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Wednesday, June 13, 2007

Why One COPD Medication Instead of Another?

Why Take a Bronchodilator? Bronchodilator inhalers and pills relax the airways, making them wider so that you can breathe more easily. The goal of bronchodilator therapy is to reduce shortness of breath. If you are not short of breath, or if they don’t noticeably relieve your shortness of breath, then perhaps you don’t need to take a bronchodilator regularly. Discuss this with your doctor.

What Side-Effects are Possible from Bronchodilators? Bronchodilator inhalers and pills are stimulants, like the caffeine in coffee and tea. Thus you may experience nervousness (anxiety), shakiness (tremor), a more rapid pulse, insomnia, or stomach upset (nausea). These will only last for the duration of the effect of the bronchodilator (2 to 4 hours for short-acting inhalers, but 12-24 hours for long-acting inhalers). If you also have heart disease, you may experience palpitations (worrisome cardiac arrhythmias), or angina. If this happens, contact your doctor and discuss it.

Why Take an Inhaled Corticosteroid? These inhalers are designed to reduce airway inflammation and swelling. This beneficial effect takes several days of daily use. These inhalers are often used when some degree of asthma is also present along with COPD. When taken every day, these inhalers may reduce the risk of an exacerbation (temporary worsening) of COPD.

What Side-Effects are Possible from Inhaled Corticosteroids? Many people develop yeast (Candida) infections in their throat (thrush) after using them for several weeks or more. These yeast infections are not serious, but often cause a sore throat, a sore tongue, a white coating at the back of the throat and tongue (which you can see by shining a light at the back of your throat and looking in a mirror). These yeast infections sometimes extend to your vocal cords, causing a change in your voice (hoarseness). Use of a spacer and gargling after taking the inhaler can reduce the risk of thrush. Antifungal lozenges (Nystatin, TM) can be prescribed to kill the Candida yeast.

High daily doses of inhaled corticosteroids (1000 mcg or more) taken for long periods of time may also cause some of the side-effects of prednisone (see that box). Poverty is also a possible side-effect, if you have to pay for these brand-name inhalers out of your own pocketbook.

Why Take Prednisone? Prednisone pills are strong medicine, but very inexpensive since they are generic. They reduce the airway inflammation caused by viral respiratory infections. Prednisone (or its expensive cousin, prednisolone) is often given to treat a COPD exacerbation (worsening).

What are the Side-Effects of Prednisone? Because it is so strong, and distributed to the entire body, prednisone causes some side-effects in most patients. The higher the dose, the more likely side-effects will occur, so most doctors like to stay below 60 mg per day. The longer the time that prednisone is taken, the more likely that serious side-effects will occur, so most doctors like to give only “bursts” of prednisone for 5 to 14 days.

When taken for only a few days, prednisone may cause changes in mood (good or bad) or increased appetite. When taken for months to years, prednisone may cause serious side-effects, such as adrenal suppression (so you must not stop it cold turkey), fluid retention (a moon-shaped face), thinning of the bones (osteoporosis), cataracts, immune system suppression (increased risk of infection), and many other possible side-effects.

Why One Inhaler Versus Another? The primary goal of inhalers is to deliver most of the medication deep into the lungs, where it will be most effective. A secondary goal of inhaler devices is to minimize the amount of drug deposited at the back of the throat.

Small inhalers which you can put in your pocket or purse are generally preferred by patients. These are called metered-dose inhalers (MDIs). Over the last decade, they have evolved to become easier to use, more efficient, and more expensive. In 2007, the FDA eliminated generic albuterol, which used freon as a propellant, so it has been replaced by HFA propellants or by dry powder inhalers (DPIs). The best new inhalers are breath-activated, triggering themselves automatically when you begin to inhale deeply. This makes it more likely that most of the medication will be delivered deep into your lungs. Dry powders and spacers reduce the amount sticking to the back of your throat.

Why Use a Nebulizer Instead of a Pocket Inhaler? The primary advantage of a nebulizer is that you only breathe quietly. Some doctors also believe that nebulizers are more effective for some patients. Nebulizers to deliver a mist of medication have been around for more than 100 years. The air pressure needed to nebulize the liquid medication was first generated by a hand-bulb, then a tank of oxygen, then an electric pump (compressor), and most recently by ultrasound. Usually, about 3cc (about a teaspoon) of the medication solution is placed into the nebulizer. Then you breathe quietly from the nebulizer mouthpiece for a few minutes.

The Disadvantages of Nebulizers:

  1. you have to pour the medication into the nebulizer;
  2. it takes longer to deliver the medication;
  3. the device is more expensive;
  4. compressors are noisy and must be plugged into the wall;
  5. the nebulizers should be cleaned routinely.

On the other hand, the primary disadvantage of most pocket inhalers is that technique is important — you have to figure out how to trigger the inhaler at the beginning of a slow and very deep inhalation and then hold your breath for several seconds. Sometimes you are not confident that the pocket inhaler actually delivered the medication into your lungs, because you can’t see the mist or powder.

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Posted by: Paul Enright MD at 5:10 pm


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