RESPIRATORY MEDICATION EDUCATION
Bronchodilators are medications that relax the muscles that wrap around your breathing tubes (airways), allowing the tubes to become larger and easier to breathe through. Each bronchodilator is different, based on its: 1) chemical make-up, 2) how fast it works, and 3) how long it lasts. Your healthcare provider will decide with you which of these medications or combinations work best for you.
Types of bronchodilators:
Inhaled beta-2 agonists can be fast-acting (start to work within 3 to 5 minutes) or slow-acting (take 20 minutes to work).
Short-acting beta-2 agonists (SABA) are known as rescue or reliever medicines because they bring quick relief for breathlessness, but do not last long enough to provide 24-hour relief. Using your reliever medication before an activity that you know makes your breathing worse (such as exercise, showering, or going out into the cold air) may help lessen or prevent your breathing difficulty. Inhaled beta-2 agonists are short-lasting (last 4 to 6 hours) or long-lasting (last 12 to 24 hours). Examples of short-lasting beta-2 agonists are albuterol, levalbuterol, pirbuterol, salbutamol, and terbutaline.
Long-lasting beta-2 agonists (LABA) are taken every 12 to 24 hours, providing more convenient treatment of COPD than short-acting drugs that are usually used as “rescue medications” to relieve sudden onset of shortness of breath. Examples of long-lasting beta-2 agonists are salmeterol, formoterol, indacaterol, and vilanterol.
Side Effects: Beta-2 agonists are generally safe medications when inhaled but can cause a fast heartbeat, tremors (shakiness), and rarely cramping of the hands, legs, and feet, particularly if they are used too often or too many puffs are inhaled at once. These medications may also keep you awake at night. The combination of a fast heartbeat and shakiness can cause feelings of anxiety and worsen breathlessness. These side effects often last for only a few minutes after taking the medicine and may totally go away after a few days of regular use. If the side effects do not go away, talk to your healthcare provider. You may need to try a lower dose, change to another type or brand of beta-2 agonist, or stop the beta-2 agonist. If you have difficulty going to sleep after taking your beta-2 agonist, take it an hour or two before bedtime.
Anticholinergic bronchodilators are also inhaled medicines. They have a slower onset of action than beta-2 agonists and, therefore, they should never be used for quick relief. Anticholinergics can be short or long-lasting.
The short-lasting form (SAMA) ipratropium works in about 15 minutes, lasts for 6–8 hours, and is usually taken up to 4 times a day.
The long-lasting (LAMA) forms take about 20 minutes to begin working and lasts for 12 hours (aclidinium) or 24 hours (tiotropium, umedclidinum).
Anticholinergic bronchodilators do not have as many possible side effects as beta-2 agonists. The most common side effects are dry mouth and rarely, difficulty passing urine (urinary retention).
It may be confusing to understand why you are taking two different bronchodilators. Research studies have shown that combinations of two bronchodilators work better than either alone. A common combination is to give a long-acting beta-2 agonist and a long acting anticholinergic.
Theophylline is a bronchodilator that is not commonly used for COPD in the U.S. since most people can use inhaled bronchodilators. It is usually taken by mouth as a pill. A blood test must be done to monitor your theophylline level to make sure the drug level is high enough to be effective, but not high enough to cause serious side effects. The amount of theophylline that you take needs careful supervision since your theophylline blood level can change when you start a new medicine, stop smoking, or change your diet. A common side effect is shakiness, but very serious side effects include severe nausea, vomiting, heart beat irregularities, and seizures. If you experience any of these, get medical care right away immediately.
INHALED CORTICOSTEROIDS (ICS)
Steroids, also known as corticosteroids, are medications used to reduce swelling in the airways. These drugs are not the same as anabolic steroids (misused by athletes) to build muscles. Steroids are usually taken by inhaler, often in combination with a bronchodilator. They do not work quickly and may take a week or more before you notice the benefits. If you have an exacerbation or worsening of your COPD symptoms, steroids may be given by mouth in a pill form because pills can act faster (within 24 hours) and provide a higher dose of steroids than the inhaled forms.
Using oral steroids for a long period of time (chronically) is discouraged due to significant side effects. Side effects depend upon the dose, length of use, and whether taken by pill or inhaled form. The most common side effects of inhaled steroids are a sore throat, hoarse voice, and infections in the throat and mouth.
