Asthma corticosteroid inhalation

Corticosteroids are the most efficacious treatment available for the long-term treatment of asthma, and inhaled corticosteroids are considered to be a first-line therapy for asthma (247). In the early 1950s, cortisone (31) and cortisol (29) were used to treat asthma. However, dmgs with fewer side effects and with... 

For severe, persistent asthma, the inhaled corticosteroid dose should be increased to the high-dose range, and addition of systemic corticosteroids may be needed. 

A major breakthrough in asthma therapy was the introduction in the 1970s of aerosol corticosteroids These agents (Table 39.3) maintain much of the impressive therapeutic efficacy of parenteral and oral corticosteroids, but by virtue of their local administration and markedly reduced systemic absorption, they are associated with a greatly reduced incidence and severity of side effects. The success of inhaled steroids has led to a substantial reduction in the use of systemic corticosteroids. Inhaled corticosteroids, along with 2-(tdreno-ceptor agonists, are front-line therapy of chronic asthma. 

Asthma is best thought of as a disease in two time domains. In the present domain, it is important for the distress it causes—cough, nocturnal awakenings, and shortness of breath that interferes with the ability to exercise or to pursue desired activities. For mild asthma, occasional inhalation of a bronchodilator may be all that is needed. For more severe asthma, treatment with a long-term controller, like an inhaled corticosteroid, is necessary to prevent symptoms and restore function. The second domain of asthma is the risk it presents of future events, such as exacerbations, or of progressive loss of pulmonary function. A patient s satisfaction with his or her ability to control symptoms and maintain function by frequent use of an inhaled 32 agonist does not mean that the risk of future events is also controlled. In fact, use of two or more canisters of an inhaled 3 agonist per month is a marker of increased risk of asthma fatality. 

Kemp JP, Cook DA, Incaudo GA, Corren J, Kalberg C, Emmett A, Cox FM, Rickard K. Salmeterol improves quality of life in patients with asthma requiring inhaled corticosteroids. Salmeterol Quality of Life Study Group. J Allergy Clin Immunol 1998 101(2 Pt l) 188-95. 

HPI KG is a 39-year-old woman with asthma on fluticasone and albuterol complaining of SOB associated with exercise. Three months ago she started an aerobic exercise program that has been hampered by chest tightness and SOB shortly after she begins running. She admits to poor compliance with her corticosteroid inhaler and requests an oral medication to control her asthma symptoms. Her PMH is significant for mild, persistent asthma for 35 years and allergic rhinitis. Her medications include fluticasone and albuterol inhalers and fexofenadine. Pulmonary function tests (PFTs) reveal her forced expiratory volume in the first second (FEV,) = 89% of predicted. 

Orally administered corticosteroids are effective in the treatment of chronic bronchial asthma. The inhalation route has been widely used in attempts to avoid systemic side-effects, such as adrenal suppression, but evidence suggests that inhaled steroids are absorbed systemically to a significant extent. The respiratory tract epithelium has permeability characteristics similar to those of the classical biological membrane, so lipid-soluble compounds are absorbed more rapidly than lipid-insoluble molecules. Cortisone, hydrocortisone and dexamethasone are absorbed rapidly by a nonsaturable diffusion process from the lung, the half-time of absorption being of the order of 1-1.7 min. Quaternary ammonium compounds, hippurates and mannitol have absorption half-times, in contrast, of between 45 and 70 min. 

Indications Allergic rhinitis, Asthma Category Corticosteroid, inhaled Half-life N/A... 

Trade names Aerobid (Roche) Nasalide (Ivax) Nasarel (Ivax) Indications Asthma, rhinitis Category Corticosteroid, inhaled Half-life N/A... 

The client with asthma asks the nurse, Why should I use the corticosteroid inhaler instead of prednisone Which statement by the nurse would be most appropriate ... 

Frost GD, Penrose A, HaU J, MacKenzie DI. Asthma-related prescribing patterns with four different corticosteroid inhaler devices. Respir Med 1998 92 1352-1358. 

O Byrne PM, Pedersen S, Carlsson LG, Radner F, Thoren A, Peterson S, Ernst P, Suissa S. Risks of pneumonia in patients with asthma taking inhaled corticosteroids. Am J Respir Crit Care Med 2011 183(5) 589-95. 

Improvements in asthma treatment include the development of more effective, safer formulations of known dmgs. The aerosol adrninistration of P2-agonists or corticosteroids results in a decrease in side effects. Also, the use of reUable sustained release formulations has revolutionized the use of oral xanthines which have a very narrow therapeutic index (see Controlled release technology). For many individuals, asthma symptoms tend to worsen at night and the inhaled bronchodilatots do not usually last through an entire night s sleep (26,27). 

