Drug For Allergy And Route.pdf

DRUG THERAPY FOR ALLERGY DISEASES AND ROUTE OF ADMINISTRATION

Mae Sri Hartati Wahyuningsih Pharmacology and Therapy Dept. Faculty of Medicine UGM-Yogyakarta

OBJECTIVES The students are expected to: 1. Know the kind of allergy diseases 2. 3. 4. 5.

Describe the drug therapy for allergic diseases Know the route of administration Know the kind of drug administration Know the dosage and preparation of anti allergy medications

P A Allergic Reaction: T - Immediate H response - Late response O (3-24 hour) G E N E S I S

Factors Affecting Clinical Outcomes of Allergic Diseases Treatment

Environmental • Allergens

• Irritants • Westernization

• Anti-inflammatory

Genetic

• Anti-allergic • Relievers

Degree of atopy

Compliance • Avoidance

Infection

• Medication uses

• Viral

• Bacterial

Allergen Immunotherapy

Allergic Diseases Remission

Mild

Moderate

Future Therapy ?

Severe AllergyChula

Epidemiology of Allergic Diseases in Thai Children

1990

13

Asthma

1995

4.2 40

Allergic Rhinitis

17.9

Atopic Dermatitis

13

0

10

20 Prevalence (%)

30

40

RHINITIS ALLERGIC Inflamasi pada membran mukosa hidung disebabkan oleh adanya alergen yang terhirup dan dapat memicu respon hipersensitivitas

Pattern of symptoms in intermittent and persistent allergic rhinitis Characteristic

Intermittent (gejala <4 hr/mg)

Persistent (gejala >4hr/mg)

Obstruction

Variable

Always, predominant

Secretion

Watery, common

Seromucous, postnasal drip, variable

Sneezing/bersin

Always

Variable

Smell disturbance

Variable

Common

Eye symptoms

Common

Asthma

Variable

Common

Chronic sinusitis

Occasional

Frequent

Rare

(van Cauwenburge et al, 2000)

Management of therapy Using medications to reduce symptoms Antihistamines Decongestants Corticosteroid nasal Cromolyn sodium Ipratropium bromide Leukotriene antagonist

Treatment options for allergic rhinitis adapted from ARIA, 2001. Type of allergic rhinitis

First-line treatments

Alternative or addon treatments*

Comment

Mild intermittent

Oral antihistamines, Intranasal Antihistamines

Intranasal decongestants

Allergen avoidance may eliminate need for drugs.

Mild persistent or moderate severe intermittent

Oral antihistamines, Intranasal corticosteroids, intranasal Antihistamines

Intranasal decongestants, Sodium cromoglicate

Sodium cromoglicate is a useful alternative to antihistamines and corticosteroids, especially in children.

Moderate severe Persistent

Intranasal corticosteroids

Oral antihistamines, intranasal antihistamines, sodium cromoglicate, Ipratropium bromide, Leukotriene antagonists†

Ipratropium bromide is useful for persistent runny nose. Leukotriene antagonists may be useful if there is coexisting asthma.

ARIA=Alergic Rhinitis and its Impact on Asthma Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):S147

Kind of Antihistamin Nama Obat

Efek samping

Penggunaan umum Rinitis

Alergi kulit

Klorfeniramin



Bromfeniramin Deksklofeniramin

Sedasi

Antikoli nergik



Sedang

Minimal

6-12





sedang

minimal

4-6





Sedang

Minimal

4-6



kuat

Sedang

4-6



sedang

sedang

4-6

kuat

sedang

4-6

Difenhidramin

Sedasi

Premedika Mual/ si muntah

Durasi aksi (jam)



Dimenhidrinat Prometazin





Astemizol





minimal

minimal

>12

Cetirizin





minimal

minimal

>12

Loratadin





minimal

minimal

>12

Terfenadin





minimal

minimal

>12

Triprolidin





Sedang

minimal

6-12

Fexofenadin





minimal

minimal

>12

Desloratadin





minimal

minimal

>12

Levocetirizin





minimal

minimal

>12





• • • • •

First-line treatment of allergic Not selective - Anticholinergic effects (what?) Well absorbed and metabolized in the liver The first generation: effect of sedatives, short duration of action The second generation: no sedative effect, duration of action is more long • The third generation?

