Combination Inhalers: Asthma & COPD Treatment

• Respiratory inhalant combination medications contain two or three fixed-dose medications, controlling bronchoconstriction and inflammation in asthma and COPD.
• Combining medications into a single inhaler enhances convenience versus separate administrations.

Inhaled Medication Categories Included in Combinations

• Inhaled corticosteroids reduce airway inflammation.
• Beta2-adrenergic agonists, including short-acting (SABAs) and long-acting (LABAs), relax bronchial smooth muscles.
• Anticholinergics (muscarinic antagonists), including short-acting (SAMAs) and long-acting (LAMAs), block acetylcholine to prevent bronchoconstriction.

Combination of SABA and SAMA

• Prototype medication: albuterol/ipratropium.
• Used for COPD treatment.

Combination of LABA and LAMA

• Prototype medication: vilanterol/umeclidinium.
• Other medications: formoterol/glycopyrrolate, formoterol/aclidinium, and olodaterol/tiotropium.
• They are used for maintenance treatment of COPD.

Combination of Inhaled Glucocorticoid and SABA

• Prototype medication: budesonide/albuterol.
• It is used to prevent bronchoconstriction and reduce asthma exacerbations.

Combination of Inhaled Glucocorticoid and LABA

• Prototype medication: fluticasone/salmeterol.
• Other medications: fluticasone/vilanterol, mometasone/formoterol, and budesonide/formoterol.
• It is used for maintenance treatment of COPD.

Combination of Inhaled Glucocorticoid, LABA, and LAMA

• Prototype medication: fluticasone/vilanterol/umeclidium.
• Another medication: budesonide/formoterol/glycopyrrolate.
• For maintenance treatment of COPD, especially with exacerbations despite dual therapy.
• Used for maintenance treatment of severe asthma.

Expected Pharmacologic Action – Combination of SABA/SAMA

• Albuterol/ipratropium prevents bronchoconstriction by relaxing bronchial smooth muscles.
• Albuterol stimulates beta2-adrenergic receptors (SABA effect).
• Ipratropium inhibits acetylcholine at muscarinic receptors (SAMA effect).

Expected Pharmacologic Action – Combination of LABA/LAMA

• Vilanterol/umeclidinium prevents bronchoconstriction through bronchodilation.
• Vilanterol stimulates beta2-adrenergic receptors (LABA effect).
• Umeclidinium inhibits acetylcholine at muscarinic receptors (LAMA effect).
• Maintenance treatment for COPD exacerbation prevention, not for asthma.

Expected Pharmacologic Action – Combination of Inhaled Glucocorticoid/SABA

• Budesonide/albuterol decreases inflammation and relaxes bronchial smooth muscles to prevent acute bronchoconstriction.
• Budesonide is a corticosteroid, reducing inflammation.
• Albuterol stimulates beta2 receptors (SABA effect).
• Used to prevent acute bronchoconstriction in asthma.

Expected Pharmacologic Action – Combination of Inhaled Glucocorticoid/LABA

• Fluticasone/salmeterol treats airway inflammation and bronchoconstriction.
• Fluticasone reduces inflammation.
• Salmeterol stimulates beta2 receptors (LABA effect).
• Used as maintenance treatment to prevent COPD exacerbations.

Expected Pharmacologic Action – Combination of Inhaled Glucocorticoid/LABA/LAMA

• Fluticasone/vilanterol/umeclidium reduces inflammation and treats bronchoconstriction.
• Fluticasone reduces inflammation.
• Vilanterol stimulates beta2-adrenergic receptors (LABA effect).
• Umeclidinium inhibits acetylcholine at muscarinic receptors (LAMA effect).

Adverse Drug Reactions

• Due to the combination nature of these medications, it’s important to know the adverse effects of each component
• Beta2-adrenergic agonists may cause tachycardia, heart palpitations, tremors, or chest pain.
• Anticholinergics may cause dry mouth, pharyngeal irritation, increased intraocular pressure, urinary retention, tachycardia, arrhythmias, chest pain, headaches, dizziness, epistaxis, bronchospasm, and hypotension.
• Inhaled corticosteroids may cause oral candidiasis and hoarse voice.

Interventions

• Continuously monitor client's respiratory status, breathing effort, lung sounds, and oxygen saturation.
• Correct inhaler technique (MDI, dry powder, fine mist) is essential.
• If beta2-adrenergic agonist is included, monitor for tachycardia, heart palpitations, and chest pain.
• If anticholinergic is included, monitor for dry mucous membranes and urinary retention: provide water, hard candy and glaucoma tests if needed.
• If glucocorticoid is included, use a spacer to minimize side effects like oral candidiasis and notify the provider if it occurs.

Administration – Combination of SABA/SAMA

• Albuterol/ipratropium is available as MDI or nebulizer solution.
• Dosage: one MDI inhalation or nebulizer treatment four times daily, up to six times daily maximum.
• Store in a dry place; avoid temperature extremes, and used to treat acute and exacerbated COPD

Administration – Combination of LABA/LAMA

• Vilanterol/umeclidinium is available as MDI, soft mist inhaler, or dry powder inhaler.
• Dosage: one inhalation daily.
• Store in a dry place and do not use for acute bronchospasms.

