Medications, Techniques, Devices



MEDICATIONS

The medications used to treat asthma help relieve the symptoms caused by an asthma episode, and/or treat chronic inflammation in children with asthma. Campers will learn to identify their medications as Controllers or Relievers. Controller medications are used to prevent frequent asthma symptoms and decrease airway hyper-responsiveness. Reliever medications are used to treat the symptoms of an asthma episode. Campers learn that asthma is controlled with daily medications and monitoring. Symptoms may still occasionally occur and are relieved with the proper medications.

Asthma Medications - Bronchodilators

Asthma is a disease characterized by inflammation leading to hyperreactivity. Bronchoconstriction is often the first and most noticeable symptom a patient with asthma feels. Relaxation of the airways and bronchodilation occurs when these medications stimulate beta type 2 (ß2) receptors in the lungs.

|Brand Name |Generic Name |Pharmacology |Adverse Effects/Other |

|Quick-Acting Inhaled Bronchodilators |

|Proventil |Albuterol |• Relievers |• Tremor, CNS stimulation, tachycardia, and |

|Proventil HFA | |• Causes bronchial muscle relaxation by stimulation|headache are common but short-lived. |

|Ventolin | |of ß2 receptors resulting in bronchodilation |• Proventil HFA contains a new propellant (non-CFC)|

| | |• Opens airways to let oxygen and other inhaled |which is safer for the environment. |

|Maxair |Pirbuterol |medications in. |• Albuterol and terbutaline can be given by |

| | |• Wait 1-3 minutes between puffs. |nebulization. |

|Brethair |Terbutaline | |• Albuterol comes as rotacaps. |

|Brethine | |• Onset of effect 5 minutes | |

| | |• Peak 0.5-2 hours | |

|Alupent |Metaproterenol |• Duration 3-5 hours | |

|Long-Acting Inhaled Bronchodilators |

| Serevent |Salmeterol |• Controller |• Tremor, CNS stimulation, headache, cough, and |

| | |• Causes bronchial muscle relaxation by stimulation|tachyphylaxis. Tachycardia less common. |

| | |of ß2 receptors resulting in bronchodilation |• Serevent comes as an MDI and Diskus (powder |

|Foradil |Formoterol | |inhaler) |

| | |• Salmeterol Onset of effect 20 |• Foradil comes as a DP+ |

| | |minutes + |• NOT for acute exacerbations. |

| | |• Formoterol Onset 15 minutes |• May become "tolerant" to salmeterol. |

| | |• Peak 3 hours | |

| | |• Duration up to 12 hours | |

|Long-Acting Oral Bronchodilators |

|Proventil-Repetab |Albuterol |• Controllers |• Nausea, vomiting, tremors, sleep disturbances, |

|Volmax | |• Causes bronchial muscle relaxation by stimulation|bed wetting, behavior changes. |

| | |of ß2 receptors resulting in bronchodilation. |• Theophylline - need to follow blood levels long |

|Slo-bid | |• Extended release products with longer duration. |term. |

|Theo-Dur |Theophylline |• Theophylline is metabolized to caffeine in the |• Do not crush or chew extended release products. |

|Slo-phyllin | |body. |• A water-soluble form of theophylline |

|Uniphyl | | |(aminophylline) is given IV for severe acute |

| | |• Onset of effect 30 minutes + |exacerbations. |

| | |• Peak 2-3 hours | |

| | |• Duration 6-12 hours | |

|Inhaled Anticholinergic Medications |

|Atrovent |Ipratropium |• Relievers |• Anticholinergic side effects: dry mouth, urinary |

| | |• Reduce bronchoconstriction and secretion |retention, tachycardia, flushed (red) skin. |

| | | |• Side effects can limit use. |

Asthma Medications - Anti-inflammatory

Inflammation of the airways and release of mediators of inflammation results in prolonged bronchial hyperreactivity. Blocking the release of these mediators and preventing inflammation is a long-term goal in any patient with asthma.

