598

SECTION 5 Problems of Oxygenation: Ventilation

TABLE 29-7

DRUG THERAPY

Asthma and Chronic Obstructive Pulmonary Disease

ROUTE OF
DRUG
ADMINISTRATION
Antiinflammatory Agents
Corticosteroids

SIDE EFFECTS (SE)

COMMENTS*

With long-term use: cushingoid

appearance, skin changes (acne, striae,
bruising), osteoporosis, increased
appetite, obesity, peptic ulcer,
hypertension, hypokalemia, cataracts,
menstrual irregularities, muscle
weakness, immunosuppression,
catabolism.
With short-term use (e.g., <2 wk): sleep
disturbances, increased appetite.
Oral candidiasis (thrush), hoarseness,
irritated throat, headache, sinus
infection, upper respiratory infection.

Alternate-day therapy minimizes SE. Oral dose

should be taken in morning with food or milk.
When given in high doses, observe for epigastric
distress. Long-term corticosteroid therapy
requires supplementation with vitamin D and
calcium to prevent osteoporosis.
Discontinue gradually over time to prevent adrenal
insufficiency. If during tapering symptoms recur,
health care provider should be notified.

hydrocortisone (Solu-Cortef)
methylprednisolone
(Medrol, Solu-Medrol)
prednisone

IV
Oral, IV

fluticasone (Flovent HFA,

Flovent Diskus)

MDI, DPI

beclomethasone (Qvar)

MDI

budesonide (Pulmicort
Turbuhaler)
mometasone (Asmanex
Twisthaler)
ciclesonide (Alvesco)

DPI

Oral candidiasis, hoarseness, irritated

throat, dry mouth, cough, few systemic
effects except for headache.
Same as above.

DPI

Same as above.

MDI

Headache, nasopharyngitis.

Oral candidiasis and other localized oropharyngeal

effects (e.g., hoarseness). Fewer SE than other
ICSs because of small particle size with minimal
activation in oropharynx.

Nebulizer, MDI

Drying of oral mucosa, cough, flushing

of skin, bad taste.

Alternating schedules of -adrenergic agonists

and atropine administration may be helpful
in some patients. Temporary blurred vision if
sprayed in eyes. Use cautiously in patients with
narrow-angle glaucoma or prostatic enlargement.
Ongoing review to determine if this class
of anticholinergics places patients at risk for
cardiovascular events, including strokes.

DPI

Dry mouth, upper respiratory infection.

Blurred vision if powder comes in contact with

eyes. Must discontinue use of ipratropium while
on tiotropium. Patient must use short-acting
-adrenergic agonists for quick-relief medication.
See above related to class risk.

Subcutaneous
injection

Injection site reaction (e.g., bruising,

redness, warmth, pain).

Only for moderate to severe persistent allergic

asthma with symptoms not adequately
controlled by ICS. Not for acute bronchospasm.
Administer only under direct medical supervision
and observe patient for a minimum of 2 hr
following administration as anaphylaxis has been
reported with use.

Oral

Anticholinergics
Short-Acting
ipratropium (Atrovent HFA)

Not recommended for acute asthma attack. Rinse

mouth with water or mouthwash after use to
prevent oral fungal infections. Use of spacer
device with MDI may decrease incidence of oral
candidiasis. With inhaled corticosteroids, may
not see effects until after at least 2 wk of regular
treatment.
Same as fluticasone except less oral candidiasis
because of very small particle size which is
deposited deeper in the airways.

Long-Acting
tiotropium (Spiriva
HandiHaler)

Anti-IgE
omalizumab (Xolair)

BP, Blood pressure; CNS, central nervous system; DPI, dry powder inhaler; GI, gastrointestinal; HFA, hydrofluoroalkane (propellant); ICSs, inhaled corticosteroids; IV, intravenous;
MDI, metered-dose inhaler.
*For patient instructions in English and Spanish for the devices, see www.chestnet.org/patients/guides/inhaledDevices.php.
FDA is continuing to review clinical trial data to assess mood and behavioral adverse events related to drugs that act through the leukotriene pathway, and further updated
information can be found at www.fda.gov/medwatch.

