Pharmacology
Asthma & COPD inhalers — stepwise therapy
Pharmacology

Asthma & COPD inhalers — stepwise therapy

SABA, ICS, LABA, LAMA, biologics — when each gets added.

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◆Asthma stepwise (GINA-ish)

  • •Step 1: low-dose ICS + formoterol PRN (preferred to SABA-only)
  • •Step 2: daily low-dose ICS + SABA or ICS/formoterol PRN
  • •Step 3: low-dose ICS-LABA (formoterol or salmeterol) + SABA
  • •Step 4: medium-dose ICS-LABA
  • •Step 5: high-dose ICS-LABA + LAMA (tiotropium) + consider biologic
  • •Biologics: omalizumab (anti-IgE — allergic asthma), mepolizumab/benralizumab (anti-IL-5 — eosinophilic), dupilumab (anti-IL-4/13 — type 2 inflammation)

◆COPD stepwise (GOLD)

  • •Group A (low risk, few sx): SABA or SAMA PRN
  • •Group B (low risk, more sx): LABA or LAMA
  • •Group E (high risk regardless): LABA + LAMA; add ICS if eos ≥ 300 or frequent exacerbations
  • •DON'T use ICS monotherapy in COPD (no benefit, increased pneumonia risk)
  • •Roflumilast for severe COPD with chronic bronchitis + frequent exacerbations
  • •Pulmonary rehab + smoking cessation + vaccines (influenza, pneumococcal, COVID) — biggest non-drug interventions

◆Acute exacerbations

  • •Asthma exacerbation: O2, nebulized albuterol + ipratropium, systemic steroids (PO if mild–moderate, IV if severe), IV magnesium if severe
  • •Asthma escalation: BiPAP if respiratory failure; intubate if AMS, exhaustion, hypercapnia worsening
  • •COPD exacerbation: O2 (target SpO2 88–92%), bronchodilators, steroids (prednisone 40 mg × 5 days), antibiotics (if purulent sputum, increased dyspnea, mechanical ventilation)
  • •COPD severe: BiPAP if pH < 7.35 with hypercapnia and respiratory acidosis (decreases intubation rate)

◆Side effects

  • •SABA (albuterol): tachycardia, tremor, hypokalemia, hyperglycemia
  • •LAMA (tiotropium): dry mouth, urinary retention (caution in BPH); paradoxical bronchospasm
  • •ICS: oral candidiasis (rinse mouth), dysphonia, ↑ pneumonia in COPD, growth velocity slightly slowed in kids (catches up)
  • •Theophylline (rare use): narrow therapeutic index, arrhythmia, seizures, GI

High-yield pearls

  • ◆Asthma + β-blocker → use cardioselective only (or avoid); non-selective can trigger bronchospasm
  • ◆Asthma + aspirin sensitivity + nasal polyps = Samter's triad → use leukotriene modifier (montelukast) or biologics
  • ◆COPD goal O2 sat 88–92% (avoid V/Q mismatch and CO2 retention)
  • ◆BiPAP saves intubation in COPD exacerbation with hypercapnic respiratory acidosis (pH < 7.35)
  • ◆ICS in COPD only when eosinophils ≥ 300 or frequent exacerbations on dual bronchodilator
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