Names and pronunciation
(floo-tic′a-sone/sal-mee′ter-ol) Advair Diskus, Advair HFA, AirDuo Digihaler, AirDuo RespiClick 113/14, AirDuo RespiClick 232/14, AirDuo RespiClick 55/14, Wixela Inhub
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Drug reference
(floo-tic′a-sone/sal-mee′ter-ol) Advair Diskus, Advair HFA, AirDuo Digihaler, AirDuo RespiClick 113/14, AirDuo RespiClick 232/14, AirDuo RespiClick 55/14, Wixela Inhub
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Func. class.: Corticosteroid, long- acting/β2-adrenergic agonist
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ACTION: Decreased inflammation in inhibiting mast cells, macrophages and leukotrienes; antiinflammatory and vaso- constrictor properties relax bronchial smooth muscles
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USES: Maintenance of asthma (long term), COPD
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CONTRAINDICATIONS: Hyper- sensitivity, acute asthma/COPD episodes, severe hypersensitivity to milk proteins Precautions: Pregnancy, breastfeeding, active infections, diabetes mellitus, glau- coma, immunosuppression, hyperthyroid- ism, Cushing syndrome, hypertension, QT prolongation, pheochromocytoma, sei- zures, MAOIs, other long-acting B2 ago- nists, inhaled corticosteroid
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Black Box Warning: Asthma-related deaths Black Box Warning: Asthma-related deaths: if wheezing worsens and cannot be relieved during an acute attack, pro- vide emergency response • Pregnancy/breastfeeding: use only if benefits outweigh fetal risk; use cau- tion in breastfeeding, excretion un- known Black Box Warning: Asthma-related deaths: seek medical attention immedi- ately if wheezing worsens and cannot be relieved during an acute attack • To rinse mouth after inhaled product to reduce the risk of oral candidiasis; not to swallow
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SIDE EFFECTS CNS: Fever, headache, nervousness, dizzi- ness, migraines, insomnia, tremors, agita- tion, anxiety, depression, hyperactivity, irritability EENT: Pharyngitis, sinusitis, rhinitis, lar- yngitis, hoarseness, dry eyes, cataracts, nasal discharge, epistaxis, hypersalivation, eye edema, dysphonia, conjunctivitis GI: Diarrhea, abdominal pain, nausea, vomiting, oral candidiasis GU: UTI INTEG: Urticaria, dermatitis META: Hyperglycemia, growth retarda- tion in children, cushingoid features MISC: Influenza, eosinophilic condi- tions, angioedema, Churg-Strauss syn- drome, anaphylaxis, adrenal insufficiency (high doses), reduced bone mineral den- sity, HPA axis suppression MS: Osteoporosis, muscle soreness, joint pain, decreased growth velocity RESP: Upper respiratory infection, dys- pnea, cough, bronchitis, bronchospasm
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INTERACTIONS Increase: CNS stimulation—theophylline Increase: fluticasone levels—CYP3A4 inhibitors (ketoconazole, itraconazole), darunavir, nelfinavir, ritonavir, amprena- vir, fosamprenavir, atazanavir, delavir- dine, saquinavir, MAOIs, linezolid Increase: tendinitis, tendon rupture— quinolones Increase: hypokalemia—loop diuretics, thiazides, theophylline Drug/Lab Test Increase: LFTs Decrease: Potassium
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DOSAGE AND ROUTES Asthma maintenance • Adult/adolescent ≥12 yr: INH 1 inha- lation of Advair Diskus q12hr, or 2 inha- lations of Advair HFA q12hr • Child 4-11 yr: INH 1 inhalation of fluticasone 100 mcg/salmeterol 50 mcg (Advair Diskus) q12hr, must be 12 hr apart COPD • Adult: INH 1 inhalation of Advair 250/50 Diskus q12hr, must be 12 hr apart
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Available forms: Inhalation 100/50, 250/50, 500/50 mcg fluticasone/salme- terol; aerosol spray 45/21, 115/21, 230/21 mcg fluticasone/salmeterol
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Administer: Oral inhalation route Powder for oral inhalation (Diskus): • Most children <4 years of age do not generate sufficient inspiratory flow to ac- tivate dry powder inhalers • Give with the Diskus device: • Mouth should be rinsed, spit out water • Discard device after 1 mo or when counter reads 0 (whichever comes first) HFA aerosol: • Shake canister; prime the inhaler before first use with 4 sprays away from face or with 2 sprays (away from the face) if it has not been used for more than 4 wk, or after dropping; use spacer if unable to coordi- nate inhalation/activation • Rinse mouth with water after use, clean mouthpiece at least every day; discard inhaler after 120 sprays or when the counter reads 000 Powder for inhalation (AirDuo RespiClick) • Do not use a spacer or volume holding chamber • Before using for the first time, check the dose counter window to ensure that the inhaler is full and the number “60” is in the window. The dose counter will count down each time the mouthpiece cap is opened and closed • Following use, instruct patient to rinse mouth with water without swal- lowing • Do not wash inhaler. If the mouthpiece needs cleaning, gently wipe it with a dry cloth or tissue • When there are “20” doses left, the numbers on the dose counter will change to red; refill the prescription • When the dose counter reaches “0,” the background will change to solid red • Throw away the inhaler 30 days after removing it from the foil pouch, when the counter displays “0,” or after the expira- tion date, whichever comes first
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Assess: • Respiratory status: vital capacity, forced expiratory volume, ABGs, lung sounds, heart rate/rhythm • Withdrawal symptoms from oral corti- costeroids: depression, pain in joints, fa- tigue • Adrenal insufficiency: nausea, weak- ness, fatigue, hypotension, hypoglycemia, anorexia; can occur when changing from systemic to inhalation corticosteroids; may be life threatening; adrenal function tests periodically: hypothalamic–pitu- itary–adrenal axis suppression in long- term treatment • Growth rate in children; blood glucose, serum potassium for all patients
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Evaluate: • Therapeutic response: decreased se- verity of asthma
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • To use bronchodilator first, before us- ing inhalation, if taking both; may use spacer or valved chamber • Not to use for acute asthmatic attack; acute asthma might require oral cortico- steroids; may use short-acting B2 ago- nists for rescue • To avoid smoking, smoke-filled rooms, those with URIs, those not immunized against chickenpox or measles
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PHARMACOKINETICS Fluticasone: half-life 8 hr, peak 1-2 hr; salmeterol: half-life 5.5 hr, peak 5 min
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• Adult/adolescent ≥12 yr: INH 1 inha- lation of Advair Diskus q12hr, or 2 inha- lations of Advair HFA q12hr
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• Adult: INH 1 inhalation of Advair 250/50 Diskus q12hr, must be 12 hr apart
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