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Inhaled Budesonide (Pulmicort)

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Hey all welcome back to the real life pharmacology podcast i’m your host pharmacist eric christensen thank you so much for listening today as always go check out grab your free 31 page pdf it’s a great study guide or review on the top 200 drugs and things that i’ve seen in clinical practice as well as things that often show up on board

Exams whether you’re a nurse pharmacy student med student a great resource there simply an email uh we’ll get you access to that then of course we’ll also get you updates when we’ve got a new podcast available as well as well as other new content the drug of the day today is inhaled budesinine and brand name of this medication is pulmocort and budesinide i

Have covered this a little bit in the past i’ve covered systemic budestinide use but i haven’t specifically focused on just inhaled budesinine now it should be noted that it does come in other combinations so brez tree and symbicort are combinations of budesonide with other uh inhaled agents that are typically going to be used in asthma and copd for example but

I do see a fair amount of pulmocor use on its own uh and again those indications asthma copd and with recent gina guidelines recommendations uh we’re seeing these um inhaled corticosteroids used more and more in acute exacerbations and getting that steroid on board and obviously trying to prevent re-exacerbation and obviously help acutely with the situation as

Much as we can but i’ll talk about the onset and some of the pharmacokinetics a little bit later and why it doesn’t necessarily work instantaneously but i’ll dig into that a little bit later so let’s talk about uh the dosage forms a little bit uh so pulmicort or pudesinide comes as a dry powder and that’s called the flexhaler is the device there at 90 and 180

Micrograms per inhalation is the dosing there and then we also have a nebulized formulation and in practice where i’ve seen the nebulized formulation used the most are pediatric patients and geriatric patients so these are patients that can’t necessarily coordinate the timing of their breath or in maybe geriatric situations maybe that breath isn’t uh deep enough

And strong enough uh to allow us to use the dry powder product so you’ll definitely see um nebulized budesinine used in those patient populations now the different dosing is is laid out so for nebulized formulation 0.25 to 1 milligrams per 2 ml neb and depending upon what we’re trying to do and how aggressive we want to be we can get to low medium and high

Dosing now if you remember this is laid out in asthma guidelines low medium and high uh corticosteroid dosing rlp if you create a free account there you can get an awesome chart that lays out all those different strengths and what category they fall in i know this is definitely something generally more advanced pharmacology board exams that might come

Up but just understanding and recognizing what category of aggressiveness they’re in low medium or high based upon the drug we’re using and the dose we’re using so for example pomocort dry powder flex inhaler per gina guidelines so low dose would be considered 200 to 400 micrograms per day medium dose would be considered anything above 400 micrograms to up to

800 micrograms per day and high dose would be considered above 800 micrograms per day so i think that kind of lays that out a little bit and again that reference pearls rlp if you haven’t taken advantage of that they’ve got a free chart that you can have access to once you you create a free account there so definitely go go take advantage of that so

Mechanistically i’m not going to go through this a ton it’s an inhaled corticosteroid has glucocorticoid activity ultimately reduces action of things like leukocytes which reduces inflammation and if you remember this is one of the primary issues in asthma is that kind of hyperactivity hyperinflation inflammation excuse me issue in asthma administration so one

Important thing for you know all inhaled corticosteroids are we’re going to want to rinse so rinse and spit after use and that’s to help prevent infection thrush things like that uh there is a couple things i wanted to mention um specifically with with each of the two major products so the flexhaler it does need to be primed but it only needs to be primed uh the

Very first time the patient uses it okay so you don’t obviously pre you know if they take a dose and then they skip a day it only needs to be primed that very very first time so one time priming only and then being a dry powder device we do not shake the flexhaler okay so many patients are used to doing that with you know an albuterol inhaler or something like

That where you got to shake it this should not be shaken now the nebulized formulations let’s mention them a little bit probably one of the biggest questions i get asked are can i mix nebulized formulations so two of the big ones most common ones um albuterol and epitroprium uh it is there is some evidence supporting that uh mixing these is okay for delivery

So um i would definitely refer you to look at your organization’s policy and procedures and what’s allowed and not allowed but if you do go look at the literature there is some evidence to support that mixing is okay it’s not going to harm the patient and they’re going to get the the drug there as well adverse drug reactions uh upper respiratory tract infections

Thrush uh those are are two risks associated with inhaled corticosteroids like budestinite here uh some local irritation cough things like that can happen as well and another question i i get from patients generally after they’ve done some research online is um you know should i be concerned whether it’s you know pediatric patient or you know risk of osteoporosis

Thinking about some of the issues with systemic long-term corticosteroid use do i need to be concerned about those issues and you know the the risk of issues is extremely extremely low because the percent absorbed systemically is extremely extremely low with that said it’s it’s something to to think about for sure adrenal suppression elevated blood sugars

Osteoporosis insomnia immunosuppression risk those are risks that are going to be generally more associated with longer term corticosteroid use where we’re using those systemically not necessarily inhaled so again not to say that it absolutely cannot happen but the risk is extremely extremely low there flexhaler i did want to mention also contains lactose

So there have been reports of anaphylactic reactions to that so definitely pay attention to that if you know somebody has had an issue with that monitoring parameters obviously we’re using this for respiratory conditions that’s what we’re going to be monitoring so your fev1 your peak flow other kind of pulmonary function tests as well there and then i wanted

To mention kinetics so i kind of alluded to that earlier how quickly does this medication start working when we use it for asthma and copd and things like that so it takes definitely at a minimum hours more likely days to really begin working and show its effects so that leads to an important patient education point for sure we got to make sure that patients

Understand uh that this medication does take a while to work so if they take one dose and they don’t feel any better within 15 minutes half hour hour that’s what’s supposed to happen it’s supposed to take a little time to work and that’s okay so we have to do that patient education so they don’t take a dose and a half hour hour later i’m not breathing any better

This medication’s junk you know so i’ve i’ve had to have those conversations with patients in the past who have quit taking their inhaled corticosteroid so really really important patient education point to ensure that patients are actually getting the medications that we are prescribing or dispensing or you know administering them to them as well all right

Let’s take a quick break from our sponsor and we’ll wrap up with drug interactions if you’re in the market for pharmacist board certification study material like bcps ambulatory care geriatrics go check out store story in addition if you’re a student whether that be nursing med student we’ve got tons of books case studies food drug interactions drug

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With us to help keep this podcast going all right let’s wrap up with drug interactions so there aren’t a ton which is nice and we don’t have a ton of systemic absorption with this drug uh budestini and inhaled budesinine specifically so that’s not a major major concern in my mind as far as drug interactions but there is a couple things i think of of note that

We should pay attention to so sip 3a4 inhibitors definitely not an absolute contraindication but they can potentially raise uh systemic concentrations of budesinine the other interaction that i did want to mention something that i look out for is infection risk so you know thrush a respiratory tract infection that risk is potentially elevated a little bit with

The use of an inhaled corticosteroid like budasani in normal immunocompetent patients and i don’t really worry about it a ton but if you get patients that are immunosuppressed that might just be one more thing that kind of tips the scales toward them being more at risk for an infection to happen so any type of transplant patient that’s on you know significant

Immunosuppressives a lot of patients with autoimmune diseases may have other immunosuppressives on board so those are situations where we we may have a little bit more heightened risk for various types of infections so again something we’re going to monitor and if patients are having frequent infections obviously we’ve got a kind of weigh risk versus benefits

Of the medications that we’re utilizing that could potentially suppress that immune system and increase the risk for infection there all right well i think that’s going to wrap up the podcast for today thank you so much for listening uh don’t forget uh to support the sponsor met at stre if you enjoyed this podcast found it beneficial uh share us with a

Friend uh leave a rating review on itunes or wherever you’re listening go subscribe at get that free 31 page pdf and of course support our sponsor today as well so pyrls rlp go sign up and get your free chart on the inhaled corticosteroids if you want to reach out to me got suggestions comments concerns education 101

Otherwise you can find me eric christiansonbcpsbcgp on linkedin thank you so much for listening and i hope you have a great rest of your day

Transcribed from video
Inhaled Budesonide (Pulmicort) By Eric Christianson