|Brand Name |Generic Name |Pharmacology |Adverse Effects |

|Inhaled Corticosteroids |

|Aerobid |Flunisolide |• Controllers |• Hoarseness and possibly thrush. Thrush may be |

| | |• Decrease inflammation and edema in respiratory |prevented by rinsing mouth and spitting after |

|Azmacort |Triamcinolone |tract. |each use of the inhaled steroid or by use of a |

|Kenalog | |• Should be given 5 minutes after short acting |spacer. |

| | |bronchodilator only if symptomatic. |• Adrenal insufficiency unlikely. |

|Beclovent |Beclomethasone |• Mainstay of all asthma therapy (except patients |• Fluticasone (Flovent) comes in three strengths |

|Vanceril | |with mild intermittent asthma). |of MDIs and a Diskhaler (dry powder inhaler) with |

| | | |4 different strengths. |

|Flovent |Fluticasone |• Onset of effect 1-2 weeks |• Budesonide (Pulmicort) comes as a dry powder |

| | | |inhaler (Turbuhaler). |

|Pulmicort |Budesonide | | |

|Oral Corticosteroids |

|Pediapred |Prednisolone |• Reliever or controller |• Short-term use: irritability, "hyperactivity", |

|Prelone | |• Decrease inflammation and edema in respiratory |water retention, stomach pain, increased appetite,|

| | |tract. |facial flushing. |

|Deltasone |Prednisone |• Given in "bursts" for uncontrolled acute |• Long-term use: softening of bones, growth |

| | |exacerbations or chronically (daily or every other |retardation, central obesity, peptic ulcers, |

|Medrol |Methylpred-nisolone |day) for severe asthma. |hypertension, risk of infections, and adrenal |

| | |• Take with food to prevent gastritis. |insufficiency. |

|Inhaled Anti-inflammatory Medications |

|Intal |Cromolyn |• Controllers |• Throat irritation. Very safe. |

| | |• Prevents release of inflammatory mediators from |• Unlikely to be effective unless used regularly. |

|Tilade |Nedocromil |mast cells. |• Expensive. |

| | |• Use for PREVENTION only (Intal can prevent of | |

| | |exercise-induced) | |

| | | | |

| | |• Onset of effect - 2-4 weeks | |

|Leukotriene Medications |

|Accolate |Zafirlukast |• Controllers |• Nausea and vomiting and headache. Hepatitis |

| | |• Leukotrienes are mediators of inflammation that |(2-5%) with Zileuton. |

|Zyflo |Zileuton |are thought to be very important in asthma. |• Long term safety unknown. |

| | |- Zafirlukast and montelukast- block leukotriene |• These drugs are NOT used for acute |

|Singulair |Montelukast |receptors resulting in decreased |exacerbations. |

| | |bronchoconstriction and inflammation. |• All have drug interactions with other |

| | |- Zileuton - prevents the production of |medications (e.g. Dilantin, Propulsid). |

| | |leukotrienes. | |

| | |• Oral medications. Take Zafirlukast on an EMPTY | |

| | |stomach twice daily. Take Zileuton with or without | |

| | |food four times daily. Take Montelukast with or | |

| | |without food daily in the evening. | |

| | |• Onset of effect - 2-3 weeks. | |

Asthma and Other Medications

New medications aimed at the effects of leukotrienes in asthma have recently been approved by the FDA. These medications are equally effective to inhaled corticosteroids in patients with mild-moderate asthma. These medications decrease bronchconstriction through a mediator called leukotriene. The CNS stimulants are used for ADHD; DDAVP is used for bedwetting.

|Brand Name |Generic Name |Pharmacology |Adverse Effects |

|CNS Stimulants |

|Ritalin |Methylphenidate |• CNS stimulant - increase release of chemical |• Anorexia, hypertension, psychotic episodes, |

| | |mediators to increase slow behaviors and decrease |restlessness. |

|Cylert |Pemoline |fast |• Cylert - liver dysfunction and exacerbation of|

| | | |Tourrette's. |

|Dexedrine |Dextroamphetamine |• Onset of effect: |• Tolerance and dependence can occur - need to |

| | |- Ritalin regular tablets: 2 hrs |be weaned off medication when discontinuing. |

|Adderall |Amphetamine/ |- Ritalin SR tablets: 4-7 hrs |• Do not crush or chew sustained release |

| |Dextroamphetamine |– Cylert - 4 weeks |products. |

| | |- Dexedrine - 1-1.5 hrs | |

| | |• Duration of effect: | |

| | |- Ritalin reg. tablets: 3-6 hrs | |

| | |- Ritalin SR tablets: 8 hrs - give several hrs | |

| | |before hs | |

|DDAVP |

|DDAVP |Desmopressin |• Promotes reabsorption of water in distal tubules |• Facial flushing, water intoxication, |