1. 2. 3. 4. 5. 6.

Alkylamines Ethanolamines Ethylenediamines Piperazines Phenothiazines Piperadines

Alkylamines Chlorpheniramine maleate (Chlor Trimeton®) • CTM

: Agen antialergi (Histamin) -- H1-receptor antagonist.

• Nama kimia : 2-Pyridinepropanamine, b-(4-chlorophenyl)-N,N-dimethyl. • Indication: Allergy, urticaria, food allery, Emergency treatment of anaphylaxis • Dosage : - Oral 0.1 mg/kg/dose (adult 4 mg) every 6-8 hour • Side effects : Drowsiness, sedation, digestive tract disorders,hypotension, and Pain head. • Contraindications : Epilepsi, liver, hypersensitivity

Ethanolamines/Benadryl

CH3 C H

O

C C N H2 H2

HCl CH3

• Relieve allergic rhinitis (seasonal allergy) Diphenhydramine Hydrochloride symptoms including sneezing, runny nose, itching, and watery eyes • Relieve itching and swelling associated with uncomplicated allergic skin reactions. • Control coughs due to colds or allergy.

Side Effects: fatigue, dizziness, and sedation. Due to: the peripheral anticholinergic effects and the “interactions with a number of neurotransmitter systems in the CNS” Structure fits relatively well to serve as an anticholinergic agent (specifically at the muscarinic receptor) and has the ability to penetrate the blood brain barrier due to their relative lipophilicity.

(Piperazines) Hydroxyzine HCl (Atarax)

(Phenothiazines) Promethazine HCl (Phenergan®)

(Piperadines) Azatadine (Optimine®) See the MIMS

Terfenadine (Seldane®)  Non-sedating

 Dosage: Children: 1 mg/kg/dose (adult 60 mg) 12 H oral. • Low lipid solubility, does not cross the blood-brain barrier,

binds to plasma proteins, long half-life. Metabolized by cytochrome P450. If excretion impaired, may be toxic to CNS. • Ineffective in motion sickness. • Serious side effects in case of hepatic dysfunction, concomitant administration of some drugs (erythromycin) or overdose. Erythromycin inhibits cytochrome P450.

Second…………….

Fexofenadine HCl(Allegra®) • Safe metabolite of Terfenadine • Non-sedating • Clinical studies showed no cardiac side effects - Active metabolite of terfenadine

- Does not cross the blood-brain barrier, no anticholinergic or a1- adrenergic receptor blocking effect - Half life of 14 hrs., 95% excreted in urine unmetabolized.

Loratadine (Claritin®)  Developed from Azatadine

 Non-sedating  No reported cardiac side effects up to 160 mg  Dosage (Oral) - Children 0.2 mg/kg - Adult 10 mg) daily

INDICATION: Claritin (Loratadine) is indicated for the relief of nasal and non-nasal symptoms of seasonal Allergic Rhinitis and for the treatment of Chronic idiopathic urticaria in patients 2 years of age or older.

Loratadine (Claritin®) Dosage: Adults and children 6 years : 10 mg tablet or reditab, or 2 teaspoonfuls (10 mg) of syrup once daily. Children 2 to 5 years of age : Syrup is 5 mg (1 teaspoonful) once daily.