Inhaled steroids (commonly used are beclomethasone, budesonide, triamcinolone, fluticasone, flunisolide) appear to attenuate the inflammatory response, to reduce bronchial hyperreactivity, to decrease exacerbations and to improve health status they may also reduce the risk of myocar dial infar ction, but they do not modify the longterm decline in lung function. Whether- steroids affect mortality remains unclear. Many patients appear to be resistant to steroids and large, long-term trials have shown only limited effectiveness of inhaled corticosteroid ther apy. Certainly, the benefit from steroids is smaller in COPD than in asthma. Topical side-effects of inhaled steroids are oropharyngeal candidiasis and hoarse voice. At the normal doses systemic side-effects of inhaled steroids have not been firmly established. The current recommendation is that the addition of inhaled gluco-coiticosteroids to bronchodilator treatment is appropriate for patients with severe to veiy sever e COPD. 

Corticosteroids, such as beclomethasone (Beclovent), flu-nisolide (AeroBid), and triamcinolone (Azmacort), are given by inhalation and act to decrease the inflammatory process in the airways of the patient with asthma, hi addition, the corticosteroids increase the sensitivity of the p2-receptors. With increased sensitivity of the ( -receptors, the p2-receptor agonist drugs are more effective... 

Maintenance and prophylactic treatment of asthma for asthma patients who require systemic corticosteroid administration when adding an inhaled corticosteroid may reduce or eliminate the need for systemic corticosteroids... 

In general, treatment of the asthma underlying NSAlDs sensitivity should follow standard asthma guidelines. This type of asthma is often severe and frequently high doses of inhaled corticosteroids and daily doses of oral corticosteroids are necessary. A special treatment option is a chronic desensitization to aspirin [8]. Desensitization and aspirin maintenance is routinely used in some centers for treatment of chronic rhinusinusitis with nasal polyposis. It is the only available procedure which allows AIA patients with ischemic heart disease to use aspirin. During the state of desensitization to aspirin, not only aspirin but almost all strong NSAIDs are tolerated, so desensitization and NSAID maintenance could be used for treatment of rheumatic disease or chronic pain syndromes. 

In persistent asthma, inhaled corticosteroids provide the most comprehensive control of the inflammatory process. 

Airway hyperresponsiveness is defined as the exaggerated ability of the airways to narrow in response to a variety of stimuli. Although AHR exists in patients without asthma, it is a characteristic feature of asthma and appears to be directly related to airway inflammation and the severity of asthma.1,3 Treatment of airway inflammation with inhaled corticosteroids attenuates AHR in asthma but does not eliminate it.1 Clinically, AHR manifests as increased variability of airway function. Although not commonly used to diagnose asthma, AHR can be evaluated clinically using a methacholine or histamine bronchoprovocation test. 

Patients who smoke should be strongly encouraged to quit cigarette smoking decreases the efficacy of inhaled corticosteroids and can trigger an acute asthmatic response.3 All patients should also avoid secondhand smoke. Parents of children with asthma should be instructed not to smoke in the home and not to allow others to smoke in the home. Patients should also avoid outdoor activities when air quality is poor and avoid exposure to other irritants such as hairspray, paint, exhaust fumes, and smoke from any fire. 

Although both formoterol and salmeterol are effective as add-on therapy for moderate persistent asthma, neither agent should be used as monotherapy for chronic asthma. Patients treated with salmeterol alone are at greater risk of worsening asthma than those treated with inhaled corticosteroids.25,26... 

Corticosteroids are the most potent anti-inflammatory agents available for the treatment of asthma. The efficacy of corticosteroids is due to their ability to affect multiple inflammatory pathways, resulting in the suppression of inflammatory cell activation and function, prevention of microvascular leakage, decreased mucus production, and upregulation of P2-adrenergic receptors.10,18 Clinically, corticosteroids decrease airway inflammation, decrease AHR, decrease mucus production and secretion, and improve the response to P2-agonists.18 Corticosteroids for the treatment of asthma are available in inhaled, oral, and injectable dosage forms. 

In persistent asthma, inhaled corticosteroids provide the most comprehensive control of the inflammatory process and are the cornerstone of therapy.2 Inhaled corticosteroids are more effective than cromolyn, leukotriene modifiers, nedocromil, and theophylline in reducing markers of inflammation and AHR, improving lung function, and preventing emergency department visits and hospitalizations due to asthma exacerbations.2,25 The primary... 

Leukotriene modifiers either inhibit 5-lipoxygenase (zileuton) or competitively antagonize the effects of leukotriene D4 (montelukast and zafirlukast). These agents improve FEV, and decrease asthma symptoms, rescue drug use, and exacerbations due to asthma. Although these agents offer the convenience of oral therapy for asthma, they are significantly less effective than low doses of inhaled corticosteroids.2,33... 

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