Welcome to another MedCram lecture we're going to talk about inhalers so
what's the quick and dirty on inhalers well here we've got a bronchus which is
the airway that you breathe through and in the middle of that is smooth muscle
which limits the aperture or the lumen of that bronchus if the smooth muscle
contracts the lumen gets smaller and so there's two major receptors that we see
on the smooth muscle we have a orange receptor here which we're going to call
the muscarinic receptor so that's going to be an M and there's another receptor
in this case we'll call it the blue receptor which is the beta receptor so
those are the two major receptors now the thing that you should know is that
muscarinic receptors are actually going to cause smooth muscle contraction and
so what we want to do in this situation is we want to make sure that we are
inhibiting that so we want to make sure that there's a big X that we have
inhibitors of that muscarinic receptor on the beta side however we want to make
sure that that gets excited or activated because the beta receptor actually
relaxes that smooth muscle and so that's going to cause relaxation so once you
know about these two receptors and you know that you want to block the
muscarinic and excite the beta to cause bronchodilation then you're there now
the only other one that you should know is the inhaled corticosteroid which will
say here is a ICS and that basically goes everywhere there is no real
receptor but what it does is it reduces inflammation okay so the three types of
drugs that you can use for bronchi are muscarinic antagonists beta agonists and
inhaled corticosteroids so why is that important well you'll be able to
identify these different types of drugs based on what they end with so
muscarinic always end in -ium so what are examples tiotropium ipratropium
Umeclidinium these are all muscarinic antagonists they all end in
-ium now there is another one that you should
know that has been added to that category called glycopyrrolate so you
can also put -late, so if you see an -ium or a -late its a muscarinic antagonist, now on the beta agonist side
all of these end in -ol so you'll know formoterol salmeterol albuterol all those things
end in -ol now how do you know whether it's an inhaled corticosteroid you'll
know that because it ends in -one like fluticasone or
mometasone etc so once you know those three then you'll be able to put those
together so we have the muscarinic antagonists we have the beta agonists
and we have the inhaled corticosteroids so how are we going to use these in
terms of the actual clinical outcomes let's take a look at that okay
so let's go ahead and put those medications into the right place in
terms of this there are two types of beta agonists there's something called a
short-acting beta agonist which I will call a Saba okay so what does this
represent this represents like proair this looks like ventolin albuterol
basically okay now the other one that we're going to do are the long-acting
beta agonists so that's laba, LABA then we're going to go ahead and look at
the long-acting muscarinic antagonists okay and then finally we're going to go
ahead and look at the inhaled corticosteroids so for those who don't
remember remember this these are the ones that end in -one these are
the ones that end in -ol and these are the ones that end in -ium
remember glycopyrrolate is also in that category so it's -ium -ol and -one so why
do I put this into this three chambered box here with the Saba this is how we're
going to look at the treatment of COPD and asthma okay so as you can see if
we take a look at asthma first asthma is gonna go in this direction whereas COPD
is gonna go in this direction so the first thing that we would do in asthma
is we would add an inhaled corticosteroid and then we would ask the
question is the patient using a short-acting beta agonist if the answer is
somewhere between one and two times per week then we're fine with where we are
at one medication however if the patient is using the short-acting beta agonist
as a rescue inhaler three or more times per week in asthma then the inhaled
corticosteroid is not enough then what we need to do is add a long-acting beta
agonist at that point we ask the question again is the patient using a
short-acting beta- agonist or albuterol three or more times per week if the
answer is yes that means the patient is not well controlled and we will add not
just an inhaled corticosteroid and a long-acting beta agonist but we'll at
that point add a long-acting muscarinic antagonist at any point if we ask this
question is the patient using a short-acting beta agonist and the answer
is no zero times per week that means the patient is so well controlled they don't
have to use the rescue inhaler that means we can drop the long-acting
muscarinic antagonists if we're on that or if we're just on the inhaled
corticosteroid in the lung I think beta agonist then we can drop the long-acting
beta agonist and just keep on the inhaled corticosteroid so what we're
seeing here is a ramping up or a ramping down depending on the answer to the
question how often is the short-acting beta-agonist
being used notice that for asthma you will never use a long-acting beta
agonist without using an inhaled corticosteroid first okay now let's go
to the other side COPD if you have COPD the first medication
that I would add is a long-acting muscarinic antagonist so tiotropium or
Umeclidinium or glycopyrrolate and then I would ask the question is the
patient using the short-acting beta agonist if the answer is yes three times
or more per week then I would add the long-acting beta agonists notice that
the last thing I'm going to use in a patient with COPD is an inhaled
corticosteroid so this is very important you'll see that a long-acting muscarinic
and tagging this is one of the first things that we'll use in a patient with
COPD but we're always asking the question and you should see here very
clearly that everybody who has a lung disease either asthma or COPD here is
gonna get a short-acting beta agonist as a rescue inhaler like they carry it with
them wherever they go okay now as you can see at some point
you're going to be having combination of medications the drug companies are not
stupid they'll know that usually one medications not enough and so what
you'll see for COPD is you'll see these lama lama combinations and you see
that all the time so if you pick up an inhaler and it's a combination of a
medication you can simply look on there and see if they have a combination of
-ium medication and an -ol medication for instance one medication has vilanterol
Umeclidinium and that would be a lama laba combination because you
know this chart you'll know that that medication is a medication that's going
to be used for COPD let me give you another one let's go from the asthma
side you know that on the asthma side people will be combining inhaled
corticosteroids and long-acting beta agonists so if you see something like
fluticasone and salmeterol that combination goes together and that's
forms advair for instance and that would be a inhaled corticosteroid and a
laba combination now you can get laba by itself you can buy salmeterol
or formoterol by itself but that is becoming more and more rare because as
you can see based on how I have things set up that if you're on a laba you're
either going to be coupling it with an inhaled corticosteroid when you're
treating asthma or you're gonna be coupling it with a long-acting
muscarinic antagonist if you're treating COPD now as you can probably imagine
it's not gonna be long before and they have already started working on this all
three of these medications in one so you can now look up basically any inhaler
look at the contents of the inhaler in terms of the medications and you should
be able to very quickly tell first of all what type of a medication it is and
what it should be used for and now with your patients you'll be able to see
whether or not you need to escalate therapy or de-escalate therapy the one
thing that I will say is in the case of asthma if I am going down I go to an
inhaled corticosteroid and that doesn't work I will add a long-acting beta
agonist but there are exceptions to this for instance if I have a patient who has
atrial fibrillation and I'm worried that I'm gonna speed up their heart rate very
quickly instead of adding a long-acting beta agonist which could speed up their
heart I may decide to increase the dose of the inhaled corticosteroid from a low
potency to a medium or even to a high potency medication alternatively I could
also add a leukotriene receptor antagonist and I didn't put that in here
but I'll just put it up here in the corner leukotrienes
receptor antagonist and that's the type 4 okay so these are other things that
you can think about but this is the general modality that you'll see in the
treatment between asthma and COPD thanks for joining us