Ask Mark …

Mark has updated his Suggested Sequence of Using Inhalers chart in a collaborative effort with Dr. Noah Greenspan of Ultimate Pulmonary Wellness in New York City. The only inhaler not included is the new Trelegy Ellipta. It needs no “sequence”, except that it should not be taken within two hours after a short-acting β-agonist (SABA) or the SABA should not be taken until at least 30 minutes after taking Trelegy.

 

Using ONLY Long-acting Medications

Using BOTH Short and Long-acting Medications

Suggested Sequence for Use of Multiple Inhalers

IRSFT: Long-acting β-agonist (LABA) alo(ne or combined) Foradil (formoterol) Oxis (formoterol) Oxese (formoterol) Serevent (salmeterol) Advair (Serevent & Flovent) Duova (formoterol & tiotropium bromide) Seretide (salmetrol & fluticasone) Symbicort (formoterol & budesonide) SECOND: Long-acting Anticholinergic Spiriva (tiotropium bromide) Tiova (tiotropium bromide) LAST: Steroid Aerobid, Aerospan HFA (flunisolide) Asmanex (mometasone) Azmacort (triamcinolone) dexamethasone Flovent, -HFA, -Diskus (fluticasone) Pulmicort (budesonide) QVAR (beclomethasone)

IRSFT: Long-acting β-agonist (LABA) alo(ne or combined)

Foradil (formoterol) Oxis (formoterol) Oxese (formoterol) Serevent (salmeterol)

Advair (Serevent & Flovent)

Duova (formoterol & tiotropium bromide) Seretide (salmetrol & fluticasone) Symbicort (formoterol & budesonide)

 

SECOND: Long-acting Anticholinergic

Spiriva (tiotropium bromide) Tiova (tiotropium bromide)

 

THIRD: Steroid

Aerobid, Aerospan HFA (flunisolide) Asmanex (mometasone)

Azmacort (triamcinolone) dexamethasone

Flovent, -HFA, -Diskus (fluticasone) Pulmicort (budesonide)

QVAR (beclomethasone)

 

LAST: Short-acting β-agonist (SABA) alo(ne or combined)

albuterol (salbutamol in UK) Alupent (metaproterenol) Bricanyl (terbutaline) Bronkosol (isoetharine) Maxair (pirbuterol)

Medihaler-Iso, Isuprel (isoproterenol) Proventil (albuterol)

Ventolin (albuterol) Xopenex, -HFA (levalbuterol)

Combivent (Atrovent & albuterol)

 

NOTES:

Short-acting drugs must be taken at least 2 hours before long-acting drugs in the same class to avoid interfering with the long-acting drug’s action.

If albuterol is used on a regular scheduled basis, it should always be taken after the long-acting β-agonist, and never less than 2 hours before it.

If you must use albuterol on a “rescue” basis, then wait two hours before taking a long-acting β-agonist.

If Atrovent is used in addition to Spiriva/Tiova, it should always be taken after the Spiriva/Tiova, and never less than 2 hours before it.

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.