| | |to decrease urine flow. |hyponatremia. |

| | | |• Used for bedwetting caused by theophylline. |

| | |• Onset of effect: 1 hr | |

| | |• Peak effect: 1-5 hrs | |

| | |• Duration of effect: 5-21 hrs | |

Antihistamine and Decongestant Medications

Antihistamines block the effects of histamine that are usually associated with allergies (runny nose, watery eyes, sneezing, etc.). Decongestants are sometimes used for allergy symptoms such as nasal congestion, but do not prevent the symptoms from occurring.

|Brand Name |Generic Name |Pharmacology |Adverse Effects |

|Standard Antihistamines |

|Chlortrimeton |Chlorpheniramine |• Prevents histamine-induced vasodilation and |• Cross blood brain barrier (causing sedation). |

| | |increased capillary permeability. Decreases |• Drowsiness/sedative, CNS stimulation in some |

| | |symptoms of allergies. |children, anticholinergic effects. |

|Bromphed |Brompheniramine |• Also effective for itching. |• Anti-nausea effects with some of these products. |

| |Pseudoephedrine |• Often combined with decongestants as extended |• Do not crush or chew extended release products. |

|Dimetapp | |release products. Use SR for allergies. | |

| |Brompheniramine/ |• Controversial use in asthma. | |

| |Phenylpropanolamine | | |

| | | | |

|Benadryl |Diphenhydramine | | |

| | | | |

|Rynatan |Azatadine maleate and | | |

| |pseudoephedrine sulfate | | |

|Tavist | | | |

| |Clemastine | | |

|Atarax | | | |

|Vistaril |Hydroxyzine | | |

|Non-sedating (or Less-sedating) Antihistamines |

|Fexofenadine |Allegra |• Prevents histamine-induced vasodilation and |• Claritin may cause rash, dry skin, or rarely |

| | |increased capillary permeability. |photosensitivity. Headache is common with Zyrtec. |

|Loratidine |Claritin |• Cross blood brain barrier POORLY (thus, |• Claritin comes in a redi-tablet that dissolves on|

| | |less-sedating). |the tongue without water. |

|Cetirizine |Zyrtec |• Zyrtec is a derivative of hydroxyzine. |• Claritin and Allegra come in combination with |

| | |• Allegra is the "son of Seldane". |pseudoephedrine. |

| | |• Use SR for allergies. | |

|Decongestants |

|Sudafed |Pseudoephedrine |• Stimulates alpha-adrenergic receptors to cause |• Dry mouth, increased blood pressure, tachycardia,|

| | |vasoconstriction. Dries secretions. |and nervousness. |

|Actifed |Pseudoephedrine/ | |• Minimally effective in improving symptoms. |

| |Triprolidine | | |

Nasal Medications

These medications are used to control nasal symptoms of allergic/non-allergic rhinitis. Only local side effects are seen, in general. Nasally inhaled corticosteroids cannot be used as a substitute for oral steroids in patients who are dependent on them.

|Brand Name |Generic Name |Pharmacology |Adverse Effects |

|Inhaled Corticosteroids |

|Beconase AQ |Beclomethasone |• Decrease inflammation and edema in nasal |• Burning, sneezing, epistaxis, nasal stuffiness |

|Vancenase AQ | |passages due to allergic rhinitis. |• Potential Candida, hoarseness, and adrenal |

| | |• Flonase (fluticasone) and Rhinocort |insufficiency less likely. |

|Nasacort AQ |Triamcinolone |(Budesonide) come as a nasal suspension - they |• AQ products cause less nasal drying and burning. |

| | |must be SHAKEN before use. | |

|Nasalide |Flunisolide | | |

| | |• Onset of effect – 1-3 days | |

|Flonase |Fluticasone | | |

| | | | |

|Rhinocort AQ |Budesonide | | |

| | | | |

|Nasonex |Mometasone | | |

|Inhaled Anti-inflammatory Medication |

|Nasalcrom |Cromolyn |• Prevents release of inflammatory mediators from|• Nasal burning. Safe. |

