First, thank you for taking the time to reach out to us. Pharmacists are fountains of knowledge, information, and even trivia about drugs, and we love to talk about them. And that includes a lot of subject areas you may not get to see very often. Pharmaceutics, for example, is an entire branch of pharmacy/pharmaceutical science that focuses on developing and optimizing ways to deliver an active drug into the body. Other examples are drug development and regulatory control, the business and logistics of pharmacy, pharmacy law, and drug monitoring.
As a nurse, you will constantly encounter problems with medications, ranging from the insignificant to the inconvenient to the potentially life-threatening. Pharmacists and nurses working in concert makes for a magical level of efficiency in preventing or solving these problems, and the better we understand each group's roles and capabilities, the easier it becomes to coordinate. Not to mention we all secretly love when people ask us drug information questions, so don't hesitate to use us as a resource to help you provide the best patient care possible.
Let's look at these three drug products. They have a lot in common, but a few key differences.
All three are delivered using a dry-powder inhaler (DPI). It might seem counter-intuitive that a patient with breathing difficulty has to inhale powder to get his/her medication. However, these products are comprised of active ingredients plus inactive ingredients (excipients, to be exact) that are safe for use in the lungs, all milled to an incredibly fine powder that the user doesn't even perceive while inhaling it.
The benefits to using DPIs are many:
- They use long acting active ingredients and can therefore be dosed 1-2 times per day (as compared to the many-times-per-day dosing required for older drugs.
- They are easier to use for patients who have difficulty coordinating inhalation with the actuation of an aerosol inhaler (the aerosol dissipates quickly…the powder just sits tight until the patient breathes in.
- Dosing becomes a simple task that can be done in under two minutes with a couple button clicks, vs. having to spend hours tied to a nebulizer.
It’s critical to note though, that these
products are not effective as short-acting rescue bronchodilators for asthmatic
emergencies, and they will not relieve symptoms of an asthma attack/allergic
reaction. They do not replace short acting inhalers like albuterol.
Advair is a two-drug combination product containing fluticasone propionate and salmeterol HCl. Fluticasone is a corticosteroid, which are chemical compounds that mimic the effects of the steroids the body normally makes in the cortex of the adrenal glands (cortisol, for example). This means it has anti-inflammatory and immunosuppressive effects. This immunosuppression occurs in the areas exposed to the drug, which can unfortunately cause issues at times.
The throat gets the brunt of drug exposure, which can weaken the immune system in that area and allow yeasts to colonize and grow. This is called a thrush infection, and it is miserable. Thus, a major counseling point with all inhaled steroids: Rinse your mouth thoroughly without swallowing after use.
Salmeterol is a long acting agonist at beta-2-adrenergic receptors. This means it activates a specific type of receptor that is usually activated by epinephrine (adrenaline). Activation of beta-2-receptors produces different effects depending on where the receptors are. In this case, the location is the lungs, where activation causes relaxing of the smooth muscle lining the bronchial passageways, allowing them to expand a bit (or dilate, hence the term bronchodilator).
Advair is taken twice daily,
and is available in strengths (expressed as mcg of fluticasone/mcg of salmeterol)
of 100/50, 200 /50, and 500/50. All three strengths are FDA-approved for
treatment of asthma in patients 4 years of age and older. The 250/50 strength
is also approved for maintenance therapy of chronic obstructive pulmonary disease
Breo is another product that combines an inhaled corticosteroid (fluticasone furoate) and long acting beta-2-agonist (vilanterol). Although these are different active ingredients from those in Advair, they are the same type of drug, and can be expected to act similarly to one another.
Breo is available in two strengths, 100 mcg fluticasone furoate/25 mcg vilanterol, or just 100/25, as well as 200/50. Both are FDA approved for once-daily treatment of asthma in patients 18 and older. The 100/25 strength is also approved for once-daily maintenance treatment of COPD.
Just like Advair, it is recommended to rinse the mouth out after use to prevent thrush infections.
Trelegy has a major difference with the previous two, in that it contains 3 active ingredients. The first two are the exact same as Breo, fluticasone furoate and vilanterol. The third is umeclidinium, which is in a class of drugs used for COPD but not asthma called antimuscurinics. They work much like beta-2-agonists work, just on a different receptor system.
Trelegy is available as 100 mcg fluticasone furoate/62.5 mcg umeclidinium/25 mcg vilanterol. It is only approved for once-daily dosing in patients with COPD.
Again, like the others, it is important to rinse the mouth after use.
I hope this information is helpful to you in your assignment. At the very least, it was certainly a great review of asthma/COPD pharmacotherapy for this author. Thanks, and good luck in pharmacotherapy and nursing school!
ReferencesTrelegy Prescribing Information
Trelegy Ellipta for COPD: What Pharmacists Need to Know," by Timothy O'Shea, PharmD - This provides a thorough look at Trelegy.