CHAPTER 29 Obstructive Pulmonary Diseases

TABLE 29-7

599

DRUG THERAPYcontd

Asthma and Chronic Obstructive Pulmonary Disease

ROUTE OF
DRUG
ADMINISTRATION
Leukotriene Modifiers
Leukotriene Receptor Blocker

SIDE EFFECTS (SE)

COMMENTS*
Not for acute asthma attacks.
Take at least 1 hr before or 2 hr after meals.
Affects metabolism of erythromycin and theophylline. Not to be used to treat acute asthma
episodes.
Not to be used to treat acute asthma episodes.

zafirlukast (Accolate)

Oral tablets

Headache, dizziness; nausea, vomiting,

diarrhea, fatigue, abdominal pain.

montelukast (Singulair)

Oral tablets, chewable

tablets, oral granules

Well tolerated.

Oral tablets

Liver enzymes; dyspepsia, pain,

Monitor liver enzymes. May interfere with

metabolism of warfarin (Coumadin) and
theophylline. Not to be used to treat acute
asthma episodes.

Tachycardia, BP changes, nervousness,

palpitations, muscle tremors, nausea,
vomiting, vertigo, insomnia, dry mouth,
headache, hypokalemia.

Use with caution in patients with cardiac disorders

as -agonists may cause BP and heart rate,
CNS stimulation/excitation, and risk of
dysrhythmias. Has rapid onset of action
(1-3 min). Duration of action is 4-8 hr.

Tachycardia, nervousness, tremor (less

than albuterol).
Same as albuterol but cardiac effects
are less.

Too frequent use can result in loss of

effectiveness.

Leukotriene Inhibitor
zileuton (Zyflo CR)

headache.

2-Adrenergic Agonists
Inhaled: Short-Acting (SABA)
albuterol (Proventil HFA,
Ventolin HFA, ProAir HFA,
AccuNeb, VoSpire ER [oral
only])

levalbuterol (Xopenex,
Xopenex HFA)
pirbuterol (Maxair Autohaler)

Nebulizer, MDI, oral

tablets including
extended release
Note: Oral tablets not
for acute use, only
long acting
Nebulizer, MDI
MDI

Inhaled: Long-Acting (LABA)

salmeterol (Serevent)

DPI

formoterol (Foradil Aerolizer,

Perforomist)

DPI, nebulizer
Perforomist is for
nebulizer
Nebulizer

arformoterol (Brovana)

In asthma: Should never be used as

monotherapy. Should be used in
combination with inhaled steroids.
In COPD: Can be used as monotherapy.
Not used for rapid relief of dyspnea.
Headache, throat dryness, tremor,
dizziness, pharyngitis.
Angina, tachycardia, nervousness,
headache, tremor, dizziness.

Not to exceed two puffs q12hr. Not to be used

for acute exacerbations. Has a counter.
Can affect blood glucose levels. Should be used
with caution in patients with diabetes.

See formoterol.

See formoterol. For chronic COPD use.

Tachycardia, BP changes, dysrhythmias,

anorexia, nausea, vomiting,
nervousness, irritability, headache,
muscle twitching, flushing, epigastric
pain, diarrhea, insomnia, palpitations.

Wide variety of response to drug metabolism

exists. Half-life is by smoking and by heart
failure and liver disease. Cimetidine, ciprofloxacin, erythromycin, and other drugs may
rapidly theophylline levels. Taking drug with
food or antacids may help GI effects. Patient
must be encouraged to take drugs even when
feeling well.

Methylxanthines
IV agent: aminophylline
(second-line therapy)
Oral: theophylline

Oral tablets, IV, elixir,

sustained-release
tablets

Combination Agents
ipratropium and albuterol
(Combivent, DuoNeb)
fluticasone/salmeterol
(Advair Diskus or HFA)
budesonide/formoterol
(Symbicort)
mometsone furoate/
formoterol fumarate
(Dulera)

MDI, Nebulizer
DPI, MDI
MDI
MDI

Also see each component of medications for SE.

Chest pain, pharyngitis, diarrhea, nausea.
Patients must be careful not to overuse. Must take
as prescribed.
Headache, pharyngitis, oral candidiasis.
See salmeterol and fluticasone. Has a counter.
Comes in three different strengths.
Dysrhythmias, hypertension, paradoxic
See budesonide and formoterol. Has a counter.
bronchospasm.
Nasopharyngitis, sinusitis, headache