, tachycardia, and palpitations, Naus, Vom, sweating, weakness, rashrare. DI: epinephrine, MAOIs, TCAs (β agonist effect enhanced). PK: t1/2: Phase 1=40min. Phase 2=15h. F=40%. Onset=30min. Duration=3-6h. MW= 520.60g/mol. DOS: Syrup concentration=2mg/mL. Adult=20mg/10mL TID-QID. Ped: Age 4-12yo=10mg/5mL TID. Age >12yo=20mg/10mL TID. OTH: Store at room temp. Protect from light.


 

Corticosteroids - Inhaled (ICS)

IND: Treats inflammatory part of asthma. EVD: Some effect in 1w. Full effect in 8w. ADM: Rinse mouth w/ water and use spacer to avoid thrush. AE: thrush, sore mouth/throat, hoarseness, RTIs, cough, growth suppression (1.2cm), decreased BMD.


beclomethasone=Qvar: AVL: MDI. CI: < 5yo. DOS: Low: <250ug/d. Mod=251-500ug/d. High=>500ug/d.


budesonide=Pulmicort: AVL: Dry Powder Inhaler (DPI), nebules. CI: <6yo. PRG: Preferred ICS in Prg. DOS: Low=<400ug/d. Mod=401-800ug/d. High=>800ug/d.


ciclesonide=Alvesco: AVL: MDI. CI: <6yo. DOS: Low=<200ug/d. Mod=201-400ug/d. High=>400ug/d.


fluticasone=Flovent: AVL: Dry Powder Inhaler (DPI)diskus, MDI. CI: MDI CI <1yo. PK: Fluticasone furoate more potent and longer lasting vs propionate. DOS: Low=<250ug/d. Mod=251-500ug/d. High=>500ug/d.


mometasone=Asmanex: AVL: DPI (twisthaler). CI: <12yo. DOS: Low=<200ug/d. Mod=400-800ug/d. High=>800ug/d.


 

Corticosteroids - Intranasal (INCS)

IND: Allergic rhinitis, modest benefit for allergic conjunctivitis. EVD: Similar efficacy between products. Effective for sneezing, itching, runny nose, congestion, eye symptoms, inflammation. ADM: Point away from septum. Small sniff after spray. AE: Nose bleed/irritation, Headache. LAC: Safe. PK: Onset: 1-2d. Max benefit: 2w. DOS: Start at high dose then tapper down. Can take prn but continuous use is more effective. Adults: T at night since inflammation worse then. Children T in am. beclomethasone: PRG: Safe. DOS: >6yo=2 sprays each nostril BID.


budesonide: PRG: Safe. DOS: >6yo: Max=400ug/d.


ciclesonide: DOS: &t;12yo: 2 sprays/nostril daily. OTH: Has smaller spray volume.


flunisolide: DOS: >6yo: 1 spray/nostril TID. Adult=2 sprays/nostril BID.


fluticasone propionate: DOS: 4-11yo: 1-2 sprays/nostril daily. >12yo=2 sprays/nostril daily.


fluticasone furoate: DOS: 2-11yo: 1 spray/nostril daily. >12yo: 2 sprays/nostril daily.


mometasone furoate=Nasonex: DOS: 3-11yo=1 spray/nostril daily. >12yo=2 sprays/nostril daily. OTH: has a small spray volume.


triamcinolone=Nasacort: DOS: 4-11yo=1 spray/nostril daily. >12yo:2 sprays/nostril daily.


Decongestants (Intranasal)

EVD: Only effective for congestion. AE: Burning/stinging, sneezing, dryness, brady/tachycardia, hypo/hypertension, rebound congestion if >3d of use. PRG: Safe.


oxymetazoline: PK: Onset=5-10min. Duration=12h. DOS: >12yo=2-3 drops or sprays per nostril q12h.


phenylephrine: PK: Onset=5-10min. Duration=4h. DOS: >12yo=2-3 drops or sprays per nostril q4h.
xylometazoline: PK: Onset=5-10min. Duration=12h. DOS: >12yo=2-3 drops or 1-2 sprays per nostril q8h.


 

Decongestants (Oral)

IND : Allergic rhinitis. AE : Restlessness/excitability, dizziness, weakness, insomnia, tachycardia, palpitations, increased BP, BG deregulation. CI : HTN, <6yo. PRG : Not safe in first trimester. DI : MAOIs (hypertensive crisis).


phenylephrine: DOS : > 12yo=10mg q4h. 6-11yo=5mg q4h.


pseudoephedrine=Sudafed: LAC : Safe. DOS : > 12yo: 60mg q4-6h. Max=240mg/d. 6-11yo=30mg q4-6h. Max=120mg/d.


Leukotriene Receptor Antagonists (LTRA)

IND: Allergic rhinitis (not 1st line), asthma (especially if Samter’s triad present). Effective for inflammation. Inconsistent data for sneezing, itching, congestion. Similar efficacy to antihistamines but less effective vs intranasal corticosteroids.


montelukast=Singulair: AVL: PO. AE: Headache, abdominal pain, flu-like symptoms. May worsen GERD. CI: <1yo PRG: Safe. DI: Carbamazepine, rifampin, phenobarbital, and phenytoin will reduce montelukast levels. DOS: 10mg qHS.


zafirlukast=Accolate: AVL: PO. ADM: AE: Headache, Naus, Diar. CI: <12yo. DI: Carbamazepine, rifampin, phenobarbital, and phenytoin will reduce zafirlukast levels. DOS: 20mg at least 1h before or 2h after meal.


 

Mast Cell Stabilizers

cromolyn: AVL: Intranasal, Ophthalmic. IND: Allergic rhinitis. EVD: Effective for itchy eyes and inflammation. Conflicting evidence for sneezing, runny nose, itching, congestion. Less effective vs steroids. AE: Sneezing, nasal stinging/irritation, bad taste, nose bleed. PK: Onset=4-7d. DOS:>2yo: 1 spray in each nostril 3-6 times/d.


 

Methylxanthines

IND: Asthma, COPD. EVD: Less effective vs LABAs. AE: Naus, Vom, abdominal cramps, Headache, palpitations, stimulation. OTH: Uncommon due to toxicity and lack of efficacy


oxtryphilline: AVL: Avail as elixir only. DOS: Initial=200mg QID. Maintenance=800-1200mg/d divided TID or QID.


theophylline: AVL: PO. IND: Severe COPD (add on after triple therapy). ADM: T w/ food. DI: Smoking, clarithromycin, many others. MON: Target plasma levels=55-85µM. DOS: Initial=400-600mg/d can be divided BID or TID.


 

Monoclonal Antibody

omalizumab=Xolair: AVL: SubQ. IND: Moderate-severe allergies related to asthma. MOA: Binds IgE antibody. AE: Injection site rxn45%, viral infection24%, URTI19%, sinusitis16%, Headache15%, pharyngitis10%. Slight increased risk of cancer. COS: Expensive. DOS: 150-375ug SubQ q2-4w.


 

Phosphodiesterase 4 (PDE4) Inhibitors

roflumilast=Daxas: AVL: PO. IND: Add on therapy for severe COPD. MOA: Suppresses release of inflammatory mediators by inhibiting cyclic AMP breakdown. ADM: AE: Naus, Diar, weight loss, anxiety, depression, insomnia, Headache. CI: Hx of suicidal ideation. COS: DOS: 500ug once/d.


 

For Copying

AVL: IND: MOA: EVD: ADM: AE: CI/Warning: PRG: LAC: DI: PK: COS: AUX: MON: DOS: OTH: