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 The outdated chart caused confusion and we regret the error.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.

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 rescue 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, their 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

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