Cetirizine (Zyrtec®)  Metabolite of hydroxyzine Effective against rash/hives  No reported cardiac side effects  Potential for sedation

Indication:

 Seasonal Allergic Rhinitis due to allergens such as ragweed, grass and tree pollens in adults and children 2 years of age and older. Symptoms treated effectively include sneezing, rhinorrhea, nasal pruritus, ocular pruritus, tearing, and redness of the eyes.  Perennial Allergic Rhinitis due to allergens such as dust mites, animal dander and molds in adults and children 6 months of age and older. Symptoms treated effectively include sneezing, rhinorrhea, postnasal discharge, nasal pruritus, ocular pruritus, and tearing.  Chronic Urticaria is indicated for the treatment of the uncomplicated skin manifestations of chronic idiopathic urticaria in adults and children 6 months of age and older. It significantly reduces the occurrence, severity, and duration of hives and significantly reduces pruritus.

Cetirizine (Zyrtec®) Dosage Form: Tablet : 5 mg and 10 mg Syrup : 1 mg/mL Chewable tab : 5 mg and 10 mg Can be taken with or without water.

1. Cimetidine (Tagamet) associated with most side effects 2. Ranitidine (Zantac) 3. Famotidine (Pepcid) 4. Nizatidine (Axid) 5. Roxatidine

Properties of Histamine H2 Receptor Antagonists CIMETIDINE RANITIDINE Bioavailability (%)

FAMOTIDINE

NIZATIDINE

80

50

40

>90

1

5-10

32

5-10

1.5-2.3

1.6-2.4

2.5-4

1.1-1.6

Approximate duration of therapeutic effect (hrs.)

6

8

12

8

Relative effect on cytochrome P450 activity

1

0.1

0

0

Potency

Plasma half-life (hrs.)

Decongestants • Sympathomimetic class -- act on adrenergic receptors in the nasal mucosa to cause vasoconstriction, shrink the swollen mucosa, and improve breathing. • Use of topical decongestants do not cause or cause very little systemic absorption • The use of topical agents a long time (more than 3-5 days) can cause medical rhinitis, in which nasal congestion due back peripheral vasodilatation---restrict the use of

Topical decongestants and duration of drug action Drugs

Duration of Action

Short action Fenilefrin HCl

up to 4 hours

Medium action Nafazolin HCl Tetrahidrozolin HCl

4-6 hours

Long action Oximetazolin HCl Xylometazolin HCl

Up to 12 hours

(Schwinghammer, 2001)

Oral Decongestants

• Onset is slow, but the effects last longer and are less - cause local irritation not present a risk rhinitis medikamentosa Example: Phenylephrine Fenilpropanilamin Narrow TI --- the risk of hypertension Pseudo ephedrine

Mast cell stabilizers • Mast cell stabilizers untuk menstabilkan sel mast untuk mencegah degranulasi dan pelepasan mediator. Obat ini tidak biasanya digolongkan sebagai antagonis histamin, tetapi memiliki indikasi serupa.

Sodium kromolin • A mast cell stabilizer - prevent mast cell degranulation and release of mediators, including histamine. • Available as a nasal spray to prevent and treat allergic rhinitis. • Side effects: local irritation (sneezing and pains in nasal mucous membranes • The dose for patients over 6 years old is 1 spray in each nostril 3-4 times a day at regular intervals. • For seasonal rhinitis, use of these drugs at the time of initial allergy season and is used continuously throughout the season. • For perennial rhinitis, the effect may not be visible within the first 2-4 weeks, for that decongestants and antihistamines may be required during therapy is started.

Ipratropium bromida • An anticholinergic agent shaped spray nose • Useful in persistent allergic rhinitis or perennial • Antisekretori properties if used locally and beneficial to reduce runny nose that occurs in allergic rhinitis. • Available in the form of a solution with a content of 0.03%, given in 2 sprays (42 mg) 2-3 times a day. • Mild side effects, including headache, epistaxis, and nose feels dry.

