Pulmonary Medications

Pulmonary Drugs for Asthma and COPD

• Drugs for asthma and chronic obstructive pulmonary disease (COPD) are categorized into two main classes: anti-inflammatory agents and bronchodilators.
• Anti-inflammatory agents, like glucocorticoids (prednisone, budesonide, fluticasone), are taken daily to control long-term inflammation.
• Bronchodilators, including beta2 agonists (albuterol) and anticholinergics (ipratropium, tiotropium, aclidinium), provide symptomatic relief by relaxing the airways.

Inhalation Drug Therapy

• Inhalation therapy enhances therapeutic effects while minimizing systemic side effects.
• Rapid relief of acute attacks is a key advantage.
• Three types of inhalers exist: metered-dose inhalers (MDIs), respimats, and dry-powder inhalers (DPIs), as well as nebulizers.

Anti-Inflammatory Drugs: Glucocorticoids

• Glucocorticoids are considered the most effective anti-asthma drugs.
• They decrease inflammation by reducing the release of inflammatory mediators and infiltration of inflammatory cells.
• They also reduce airway edema, which is often caused by beta2 agonists.
• These drugs are commonly administered by inhalation, but intravenous and oral routes are available.
• Glucocorticoids suppress inflammation, reduce bronchial hyperreactivity and decrease airway mucus production; they may also increase the number of beta2 receptors and their sensitivity.
• Glucocorticoids are used for chronic asthma prophylaxis, not for acute attacks, as the beneficial effects take time to develop.
• Inhaled glucocorticoids are very effective and much safer than systemic glucocorticoids. These drugs are often the first line of treatment.
• Oral glucocorticoids are used for moderate to severe persistent asthma or acute exacerbations of asthma or COPD when symptoms are not controlled with inhaled medicines. This treatment needs to be brief.
• Adverse effects of inhaled glucocorticoids include adrenal suppression, oropharyngeal candidiasis, and dysphonia. In addition, their long-term use in children can negatively impact growth.

Anti-Inflammatory Drugs: Leukotriene Modifiers

• Leukotriene modifiers can suppress inflammatory reactions and reduce bronchoconstriction and symptoms like airway edema and mucus production.
• These drugs have been linked to neuropsychiatric effects, including depression and suicidal thoughts.
• Available medications include Zileuton [Zyflo], Zafirlukast [Accolate], and Montelukast [Singulair].

Monoclonal Antibody: Omalizumab [Xolair]

• Omalizumab is a monoclonal antibody that antagonizes immunoglobulin E (IgE). It is frequently used in patients with allergy-related moderate to severe asthma that is not controlled by inhaled glucocorticoids..
• Potential adverse effects of Omalizumab include injection-site reactions, viral/upper respiratory infections, sinusitis, headache, pharyngitis, cardiovascular events, malignancy, and life-threatening anaphylaxis.

Bronchodilators

• Bronchodilators provide symptomatic relief of bronchospasm but do not alter the underlying inflammatory process.
• In most cases, bronchodilators are used alongside glucocorticoids for long-term control.
• Common bronchodilators include beta2-adrenergic agonists (SABAs & LABAs) and anticholinergics (ipratropium & tiotropium).

Bronchodilators: Beta2-Adrenergic Agonists

• These drugs activate beta2 receptors in the lung, leading to bronchodilation and relief of bronchospasm.
• SABAs (short-acting) are used for quick relief (PRN) of acute attacks or before exercise (Exercise-Induced Bronchospasm or EIB). Nebulized SABAs are often the first choice for acute exacerbations. They are also commonly administered via MDI.
• LABAs (long-acting) are used for long-term control in patients with frequent attacks. LABAs are always used with glucocorticoids.
• Adverse effects include tachycardia, angina, tremor (especially in inhaled preparations), and more severe side effects (angina pectoris, tachydysrhythmias) with excessive dosage.

Anticholinergic Drugs

• Anticholinergics like ipratropium improve lung function by blocking muscarinic receptors in the bronchi. They reduce bronchoconstriction.
• They are commonly used for COPD. Ipratropium provides quick relief (within 30 seconds).
• Tiotropium, and aclidinium, are long-acting, used for COPD maintenance, and their effects become more pronounced over several days/a week.
• Side effects include dry mouth and irritation of the pharynx, glaucoma, and cardiovascular events.

Glucocorticoid/LABA Combinations

• Combining inhaled glucocorticoids with LABAs is often a preferred long-term approach for asthma and COPD treatment. Available combinations include fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort, and mometasone/formoterol (Dulera).
• These combinations are generally not recommended for initial therapy.

Management of Asthma

• Asthma management includes a stepwise approach, adjusting treatments based on severity and symptom control.

Drugs for Acute Severe Exacerbations

• Immediate attention is required. Goals include relieving obstruction and restoring normal lung function.
• Initial therapy involves administering oxygen, systemic glucocorticoids, a high-dose nebulized SABA and sometimes nebulized ipratropium to immediately alleviate airflow obstruction, and hypoxemia.

Management of Stable COPD

• Pharmacologic management typically includes bronchodilators (beta2 agonists and anticholinergics, often combined), glucocorticoids, and phosphodiesterase-4 inhibitors.

Management of COPD Exacerbations

• During COPD exacerbations, short-acting beta2 agonists (SABAs), often combined with inhaled anticholinergics, are a preferred treatment for bronchodilation.
• Systemic glucocorticoids and antibiotics may also be needed.
• Supplemental oxygen is also important.

Drugs for Allergic Rhinitis, Cough, and Colds

Allergic Rhinitis

• Allergic rhinitis is an inflammatory condition affecting the upper and sometimes the lower airways.
• Symptoms include sneezing, rhinorrhea, pruritus, nasal congestion, conjunctivitis, and sometimes sinusitis or asthma.
• The condition is triggered by seasonal or perennial allergens.
• Allergens bind to IgE antibody on mast cells, triggering the release of inflammatory mediators (histamine, leukotrienes, prostaglandins).

Classes of Drugs Used for Allergic Rhinitis

• Treatment classes include glucocorticoids (intranasal), antihistamines (oral and intranasal), and sympathomimetics (oral and intranasal).

Intranasal Glucocorticoids

• Intranasal corticosteroids are often the first-line treatment for allergic rhinitis.
• Possible mild side effects include drying of nasal mucosa, sore throat, nosebleeds (epistaxis), and headaches

Oral Antihistamines

• Oral antihistamines may be used prophylactically to prevent symptoms during allergy seasons, but do not typically reduce nasal congestion.
• Mild sedation is a possible side effect, especially with first-generation antihistamines.

Sympathomimetics

• Sympathomimetics reduce nasal congestion by stimulating alpha-adrenergic receptors in nasal blood vessels.
• Rebound congestion is a potential side effect if used long-term.
• Topical sympathomimetics (drops or sprays) generally act more quickly than oral versions.
• Drops or sprays should not be used for more than 5 consecutive days.

Antitussives

• Antitussives suppress coughing.
• Opioid antitussives include codeine and hydrocodone, while non-opioid options include dextromethorphan and benzonatate.

Expectorants

• Expectorants, like guaifenesin, make coughs more productive by stimulating secretions in the respiratory tract.