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Mark Mangus, RRT EFFORTS Board

Ask Mark …

Note: We would like to sincerely apologize for printing the wrong sequence of medication chart in our last issue! The outdated chart caused confusion and we regret the error. Hopefully, this will clear things up.

Mark Mangus and Dr. Noah Greenspan, Director of Ultimate Pulmonary Wellness in New York City, collaborated on these recommendations on the best order to take your daily medications.image061

Medications classified as Short Acting Beta Agonists (SABA), and those classified as Short Acting (Anticholinergic) Muscarinic Antagonists (SAMA), are in the white boxes without shading.

The shaded boxes in the chart are the Long Acting Beta Agonists (LABA), Long Acting (Anticholinergic) Muscarinic Antagonists (LAMA), and inhaled corticosteroids (ICS).

So that you understand how they work, the Short Acting Beta Agonists, as Albuterol, are your rescueimage062-1 inhalers. They open up your airways quickly and their effect lasts from two to four hours.

Short Acting Muscarinic Agents, as Atrovent, also open up your airways but a bit slower than the SABA – usually within 15 minutes of taking the medication and last for three to six hours.

The Long Acting Beta Agonists, as Salmeterol, are used to stabilize your airways as a maintenance drug. Inhaled corticosteroids, as Flovent, reduce inflammation in your airways. They do not provide fast relief but help to keep your airways stable. Depending on the drug, these are taken once or twice a day.

Long Acting AntiCholinergic Agents, as Spiriva, work by preventing the muscles in your airway from constricting. Taken once a day, image063their effect lasts for 24 hours.

Mark and Dr. Greenspan recommend:

If you use a SABA on a regular basis, always take it after the LABA.

If you have taken your short acting medication, wait at least two hours before the long acting drugs in the same class to avoid interference with the way the long acting drug works. Example, if you have taken Albuterol a SABA – wait for two hours before taking Serevent – a LABA If you use a SAMA, as Atrovent, in addition to your LAMA, as Spiriva, always take the

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Mark Mangus RRT, BSRC, is a member of the Medical Board of EFFORTS (the online support group, Emphysema Foundation For Our Right To Survive, www.emphysema. net). He generously donates his time to answer members’ questions.LAMA first. If you have taken the SAMA first, wait two hours before taking the LAMA.

These recommendations are based on the fact that if the long-acting AND short-acting medications are taken too closely together, they will be competing for the same receptor sites and the long-acting medications will not be as effective.

The technique of airway priming is using your SABA within a few minutes before using your LABA. For example: You inhale two puffs of Al- buterol just before taking your Breo Ellipta, to ‘open’ up your airways to better receive the Breo. Mark and Dr. Greenspan advise against airway priming. While there are no formal studies to sup- port either airway priming or LABA before SABA, the vast majority of COPD patients report reduced need to use their rescue inhaler in between doses of their LABA, resulting in less medication use and significant cost savings over time, when following these recommendations.

For further information on sequence of medica- tions, download the online edition of Ultimate Pulmonary Wellness at www.PulmonaryWellness Book.com

Inhaled Medications Chart and Suggested Sequence of Administration

 

Bronchodilators Inhaled

Corticosteroids

Anticholinergics Beta-2 Agonists
GENERIC BRAND GENERIC BRAND GENERIC BRAND
ipratropium bromide ATROVENT albuterol sulfate PROVENTIL, VENTOLIN,

PROAIR

 

dipropionate

QVAR
tiotropium

bromide

SPIRIVA levalbuterol

tartrate

XOPENEX budesonide ULMICORT
aclidinium

bromide

TUDORZA terbutaline NONE ciclesonide ALVESCO
umeclidinium INCRUSE

ELLIPTA

salmeterol

xinafoate

SEREVENT flunisolide AEROBID
aformoterol

tartrate

BROVANA fluticasone FLOVENT
formoterol

fumarate

FORADIL,

ERFOROMIST

mometasone ASMANEX
indacaterol ARCAPTA

NEOHALER

triamcinolone

acetoide

indacaterol

maleate

ONBREZ

BREEZHALER

fluticasone

furoate

ARNUITY

ELLIPTA

oldaterol STRIVERDI

RESPIMAT

Combination Medications

Brand

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mb

Bronchodilators  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ngu

Inhaled

Corticosteroids

Anticholinergics  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PT,

Beta-2 Agonists
COMBIVENT, DUONEB ipratropium bromide albuterol
ADVAIR salmeterol fluticasone propionate
SYMBICORT formoterol fumarate

dihydrate

budesonide
DULERA formoterol

fumarate dihydrate

mometasone furoate
BREO ELLIPTA vilanterol fluticasone furoate
ANORO ELLIPTA umeclidinium vilanterol
ULTIBRO

BREEZEHALER

glycopyrronium

bromide

indacaterol

maleate

STIOLTO RESPIMAT tiotropium bromide olodaterol
BEVESPI

AEROSPHERE

glycopyrrolate formoterol

fumarate

Updated Septe er 1, 2018. Noah Greenspan, D CCS, EMT-B and Mark W. Ma s, Sr., BSRC, RRT, RPFT, FAARC