Comparison of standard drugs used in allergic rhinitis Oral antihist

Nasal antihist

Nasal Steroids

Nasal decong

Nasal Ipratropium

Nasal Cromoglic ate

Runny nose

++

++

+++

0

++

+

Sneezing

++

++

+++

0

0

+

Itching

++

++

+++

0

0

+

Blockage

+

+

+++

++++

0

+

Eye symptoms

++

0

++

0

0

+

Onset of action

1h

15 min

12 h

5–15 min

15–30 min

Variable

Duration

12–24 h

6–12 h

12–48 h

3–6 h

4–12 h

Variable

ATOPIC DERMATITIS Common immune-mediated inflammatory skin disorder Prevalence in general population in Western industrialized countries: 10-20% Multi-factorial etiology Interactions of genes and environment Family history of disease usually positive for affected blood relatives AD genes localized to certain chromosomes-known genes in these areas control immune response and inflammation

FLARE FACTORS IN ATOPIC DERMATITIS

SIGNS AND SYMPTOMS       

Pruritus (itching) Dry, scaly skin Ruam di wajah, kulit kepala, tangan, kaki Benjolan kecil terbuka Kemerahan dan pembengkakan kulit Penebalan kulit (with chronic dermatitis) Location of Dermatitis Lutut, Tikungan siku Wajah Bagian luar pergelangan kaki Leher

TREATMENT OF ATOPIC DERMATITIS • Identify and control “flare factors” • Topical treatments – Glucocorticosteroids – Newer “non-steroidal” TIMs • Emollients – Moisturizers – Baths with added lubricants • Systemic treatments – Oral antihistamine (a cornerstone of treatment) – Oral antibiotics – Systemic steroids – Immunosuppression (phototherapy, cytotoxic drugs)

TOPICAL GLUCOCORTICOIDS STEROID

ADVANTAGE

DISADVANTAGE

CLASS I

SUPER-POTENT, FAST ACTING

CAUSES THIN SKIN, NOT SAFE IN KIDS SHORT-TERM USE ONLY

CLASS III

INTERMEDIATE,STILL CAUSES SAFER FOR THINNING OVER CHRONIC USE LONG-TERM

CLASS VI

LOW POTENCY, LIMITED SAFE IN KIDS, EFFECTIVENESS THIN SKIN AREAS

Betamethasone Propionate - Approved in 2001 • Diprolene AF Cream, 0.05% - a Class II steroid • Diprosone Ointment, 0.05% - a Class II steroid • Diprosone Cream, 0.05% - a Class III steroid • Diprosone Lotion, 0.05% - a Class V steroid • Lotrisone Cream and Lotion (clotrimazole and betamethasone propionate)

• Contents : Gel (0168-0266) betamethasone dipropionate 0.5 milligram in 1 gram • Indications : - The relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses. - This product is not recommended for use in pediatric patients under 12 years of age. • Dosage : Apply a thin layer of betamethasone dipropionate gel (augmented) to the affected skin once or twice daily and rub it in gently and completely. • Betamethasone dipropionate gel (augmented) should not be used with occlusive dressings. • Overdosage : Topically applied betamethasone dipropionate gel (augmented) can be absorbed in sufficient amounts to produce systemic effects

2002 Guidelines Update: An Overview of the Pathogenesis of Asthma • “Asthma is a chronic inflammatory disease of the airways” posing “a significant health burden” • Many cell types and cellular elements mediate the inflammation • In susceptible individuals, inflammation causes: – Increased bronchial hyperresponsiveness to various stimuli – Recurrent episodes of wheezing, breathlessness, chest tightness, and cough – Widespread, variable airflow obstruction that is often reversible with treatment

41 2002;110(pt 2):S141-219. NAEPP. Guidelines update 2002. J Allergy Clin Immunol.

Stepwise Approach to Asthma Therapy for Children Aged 5 Years Step 4 Severe Persistent

Step 3 Moderate Persistent Step 2 Mild Persistent

Step 1 Mild Intermittent No daily medication

Preferred: low-dose ICS Alternative: cromolyn or LTRA

Preferred: low-dose ICS + LABA or medium-dose ICS (+ LABA if needed)

High-dose ICS + LABA (+ systemic corticosteroids if needed)

Alternative: low- to med-dose ICS + LTRA or theophylline

ICS = inhaled corticosteroid; LTRA = leukotriene receptor antagonist; LABA = long-acting 2-adrenergic agonist. 42 NAEPP. J Allergy Clin Immunol. 2002;110(pt 2):S141-S219.

