Updates in Pharmaceutical Therapies for Treatment

Dr. Marla M Woods, PharmD, BCPS, CDE, AE-C Director of Pharmacy Memorial Healthcare Owosso, MI Pharmacy Systems Inc

Objective/Outline

• Participants will be able to describe new pharmaceutical entities and delivery products for the treatment of asthma • Overview of new pharmaceutical therapies • New delivery products

Vasodilation Bronchoconstriction Short-Acting β2 Agonists

Onset: 5-15 minutes; Duration: 2-6 hours

Long-Acting β2 Agonists

Onset: 30-50 minutes; Duration: 10-12 hours

Ultra Long Acting Beta Agonist (LABA)

• Carmoterol • -Arcapta- • - Breo Ellipta- • Oldaterol- Striverdi Respimat – (cartridge separate from inhaler) Ultra Long Acting Beta Agonist (LABA)

• Carmoterol • Indacaterol-Arcapta- COPD only • Vilanterol- Breo Ellipta- COPD only • Oldaterol- Striverdi Respimat – (cartridge separate from inhaler) COPD – chronic bronchitis, emphysema Inflammation and Autacoids

Inhaled Corticosteroids •Onset: 4-8 weeks •Products Available: • * (Pulmicort) • * propionate (Flovent) • * acetate (Azmacort) • * (Asmanex) • * (Alvesco) • (AeroBid) • Beclomethasone dipropionate (QVAR)

New?

• Arnuity Ellipta (fluticasone furoate inhalation powder) Company: GlaxoSmithKline Approval Status: Approved August 2014 Treatment Area: asthma

• General Information • Arnuity Ellipta contains the active component fluticasone furoate, a synthetic trifluorinated corticosteroid with anti- inflammatory activity

Combinations

• LABA and IHC Combinations: • + fluticasone (Advair) • + budesonide (Symbicort) • Formoterol + mometasone (Dulera) • Vilanterol + fluticasone (Breo Ellipta) • LA anti-cholinergic and LABA Combination: • Umeclidinium + vilanterol (Anoro Ellipta)

IgE monoclonal antibody

Vasodilation Bronchoconstriction IgE modulators

• - Xolair- neutralizes IgE in the blood 1-3 injects Q2-4 weeks • Caused by year round allergens in the air • Quilizumab- keeps IgE from being produced • inhalation every 3 months

IgE monoclonal antibody •Product available • Omalizumab (Xolair) •Administration • Subcutaneous injection only! • Dose determined by serum IgE concentrations and body weight. • 150-375mg given q 2 or 4 weeks. • Anaphylaxis! •Cost/dose: $541.25 Omalizumab (Xolair®)

• Clinical Pearls—Cost-effectiveness Figure from Oba et al, 2004. al, et Oba from Figure

What Now?? Administration of respiratory drugs Aerosol Dosage Forms

• Site-specific • More drug, fewer side effects • Quicker effect • Ban on CFCs → new HFA devices • Benefits

MDIs (Metered Dose Inhalers)

• Most common(?) • Pressurized canister with metering valve • Factors to consider: • Inspiratory flow • Breath holding • Coordination • Priming/shaking • Device cleanliness

Holding Chambers/Spacers • Use with MDI • Decrease oropharyngeal deposition and enhance lung delivery • Factors to consider: • Inspiratory flow • Time between actuation and inhalation <5s. • Required less coordination • Clean to reduce static • Holding chamber vs. open ended spacer

DPIs (Dry Powder Inhalers)

• May use a powder-filled capsule that must be punctured, or may have powder contained within device. • Factors to consider: • Inspiratory flow (breath actuated) • Tilt head back • Maintain parallel to ground once primed • Humidity

Jet Nebulizers • Produce aerosol from a liquid in a cup, creating a cloud that is inhaled. • Factors to consider: • Inspiratory flow • Breath holding • Mouthpiece vs. facemask • Tapping nebulizer to increase dose

Ultrasonic Nebulizers

• Produce aerosol by vibrating liquid, which is then inhaled. • Factors to consider: • Inspiratory flow • Breath holding • Mouthpiece vs. facemask

New Technology

• Aeroneb • OnQ™ Vibrating Mesh Technology Questions?