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3. Respiratory system
a. Review asthma, COPD, allergic rhinitis and associated drugs and side effects of
drugs
Asthma:
Recurrent episodes of wheezing, breathlessness, and chest tightness
Airflow obstruction is reversible.
 Mild intermittent: 2 days/week or less (short-acting beta
2)
 Mild persistent: >2days/week but not daily ( Low-dose inhaled corticosteriods
are the mainstay for all age patients (first line treatment)
 Cromolyn or a leukotriene modifier are alternatives.
 See dosage charge for low-dose schedule of each inhaled corticosteroid.
 Moderate persistent: daily
 Severe persistent: throughout the day
 Step 4 therapy
 Medium-dose inhaled corticosteroids plus long-acting beta agonist
 Or medium-dose inhaled corticosteroid and a leukotriene modifier or theophylline
 Step 5 therapy
 High-dose inhaled corticosteroids plus long-acting beta agonists
 Step 6 therapy

 High-dose inhaled corticosteroids plus long-acting beta agonists and oral
corticosteroids
 Severe persistent asthma requires consultation with asthma specialist.

 Once control is achieved, the patient is seen every 1 to 6 months to determine if a step up
or step down in therapy is indicated.
 Inhaled beta-agonists are drug of choice during pregnancy.
 Inhaled corticosteroids (eg. Budesonide) are the long-term drug of choice for
pregnancy
 Long-acting beta agonists should not be prescribed singly, need to be combined with an
inhaled corticosteroid.
Ipratropium (inhaled anticholinergic) for asthma maintenance is 2 to 3 puffs 4
times/day for adults. (Rinse mouth after inhaling medication.)
Children under age 12 years: 1 or 2 puffs every 6 hours
Ipratropium-albuterol combination (Combivent) is a second-line quick relief
medication in the treatment of asthma.
Tiotropium and aclidinium are not indicated for the treatment of asthma.
 Black Box warning : The risks of salmeterol (Serevent) and formoterol
(Foradil) outweighed the benefits and should not be used singly in
asthma for all ages.
COPD:
Ipratropium: 2 puffs (36 µg) 4 times/day (maximum
12 puffs per day)
Ipratropium: 1 unit dose via nebulizer 3 to 4 times/day, may be mixed with
albuterol
Ipratropium-albuterol combination (Combivent): 2 puffs
4 times/day

Tiotropium (Spiriva): 2 puffs of a single capsule once/day
Aclidinium bromide (Tudorza Pressair): 1 puff twice/day
i. Treatment for mild intermittent asthma vs mild-persistent asthma
b. Differentiate between short and long acting beta agonists
Beta 2 receptor agonist action:
Bronchodilation
Vasodilation in muscle and liver
Relaxation of the uterus muscle
Release of insulin
Can cause hyperglycemia in diabetics, arrhythmias,
Drug interactions :
 Digitalis glycosides (eg. Digoxin ): increased risk of dysrhythmia
 Beta adrenergic blocking agents: direct competition for beta sites resulting in mutual
inhibition of therapeutic effects
 Including beta blocker eye drops