Overlapping Symptoms

LRDs

“All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] Allergic Asthma

Non-allergic Asthma

“Bronchitis”

– Wheezing/Mengi

– Wheezing

– Wheezing

– Cough

– Cough

– Cough

– Dyspnea

– Dyspnea

– Dyspnea

– Chest tightness

– Chest tightness

– Rhinitis

– Conjunctivitis

LRDs

Medication: Determined By Severity Level Classification 1. Mild Intermittent

Reliever only prn 2. Mild Persistent Controller and reliever 3. Moderate Persistent Controller plus long-acting bronchodilator and reliever 4. Severe Persistent Controller plus long-acting bronchodilator and reliever

A. Tujuan terapi --- Indikasi penyakit  Cara pemberian obat  Sifat dan durasi obat B. Kondisi Pasien • Kenyamanan pasien • Keamanan • Dapat menelan/tidak • Kondisi sadar/tidak C. Sifat-sifat fisika-kimia obat • Stabilitas • Iritasi/tidak

KIND OF DRUG ADMINISTRATION Route of administration Oral (Peroral, Peros)

Location

Pharmaceutical dosage form

Mouth, GIT System Through The Mouth

Tablet, Capsul, Lotions, Syrups,

Sublingual

Under The Tongue

Tablet, Lozenges, Trochici

Parenteral Intravena (I.V.) Intraarterial (I.A.) Intrakutan/Intradermal (I.C.) Subkutan (S.C.) Intramuskuler (I.M.)

By Injection Vena Artery Skin Under the skin Muscle

Lotions, Suspension,

Epikutan (Topical)

Skin Surface

Oinment, Cream, Pasta, Plester,

Elixsir, Suspension, Jel, Powder

The pPowder is dissolved in aqua pro injection

Powder, Aerosol, Lotion, Suspension. Transdermal

Skin Surface

Cream, Plester, Powder, Aerosol, Transdermal Dosage Form (Tempel)

Cont.... Route of Adm

Location

PDF

Conjungtivital

Cornea

Ointment

Intraocular

Eye

Solutio, Suspension

Intranasal

Nose

Solutio, Spray, Inhalation

Aural

Ear

Solutio, Suspension

Intrarespiratori

Pulmonary Through The Mouth(inhaled)

Aerosol (Spray ), Turbohaler, Diskinhaler, Rotahaler

Rectal

Rectum

Solution, Ointment, Suppositoria

Vaginal

Vagina

Solution, Ointment, Emulsion, Tablet, Supositoria (Ovula)

Uretral

Uretra

Solution, Bacilla

HOW TO USE SPECIAL DOSAGE FORM  Information drug rules for special preparations to be seen/read clearly by doctors The number of PDF required one time use needs to be calculated carefully

 How to use special PDF should be well understood and correctly by doctors Instructions on the following images

KINDS OF DRUG ADMINISTRATION 1. ORAL (Drug-->mouth--> esophagus ---> GIT)

Cetirizine Zyrtec Allergy Syrup Children: 6 to 12 months : 1/2 tsp. (2.5 mg) once a day. 1 to 5 years : 1/2 tsp. [2.5 mg] Once or twice a day. 6 to 11 years : 1 or 2 tsp. [5 or 10 mg] Once a day.

Loratadine Claritin Syrup (1 mg/mL) Age 2 to 6 : 5 mg daily (1 tsp). Age 7 and above : 10 mg daily (2 tsp).