| | |mast cells. |• Available OTC. |

| | |• Onset of effect – 2 weeks of regular use. | |

|Other |

|Atrovent Nasal |Ipratropium |• Anticholinergic effects including drying of |• Systemic absorption unlikely. Cough, hoarseness, |

| | |nasal secretions. |dry mouth. |

| | | | |

|Astelin |Azelastine |• Nasal antihistamine |• Bitter taste, some systemic absorption may cause |

| | |• Decreased edema, sneezing, itching in |sedation. |

| | |allergic/non-allergic rhinitis | |

INHALED STEROID COMPARISON CHARTS

|ADULT* |Estimated Daily Dosages |

|Drug |Low dose |Medium Dose |High dose |

|Beclomethasone (Beclovent/ Vanceril) |168-504mcg |504-904 mcg |> 840 mcg |

|42 mcg/puff |4-12 puffs |12-20 puffs |> 20 puffs |

|84 mcg/puff |2-6 puffs |6-10 puffs |> 10 puffs |

|Budesonide Turbuhaler (Pulmicort) |200-400 mcg |400-600 mcg |> 600 mcg |

|200mcg/dose |1-2 inhalations |2-3 inhalations |> 3 inhalations |

|Flunisolide (Nasalide) |500-1000 mcg |1000-2000 mcg |> 2000 mcg |

|250 mcg/puff |2-4 puffs |4-8 puffs |> 8 puffs |

|Fluticasone (Flovent) |88-264 mcg |264-660 mcg |> 660 mcg |

|MDI: 44 mcg/puff |2-6 puffs (44 mcg) | | |

|110 mcg/puff |2 puffs (110 mcg) |2-6 puffs (110 mcg) |6 puffs (110 mcg) |

|220 mcg/puff | |1-3 puffs (220 mcg) |>3 puffs (220 mcg) |

|DPI: 50 mcg/dose |2-6 inhalations (50 mcg) | | |

|100 mcg/dose |1-2 inhalations (100 mcg) |3-6 inhalations (110 mcg) |> 6 inhalations (100 mcg) |

|Triamcinolone (Azmacort) |400-1000 mcg |1000-2000 mcg |> 2000 mcg |

|100 mcg/puff |4-10 puffs |10-20 puffs |> 20 puffs |

MDI = Metered Dose Inhaler * adapted from Facts and Comparison. Feb 1999. pp 180e-180f

DPI = Dry Powder Inhaler

|CHILDREN* | |Estimated Daily Dosages |

|Drug |Age |Low dose |Medium Dose |High dose |

|Beclomethasone (Beclovent/ Vanceril) |6-12 yo |84-336mcg |336-672 mcg |> 672 mcg |

|42 mcg/puff | |2-8 puffs |8-16 puffs |> 16 puffs |

|84 mcg/puff | |1-4 puffs |4-8 puffs |> 8 puffs |

|Budesonide Turbuhaler (Pulmicort) |> 6 yo |100-200 mcg |200-400 mcg |> 400 mcg |

|200mcg/dose | |1 inhalation |1-2 inhalations |> 2 inhalations |

|Flunisolide (Nasalide) |6-15 yo |500-750 mcg |1000-1250 mcg |> 1250 mcg |

|250 mcg/puff | |2-3 puffs |4-5 puffs |> 5 puffs |

|Fluticasone (Flovent) |> 12 yo |88-176 mcg |176-440 mcg |> 440 mcg |

|MDI: 44 mcg/puff | |2-4 puffs (44 mcg) |4-10 puffs (44 mcg) | |

|110 mcg/puff | | |2-4 puffs (110 mcg) |> 4 puffs (110 mcg) |

|220 mcg/puff | | |1-2 puffs (220 mcg) |> 2 puffs (220 mcg) |

|DPI: 50 mcg/dose | |2-4 inhalations (50 mcg) | | |

|100 mcg/dose | |1-2 inhalations (100 mcg) |2-4 inhalations (110 mcg) |> 4 inhalations (100 mcg) |

|Triamcinolone (Azmacort) |6-12 yo |400-800 mcg |800-1200 mcg |> 1200 mcg |

|100 mcg/puff | |4-8 puffs |8-12 puffs |> 12 puffs |

MDI = Metered Dose Inhaler * adapted from Facts and Comparison. Feb 1999. pp 180e-180f

DPI = Dry Powder Inhaler

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