Administration – Combination of Inhaled Glucocorticoid/SABA

• Budesonide/albuterol is supplied as a metered-dose inhaler.
• Give two inhalations as needed, up to 12 inhalations in 24 hours.

Administration – Combination of Inhaled Glucocorticoid/LABA

• Fluticasone/salmeterol is supplied as MDI, soft mist inhaler, or dry powder inhaler.
• Dosage: 1 to 2 inhalations twice daily.
• Store in a dry place, and do not use to treat acute bronchospasms.

Administration – Combination of Inhaled Glucocorticoid/LABA/LAMA

• Fluticasone/vilanterol/umeclidium is supplied in a dry powder inhaler.
• Give once a day for maintenance treatment of COPD and asthma, and do not use to treat acute bronchospasms.

Client Instructions

• Provide thorough education on the correct inhaler technique (MDI, dry powder, fine mist).
• Follow manufacturing instructions for inhaler use and cleaning.
• Explain the action, administration, adverse effects, and interactions; and provide instructions on when to notify provider
• Teach clients to watch for and avoid triggers, maintain a log of exacerbations, and to notify the provider of changes to the pattern of exacerbations.
• When beta2-adrenergic agonists are included, tell the client to avoid caffeine.
• When anticholinergics are included, instruct the client to suck on hard candy and sip water regularly and get routine glaucoma tests. Report any changes in urinary elimination.
• When glucocorticoids are included, encourage clients to rinse their mouths and gargle after use or use a spacer.

Safety Alert

• Report paradoxical bronchospasms, chest pain, heart palpitations, or tachycardia, especially with cardiovascular disease or hypertension history to a healthcare provider.
• Also, report dizziness, blurred vision, urinary retention, or white patches on mucous membranes.

Contraindications and Precautions – Combination of SABA/SAMA

• Use albuterol/ipratropium cautiously in clients with cardiovascular disorders, diabetes, hypokalemia, renal impairment, seizure disorders, glaucoma, and hyperthyroidism.
• Do not give to clients with atropine hypersensitivity.
• Use cautiously in clients with glaucoma, prostatic hyperplasia, or bladder neck obstructions.

Contraindications and Precautions – Combination of LABA/LAMA

• Contraindicated in clients with severe lactose or milk protein hypersensitivities.
• Use vilanterol/umeclidinium cautiously in clients with cardiovascular disorders, diabetes, hypokalemia, renal impairment, seizure disorders, glaucoma, or hyperthyroidism. Can potentiate cardiovascular effects when taking MAOIs.
• Use cautiously in clients with glaucoma, prostatic hyperplasia, or bladder neck obstructions.

Contraindications and Precautions – Combination of Inhaled Glucocorticoid/SABA

• Contraindicated in clients with severe lactose or milk protein hypersensitivities.
• Use cautiously with cardiovascular disorders, diabetes, hyperthyroidism, seizure disorders, or hypokalemia. Also, it should be used with caution for clients who are at risk for infections due to its immunosuppression effect.
• Monitor for oral candidiasis and osteoporosis risk.

Contraindications and Precautions – Combination of Inhaled Glucocorticoid/LABA

• Do not give to clients who have status asthmaticus or acute bronchospasms.
• Contraindicated with severe lactose or milk protein hypersensitivities.
• Use cautiously with cardiovascular disorders, liver disease, diabetes, glaucoma, or hyperthyroidism.

Contraindications and Precautions – Combination of Inhaled Glucocorticoid/LABA/LAMA

• Same as inhaled corticosteroid/LABA but with added caution for bladder neck obstruction, history of urinary retention, or prostatic hypertrophy.

Interactions

• Beta2-adrenergic blockers may reduce bronchodilation with beta2-adrenergic agonists.
• Monitor potassium levels with beta2-agonists and potassium-depleting medications.
• MAOIs and tricyclic antidepressants can increase the risk of hypertension and tachycardia.
• Antidiabetic medications may require increased dosing.
• Increased dosages of insulin or oral hypoglycemics are needed because corticosteroids elevate blood glucose.
• Monitor for gastrointestinal bleeding with inhaled glucocorticoids and NSAIDs.
• Monitor for infection with inhaled glucocorticoids and immunosuppressives.
• Monitor potassium levels with inhaled glucocorticoids and thiazide diuretics.
• Anticholinergics cause additive effects.

Safety Alert (Interactions)

• When giving a patient respiratory inhalant medications, be sure to monitor blood glucose, potassium, EKG changes, and manifestations of infection.

Explore combination inhalers for managing asthma and COPD. Learn about mechanisms, benefits, and appropriate medication combinations like vilanterol/umeclidinium and fluticasone/salmeterol. Understand how these inhalers prevent bronchoconstriction and reduce exacerbations.