2. PARENTERAL With injections - Im, iv, ip, intracardiac - Sc, sc, intra-arterial

Intra muskuler

Intra vena

subkutan

Injection Dosage form Aspiration of ampoules (glass and plastic)

Injection dissolving dosage (in powder form)

Injection preparations (aspiration of vials)

Techniques / How to use subcutaneous injections

Techniques / How to use Intramuscular injections

Techniques / How to use Intravenous injections

How to use Injections dosage form The reason for giving the drug by injection 1. - Want a quick effect - The only preparation that can produce the expected effect

It should be noted in the use of dosage form of injection / infusion i.v. :    

The effect (also undesirable effects ) Actions to take if there were any side effects Terms of use syringe Calculation of the volume of injection and drip infusion (according to the administered dose)

3. INHALASI Through endothelial alveoli, how inhaled through the mouth, nose (drug: solid /volatile liquid / gas)

Aerosol

Inhaler (Turbuhaler)

NASAL SOLUTION Azelastine (Astelin) Nasal solution 0,1%, 0,137mg/spray Topical : 1-2 spray/nostril 2x daily Levocabastine (Livostin) Microsuspension Nasal Spray 0,5 mg/mL Topical : 2 spray/nostril 2-4x daily

OPHTHALMIC SOLUTION Ketotifen (Zaditen) Ophthalmic solution 0,025% ≥ 3 years : 1 drop 8-12 hours (each eye)

BRONCHODILATORS

Example : Ventolin Trade Name Generic Name Therapeutic class

: Ventolin : Salbutamol : Sympathomimetic, Bronchodilators

These medications quickly control acute asthma attacks. Short-Acting Beta2-Agonists Beta2-agonists do not reduce inflammation or airway responsiveness but serve as bronchodilators, relaxing and opening constricted airways during an acute asthma attack. They are used alone only for patients with mild and intermittent asthma. Patients with more severe cases should use them in combination with other drugs.

Short-acting bronchodilators are generally administered through inhalation and are effective for 3 - 6 hours. They relieve the symptoms of acute attacks, but they do not control the underlying inflammation. If asthma continues to worsen with the use of these drugs, patients should discuss corticosteroids or other drugs to treat underlying inflammation.

Side Effects of Beta2-Agonists. Side effects of all beta2-agonists include: • • • • •

Anxiety Tremor Restlessness Headache Fast and irregular heartbeats.

Mode of administration and dosage of drugs Inhalation , oral, parenteral •

Dosage – Adult inhalation: 100-200 mcg, 3-4 times a day Oral - Adult: 2-4 mg / time, 3-4 times a day Children <2 years: 100 ug / kg, 4 times a day 2-6 years :1-2 mg / time, 3-4 times daily 6-12 yr : 2 mg / time, 3-4 times a day Preparations: 100 mcg / times, 200 dose MDI (Metered-dose inhaler) - Tablets 2 mg, 4 mg - 2 mg/5ml syrup, 60 ml

INHALER

Background An inhaler - no spacer

 Using a metered-dose inhaler (MDI) seems simple, but many people do not use them the right way. If you use your MDI the wrong way, less medicine gets to your lungs. If you have a spacer, you should use it because it helps get more of the medicine into your airways.

VENTOLIN • MDI with cap removed from mouthpiece • Vertical portion of device must be held at 90 degrees

Getting Ready    

Take off the cap and shake the inhaler hard. If you have not used the inhaler in a while, you may need to prime it. See the instructions that your inhaler came with for how to do this. Breathe out all the way. Hold the inhaler 1 - 2 inches in front of your mouth (about the width of 2 fingers).

Breathe in Slowly  

Start breathing in slowly through your mouth, and then press down on the inhaler 1 time. (If you use a spacer, press down on the inhaler before you breathe in. Within 5 seconds, begin to breathe in slowly.) Keep breathing in slowly, as deeply as you can.

