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 I see s 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 I um so what are examples tiotropium
if Petro priam Umatilla d neum these are all muscarinic antagonists they all end
in I um now there is another one that you should
know that has been added to that category called glycol pie relate so you
can also put late-1800s now on the beta-agonist side all of these and in O
L so you'll know for Mathura salmeterol albuterol all those things end in O L
now how do you know whether it's an inhaled corticosteroid you'll know that
because it ends in O and E or own like fluticasone 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 L a B a 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
that these are the ones that end in O and E these are the ones that end in O L
and these are the ones that end in I um remember glycol pie relate is also an
category so it's I um all and own 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 C o P
D 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 X 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-2 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-2 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 and the long-acting beta
agonist then we can drop the long-acting beta agonists 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 this short-acting
BAE the 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 you Mackall edenia or glycol pie relate 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 Intag and 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 lamma lamma 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 I
um medication and an OLE medication for instance one medication has Volant all
and you met LaDainian that would be a llama lab a 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
in a lab a combination now you can get l'abbé by itself you can by cell meter
all or for morale 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 lab ah 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 going to 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
for 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