1. BRONCHODILATORS
1.1. SABA
1.1.1. **ALBUTEROL (Ventolin, Proair,Proventil)
1.1.1.1. neubulized or metered dose inhlaer (MDI)
1.1.1.1.1. MDI - 1-2 puffs q4-6hrs PRN for wheezing
1.1.1.2. B2 > B1 = bronchodilation and vasodilation
1.1.1.3. 2-4 mg PO TID-QID
1.1.1.3.1. max: 32 mg/day
1.1.1.3.2. or 4-8 mg ER PO q12h
1.1.1.4. CI: MAO, TCA, ischemic heart disease, arrhythmias, hypokalemia, seizure, DM, labor and delivery, linezolid, sotalol
1.1.1.5. AE: bronchospasm, HTN, hypotension, nervousness, tremor, headache, tachycardia, palpitations, muscle cramps, nausea, dizziness
1.1.2. METAPROTERENOL (Aluent)
1.1.2.1. 20mg PO TID-QID
1.1.2.2. increased cardiac side effects, not used often
1.1.2.3. CI: tachyarrhythmias, MAO, TCA, ischemic, HTN, DM, hypokalemia, SZ, hyperthyroidism, linezolid, sotalol
1.1.2.4. AE: HTN, hypotension, angina, cardiac arrest, arrhythmia, hyperglycemia, nervousness, tachycardia, tremor, headache, palpitations, nausea, dizziness
1.1.3. when your breathing is back to normal you can do a second puff
1.1.4. use a spacer with inhaler
1.2. LABA
1.2.1. **SALMETEROL (Serevent)
1.2.1.1. 1 puff inhaled q12 hours
1.2.1.1.1. MAX: 2x day
1.2.1.1.2. NOT for long term therapy or monotherapy
1.2.1.1.3. can be used for exercise induced bronchospasm
1.2.1.2. CI: asthma monotherapy, acute asthma, MAO, COPD, TCA, HTN, arrhythmias, CVD, glaucoma, pregnancy, sz, hyperthyroid, labor and delivery, -avir, -conazole, -mycin, - olol,
1.2.1.3. AE: bronchospasm, laryngospasm, HTN, hypotension, hypokalemia, hyperglycemia, HA, thorat irritaiton, rhinitis, pharyngitis, rash, palpitations
1.2.1.4. BLACK BOX: Asthma related death, pediatric and adolescent use
1.2.1.5. in advair for combo
1.2.1.5.1. Dry powder inhaler
1.3. CHOLINERGIC ANTAGONISTS
1.3.1. COPD > ASTHMA
1.3.2. inhibits secretions: dry mouth, urinary retention
1.3.3. **IPRATROPIUM
1.3.3.1. COPD: 2 puffs QID
1.3.3.1.1. MAX: 12 puffs/day
1.3.3.2. ASTHMA: 8 puffs inhaled q20min PRN up to 3h
1.3.3.3. CI: hypersensitivity to atropine, glaucoma, BPH,
1.3.3.4. AE: Anaphylaxis, bronchospasm, bronchitis, dyspnea, nausea, sinusitisi, dizziness, dyspepsia, UTI, back pain, urinary retention
1.3.4. **TIOTROPIUM
1.3.4.1. once a day long acting
1.3.4.2. COPD: 2 puffs (2.5mcg) qd
1.3.4.2.1. MAX: 5 mcg/24hrs
1.3.4.3. ASTHMA: 2 puffs (1.25mcg)
1.3.4.3.1. MAX: 2.5 mcg/24h
1.3.4.4. CI: bronchospasm, CrCl <60, glaucoma, urinary retention, BPH, -anil, -azole, -tropine,
1.3.4.5. AE: bronchospasm, glaucoma, cough, HA, bronchitis, sinusitis, GERD, candidiasis, palpitations, dizziness, dysphonia, rash, UTI
2. MAST CELL STABILIZERS
2.1. CROMOLYN (NaslalCrom)
2.1.1. nasalcrom - nose
2.1.2. inhibits bronchospasm
2.1.2.1. anti inflammatory
2.1.3. 20mg NEB QID
2.1.3.1. takes 4 weeks for an effect
2.1.4. CI: acute asthma, status asthmaticus, arrhythmias,
2.1.5. AE: bronchospasm, anaphylaxis, throat irritation, dry throat, cough, wheeze
2.1.6. NEVER USED
3. ORAL CORTICOSTEROIDS
3.1. use a spacer, and rinse mouth after use
3.2. reverse inflammation, and causes smooth muscle relaxation
3.3. most effective treatment for control, suppression and reversal of asthma symptoms
3.4. AE: mood changes, immunosuppressive, increase WBC, hyperglycemic, K+, edema, GI upset, appetite increase, osteoporosis
3.5. **PREDNISONE
3.5.1. STEROID BURST: 30-60mg daily, 5-10 days
3.5.1.1. don't have to taper if its < 2 weeks
3.6. METHYLPREDNISONLONE
3.6.1. HOSPITAL: IV 125 mg
3.6.1.1. 2mg/kg IM/IV x 1
3.7. PREDNISOLONE
3.7.1. breakdown product of prednisone
3.7.1.1. this may work better for people who can't metabolize prednisone
4. INHALED CORTICOSTEROIDS
4.1. **FLUTICASONE (Flovent)
4.2. BECLOMETHASONE (QVAR)
5. LEUKOTRIENE INHIBITORS
5.1. Prevents inflammation and blocks bronchoconstrictions
5.2. For Asthma + Allergies
5.3. ZAFIRLUKAST (Accolate)
5.3.1. 20mg PO BID
5.3.2. CI: actue asthma, hepatic impairment, breastfeeding,