Hold Your Breath 

 

Hold your breath as you count to 10 slowly, if you can. This lets the medicine reach deep into your lungs. If you are using inhaled quick-relief medicine (beta-agonists), wait about 1 minute before you take your next puff. You do not need to wait a minute between puffs for other medicines. After using your inhaler, rinse your mouth with water, gargle, and spit out. This will help reduce unwanted side effects from your medicine.

INHALER MDI-SPACER

Background An inhaler - with spacer  If you use your inhaler the wrong way, less medicine gets to your lungs. A spacer device will help. The spacer connects to the mouthpiece. The inhaled medicine goes into the spacer tube first. Then you take two deep breaths to get the medicine into your lungs. Using a spacer wastes a lot less medicine than spraying the medicine into your mouth.  Spacers come in different shapes and sizes. Ask your doctor which spacer is best for you or your child. Almost all children can use a spacer. You do not need a spacer for dry powder inhalers

VENTOLIN MDI - SPACER

• A spacer device may be used to better direct the medication spray • Remember to shake the canister well

To Use a Spacer:

1. Shake the inhaler well before use (3-4 shakes) 2. Remove the cap from your inhaler, and from your spacer, if it has one 3. Put the inhaler into the spacer 4. Breathe out, away from the spacer 5. Bring the spacer to your mouth, put the mouthpiece between your teeth and close your lips around it 6. Press the top of your inhaler once 7. Breathe in very slowly until you have taken a full breath. If you hear a whistle sound, you are breathing in too fast. Slowly breath in. 8. Hold your breath for about ten seconds, then breath out.

HANDIHALER

Background

 Handihaler uses an inhalation capsule to deliver medicine to the lungs. People often forget critical steps when using their Handihaler which directly affects the medicine outcome.  Studies show that annually $10 Billion are wasted just because people don’t use their asthma inhalers correctly. It is not always feasible to visit your doctor or the pharmacist in case you have forgotten the steps or have misplaced the instructions that come along with your Handihaler.  Clinical studies have proved that Asthma and COPD patient's inhaler techniques can be significantly improved by educating the patients about their inhaler use. Inhaler education can be best delivered to the Asthma and COPD patients through audiovisual instructions performed by the skilled educator.

1. 2. 3. 4. 5.

Dust cap (lid) Mouthpiece Mouthpiece ridge Base Green piercing button 6. Center chamber 7. Air intake vents

1. 2. 3. 4.

Open the HandiHaler device. Separate only one of the blisters from the blister card, then open the blister Insert the SPIRIVA capsule and close the mouthpiece firmly against the gray base until you hear a click Press the green piercing button once until it is flat (flush) against the base, then release Breathe out completely. Then, with the HandiHaler in your mouth, breathe in deeply until your lungs are full. You should hear or feel the SPIRIVA capsule vibrate (rattle).

Remember: To take your full daily dose, you must inhale twice From the same Spiriva capsule

DISKHALER

Background  A Diskhaler® is a dry-powder inhaler that holds small pouches (or blisters), each containing a dose of medication, on a disk.  The Diskhaler® punctures each blister so that its medication can be inhaled.

How to use a Diskhaler®* 1.

Remove the cover and check that the device and mouthpiece are clean. 2. If a new medication disk is needed, pull the corners of the white cartridge out as far as it will go, then press the ridges on the sides inwards to remove the cartridge. 3. Place the medication disk with its numbers facing up on the white rotating wheel. Then slide the cartridge all the way back in. 4. Pull the cartridge all the way out, then push it all the way in until the highest number on the medication disk can be seen in the indicator window. 5. With the cartridge fully inserted, and the device kept flat, raise the lid as far as it goes, to pierce both sides of the medication blister. 6. Move the Diskhaler® away from your mouth and breathe out as much as you can until no air is left in your lungs. 7. Place the mouthpiece between your teeth and lips, making sure you do not cover the air holes on the mouthpiece. Inhale as quickly and deeply as you can. Do not breathe out. 8. Move the Diskhaler® away from your mouth and continue holding your breath for about 10 seconds. 9. Breathe out slowly. 10. If you need another dose, pull the cartridge out all the way and then push it back in all the way. This will move the next blister into place. Repeat steps 5 through 9. 11. After you have finished using the Diskhaler®, put the mouthpiece cap back on.