Things you can do to avoid or reduce these side effects include:
Rinsing your mouth and gargling after taking an inhaled steroid
Using a spacer/holding chamber to reduce the amount of steroid landing in your mouth and throat
People with COPD who use inhaled steroids, especially those with severe disease and who are at an advanced age, may have a higher risk of pneumonia. Taking steroids by pill, either in high doses or low doses for a long time, may cause problems including bruising of the skin, weight gain, weakening of the skin and bones (osteoporosis), cataracts, high blood pressure, increased blood sugar, mood changes, muscle weakness, and swelling of the ankles or feet. Many but not all of these side effects may improve or go away when the oral steroid is stopped. While many of these unwanted effects can be troublesome, not taking steroids when they are needed can lead to severe, life-threatening breathing problems. You should discuss any concerns about taking steroids with your healthcare provider.
These medications are often taken in conjunction with one another to establish a better baseline with regards to the underlying condition. We call these medications "maintenance medications". When prescribed and taken properly these combinations can provide a very good boost to the patients baseline lung function. This helps to allow for a better quality of life and make exacerbations and flare-ups less frequent. Maintenance medications will always include the long acting (LABA/LAMA) form of bronchodilators in order to be effective with use usually being prescribed either once or twice per day. Combination medications may be ordered with any combination of LABA, LAMA, and/or ICS. Your physician will evaluate your symptoms in addition to your medical history to determine which combination is best for you.
Am J Respir Crit Care Med Vol. 200, P3-P4, 2019 ATS Patient Education Series © 2019 American Thoracic Society
BIOLOGIC RESPIRATORY MEDICATIONS
A biologic is a medication made from the cells of a living organism, such as bacteria or mice, that is then modified to target specific molecules in humans. For asthma, the targets are antibodies, inflammatory molecules, or cell receptors. By targeting these molecules, biologics work to disrupt the pathways that lead to inflammation that causes asthma symptoms.
A biologic is used for patients who continue to have symptoms despite use of standard daily controller medications. Symptoms of poorly controlled asthma include frequent coughing, wheezing, or shortness of breath; waking up at night with difficulty breathing; requiring a fast-acting reliever medication, such as albuterol, several times a day or week; and recurrent hospital admissions, emergency room visits, or need for oral steroids for exacerbations. Before prescribing a biologic, your doctor should make sure you are taking your other controller medications as instructed, avoiding any potential triggers for your asthma, and treat any other associated medical conditions that could be making your asthma worse.
The primary benefit of biologics has been a decrease in the frequency of asthma exacerbations, including emergency room visits, hospitalizations, and need for oral steroids. Other benefits include reduced asthma symptoms, reduced dosage of other controller medication, and less missed school and work days. Biologics have been shown to improve quality of life for patients with asthma. Some biologics have been found to improve lung function in patients with severe asthma.
Currently there are five approved biologics for asthma – omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab – with several others currently in development.
Omalizumab targets allergy antibodies known as IgE.
Mepolizumab, reslizumab, and benralizumab all target pathways that affect eosinophils, a cell involved in allergic inflammation.
Dupilumab targets a receptor for two molecules that drive allergic inflammation.
Your doctor will obtain screening tests, such as blood work or environmental allergen skin prick testing, to help decide which biologic would be best to treat your asthma. Omalizumab is approved for patients as young as 6 years old, while all the other biologics except for reslizumab are approved for patients as young as 12 years old. Reslizumab is approved for adults 18 and over.
Unlike other medications for asthma, most biologics are currently administered in a doctor’s office either as a subcutaneous injection or as an intravenous infusion. With some biologics, your doctor may want to observe you in the office between 30 minutes and two hours after administration. Dupilumab is a subcutaneous injection, but unlike the other biologics it can be administered at home. The frequency of administration of each of these biologics are different, ranging from every two weeks to every eight weeks.
Overall, studies have shown biologics to be very safe. For one of these medications, omalizumab, there has been a small risk of anaphylaxis. In this case, your doctor will likely prescribe an epinephrine autoinjector to have in case of a severe reaction. With mepolizumab, your doctor may ask if you are at risk for certain types of parasitic infections or ask about your varicella vaccination status prior to administering. Other common side effects include soreness at the injection site, headache, sore throat, and fatigue.
There are currently no set recommendations on how long a patient should be on a biologic. Guidelines recommend trialing the medication for at least four months to see if it is helping improve your asthma. Your doctor will work with you to decide how long to keep you on a biologic if your asthma is under good control.