5.3.3. AE: hepatitis, eosinophilia, vaculitis, angioedema, HA, infection, nausea, diarrhea, insomnia, ALT/AST elevation
5.4. **MONTELUKAST (Singulair)
5.4.1. 10mg PO qPM
5.4.2. CI: severe asthma, PKU, -barbital, -mazepine,
5.4.3. AE: anaphylaxis, thrombocytopenia, aggression, hallucination, suicidality, HA, URI, fever, diarrhea, cough, nausea, rash, anxiety
6. COMBOS
6.1. mechanism is a little different, follow up with clinical effect
6.2. ALBUTEROL/IPRATROPIUM (Combivent)
6.2.1. nebulizer medicine
6.2.2. SABA/AC
6.3. SALMETEROL/FLUTICASONE (Advair)
6.3.1. LABA/IC
6.4. FORMOTEROL/BUDESONIDE (Symbicort)
6.4.1. LABA/IC
6.5. FORMOTEROL/MOMETASONE (Dulera)
6.5.1. LABA/IC
6.6. VILANTEROL/UMECLIDINIUM (Anoro Ellipta)
6.6.1. COPD
6.6.2. LABA/AC
7. ANTIHISTAMINES
7.1. CETIRIZINE (Zyrtec)
7.1.1. second generation
7.1.2. crosses BBB - little drowsiness but better for itching and hives
7.1.3. 5-10mg PO qd
7.1.3.1. MAX: 10mg/day
7.1.4. CI: <2 y/o, hepatic/renal impairment, carbinoxamine, doxylamine
7.1.5. AE: bronchospasm, hepatotoxicity, syncope, fatigue, drowsiness, HA, diarrhea, dizziness, N/V
7.2. LORATIDINE (Claratin)
7.2.1. second generation
7.2.2. 10mg PO qd
7.2.3. CI: hepatic/renal impairment, PKU
7.2.4. AE: bronchospasm, hepatotoxicity, seizures, syncope, drowsiness, fatigue, HA, diarrhea
7.3. DIPHENHYDRAMINE (Benadryl)
7.3.1. first generation
7.3.2. act quick,
7.3.3. 1-2 tabs PO q4-6 hrs PRN
7.3.3.1. MAX: 12 tabs/24hrs
7.3.3.2. do not exceed 300mg/day
7.3.4. CI: <2 y/o, elderly, CNS depressant use, hyperthroidism, HTN, asthma, COPD, PUD, BPH, potassium, thioridazine
7.3.5. AE: anaphylaxis, thrombocytopenia, arrhythmias, seizures, psychosis, drowsiness, hA, epgastric discomfort, dysuria, hypotension, blurred vision, tachycardia
7.4. HYDROXYZINE (Vistaril)
7.4.1. first generation
7.4.2. anti anxiety
7.4.2.1. 50-100mg IM q4-6h PRN
7.4.3. 25mg PO q6-8h
7.4.4. CI: QT prolongation, electrolyte abnormalities, bradycardia, recent MI, potasisum
7.4.5. AE: dyspnea, seizures, heat stroke, QT prolongation, torsades, drowsiness, dizziness, weakness, HA, agitation, nausea
8. DECONGESTANT
8.1. PSEUDOEPHEDRINE
8.1.1. vasoconstrictor, less secretions, increase heart rate,
8.1.2. short term use
8.1.3. IR 30-60 mg q6h
8.1.4. ER 60-120 q23
8.1.5. CI: MAO, CAD, HTN, DM, glaucoma, hyperthyroidism, BPH, PKU, 1st trimester, phenelzine, procarbazine,
8.1.6. AE: insomnia, nausea, headache, dizziness, anxiety, palpitations, tachycardia, tremor
8.2. PHENYLEPHRINE
8.2.1. OTC oral or spray
8.2.2. not better than placebo
8.2.3. 10mg PO q4 PRN
8.2.3.1. MAX: 60mg/24h
8.2.4. CI: MAO, CAD, HTN, arrhythmia, DM, glaucoma, BPH, PKU, phenelzine, procarbazine
8.2.5. AE: HA, nausea, dry mouth, dizziness, insomnia, anxiety, HTN arrhythmia
9. ANTITUSSIVES
9.1. DEXTROMETHORPHAN
9.1.1. OTC DM
9.1.1.1. Helps with sleep, does not improve cough
9.2. BENZONATATE (Tessalon perles)
9.2.1. 100mg up to TID or 200mg qHS
9.2.2. anesthetic, lessens stretch reflex
9.3. HYDROCODONE OR CODEINE
9.3.1. nasty drug, not used very often
9.3.2. if patient has been using it and requests it, you can prescribe it
10. NASAL SPRAY
10.1. NASAL ANTIHISTAMINES
10.1.1. AZELASTINE (Astelin)
10.1.1.1. supplement oral antihistamines
10.1.1.2. NOT decongenstant
10.1.1.3. stings when used
10.2. NASAL STEROIDS
10.2.1. mainstay for allergic rhinitis
10.2.2. OTC
10.2.3. takes 1-2 weeks for effects
10.2.4. cross arm, spray behind eye, lean forward
10.3. ANTICHOLINERGIC
10.3.1. ipratropium (atrovent nasal)
10.3.1.1. OTC
10.3.1.2. caution wiht glaucoma, BPH, too drying
11. EXPECTORANT
11.1. GUAIFENESIN (Robitussin)
11.1.1. increases bronchial secretions, more productive cough
11.1.2. 200-400mg PO 14h PRN
11.1.3. CI: nephrolithiasis, <6 y/o
11.1.4. AE: nephrolithiasis, rash N/V
12. PDE4i
12.1. roflumilast
12.1.1. end stage COPD
12.1.2. reduces inflammaotry process