TURBOHALER

Background How does it work?  The Turbohaler can be used to provide different types of medication depending on your problem and how severe it is  It is likely to be either: Terbutaline (Bricanyl) or Formoterol (Oxis) and Budesonide (Pulmicort) or Symbicort. Budesonide and Symicort contain a steroid.  If you have an inhaler that contains a steroid you must rinse your mouth out with water to prevent developing a sore mouth, husky voice or oral thrush.  These inhalers work by relaxing the muscles of the large airways and/or reducing inflammation.

How to use Turbuhaler 1. 2.

3.

4. 5. 6.

7.

Unscrew the protective cap and take it off. Check the number of remaining doses in the dose counter window. Hold the Turbohaler® in an upright position and hold the white section securely with one hand. With the other hand, first rotate the red grip to the right and then to the left, until you hear a click First breathe out. Only then, place the mouthpiece between your teeth, close your lips around it and breathe in forcefully and deeply. Remove the Turbohaler® from your mouth, hold your breath for 7 to 10 seconds, and then breathe out. If you have to take multiple doses, then repeat steps 2, 3 and 4 after 30 seconds. Clean the Turbohaler® with a dry cloth – avoid any contact with water. Replace the protective cap and store the Turbohaler in a dry place. Finally, rinse your mouth with water.

NEBULIZER

Background  A nebulizer is a small machine that turns liquid medicine into a mist. You sit with the machine and breathe in through a connected mouthpiece. Medicine goes into your lungs as you take slow, deep breaths for 10 to 15 minutes. It is easy and pleasant to breathe the medicine into your lungs this way.

 If you have asthma, you may not need to use a nebulizer. You may use an inhaler instead, which is usually just as effective. But a nebulizer can deliver medicine with less effort than an inhaler. You and your doctor can decide if a nebulizer is the best way to get the medicine you need. The choice of device may be based on whether you find a nebulizer easier to use and what type of medicine you take.  Most nebulizers are small, so they are easy to transport. Most nebulizers also work by using air compressors. A different kind, called an ultrasonic nebulizer, uses sound vibrations. This kind of nebulizer is quieter, but costs more money.

 Nebulizer for asthma, COPD, or another lung disease

How to use nebulizer

1. Connect the hose to an air compressor. 2. Fill the medicine cup with your prescription. To avoid spills, close the medicine cup tightly and always hold the mouthpiece straight up and down. 3. Attach the hose and mouthpiece to the medicine cup. 4. Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. 5. Breathe through your mouth until all the medicine is used. This takes 10 to 15 minutes. If needed, use a nose clip so that you breathe only through your mouth. Small children usually do better if they wear a mask. 6. Turn off the machine when done. 7. Wash the medicine cup and mouthpiece with water and air dry until your next treatment.

REFERENCES : • Gennaro,A.F. Remington : The Science and Practice of Pharmacy, Philadelphia 2000 • WHO Model Formulary, World Health Organization, Geneva, 2004 • Hay, W.W., Hayward, A.R., Levin, M.J., and Soudheimer, J.M., 2002. Current Pediatric Diagnosis and Treatment, E Bood : Mc Graw Hill Education, Europe. • The handbook on Injectable Drugs, 14th ed. (Trissel, 2007) • Michael A Kaliner, 2005, Histamine and H1-Antihistamines in Allergic disease, Clinical allergy and immunology , 2nd Ed • Laube BL, Dolovich MB. Aerosols and aerosol drug delivery systems. In: Adkinson NF Jr, Bochner BS, Burks AW, et al., eds. In: Middleton's Allergy Principles and Practice. 8th ed. Philadelphia, PA: Elsevier Mosby; 2013:chap 66

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