Presented by : Abdulhadi Burzangi . Pharm.d Bronchial Asthma Presented by : Abdulhadi Burzangi . Pharm.d 1

Key Point.. Background of Asthma. Clinical presentation. Drug used in asthma. Stepwise approach for managing asthma. Steps for using inhaler. Case. 3

I- Background Definition : of airway associated with inflammation, - Asthma is a chronic inflammatory disease of airway associated with inflammation, obstruction and increase airway hyper- responsiveness. 4

SABA use for symptoms control Interference with normal activity Types of asthma : Persistent Mild Moderate Severe Intermittent Through out the day Daily > 2 days/week but not daily < 2 days/week symptoms Often 7 days/w > 1 day/week 3-4 days/month < 2 days/month Night time awakening Several time per day SABA use for symptoms control Extremely limited Some limitation Minor limitation None Interference with normal activity

Asthma triggers : 1- Allergens. 2- Occupational exposure. 3- Disease. 4- Environmental changes. 5- Emotions. 6- Exercise. 7- Drugs and preservatives.

11- Clinical presentation - In case of chronic ambulatory asthma : 1- Episode of dyspnea. 2- Chest tightness. 3- Coughing ( particularly at night ). 4- Wheezing or a whistling sound when breathing. - In case of severe acute asthma : 1- Severe dyspnea. 3- S.O.B 4- The patient is able only to say a few words with each breath. 5

111- Drugs used in asthma 1- Short acting beta agonist (SABA). 2- Long acting beta agonist (LABA). B. Corticosteroids (CS). 1- Inhaled. 2- Oral. C. Leukotrine receptor antagonist. D. Mast cell stabilizer. E. Phosphodiestrease inhibitor. F. Anti IgE. G. Anticholinergic. 6

- e.g : Albuterol . A. Beta 2 agonist SABA : LABA : - Uses - e.g : 1-Salmetrol 2-Formetrol . - Side effect of both : 1- Tachycardia. 2- Palpitation. 3- Tremor. 4- Hypokalemia. 7

- e.g : 1- Beclomethasone. B. Corticosteroid Inhaled CS : Oral CS : 2- Budesonide. 3- Flunisolide. 4- Fluticasone. 5- Trimcinolone. - Uses Oral CS : - e.g : 1-predinsone, 2-predinsolone 3-methylpredinsolone - Uses 8

Short term and long term side effect : Long term S.E Short term S.E HPA axis suppression. Growth retardation. HTN. Osteoporosis. Hirsutism. Myopathy. Facial flushing. Appetite stimulant. GIT irritation. Mood change. Acne. Weight gain. Hyperglycemia. Leukocytosis. Hypocalsemia. 9

C. Leukotriene receptor antagonist - e.g : ( Montelukast, Zafirlukast and Zileuton ). - Uses D. Mast cell stabilizer - e.g : ( Cromolyn Na+ and Nedocromil ). 10

E. Phosphodiestrase inhibitors - e.g : ( Theophylline ). - use - Factors affecting serum theophylline concentration : Increase Theophylline conc. Decrease Theophylline conc. High carbohydrate diet. Systemic viral infection. Cimetidine. Erythromycin. Ciprofloxacin. Ticlopidine. High protein diet. Smoking. Rifampin. Phenytoin. Phenobarbital. Carbamazepine. 11

Other Drugs F. Anti IgE (Omalizumab). G. Anticholinergic (Ipratropium). 13

IV. Stepwise approach for managing asthma. 14

V. Steps for using inhaler. 1. Remove the cap and hold inhaler upright. 2. Shake the inhaler. 3. Tilt your head back slightly and breathe out slowly. 4. Position the inhaler in one of the following ways 5. Press down on the inhaler to release medication as you start to breathe in slowly. 6. Breathe in slowly (3 to 5 seconds). 7. Hold your breath for 10 seconds to allow the medicine to reach deeply into your lungs. 8. Repeat puff as directed. Waiting 1 minute between puffs may permit second puff to penetrate your lungs better. 15

VI. Case K.M is 33years old female , she came to ambulatory care department at last Saturday . She had been bronchial asthma X 13 years . She was complaining of cough, wheezing , chest tightness and drowsiness. The patient said ( sometimes my family want to take me to ED when i had asthmatic attack but i didn’t want to visit ED). She on seretid (Flutacasone/Salmetrol) for her asthma. 16

Subjective : Chief complaint: - wheezing. - cough. - chest tightness. - drowsiness. Problem list : - bronchial asthma X 13 years. - iron deficiency anemia. Social history : - single. Allergy : - Food > banana … shrimp. - Drugs > no known drug allergy. - Others > dust and costs. 17

Objective : Past medication : Vital sings : R.R : 20 rate/min Temp. : 36.8 ْc B.P : 130/61 Pulse : 81 beat/min Weight : 68.6 kg Height : 150cm. Past medication : - Inhaled beclomethasone 100 mcg puff bid. - Ventolin (Albuterol). 18

- Ventolin solution + Ventolin neublizer. Current medication : - Seretid ( Fluctasone 250mcg + Salmetrol 50mcg )BID. - Ferrose (100 mg iron as iron III hydroxide polymaltose complex). Assessment : - The patient diagnosed with mild persistent asthma. - She doesn’t response to her medication. Plan : - Ventolin solution + Ventolin neublizer. - Ferrose. 19

Recommendation Check the patient compliance….. Stop gradually….. General measure for treating asthma. 20

Thank you