Asthma and COPD Inhaler Medications: A Pharmacy Tech Guide

Understanding Respiratory Medications

Asthma and chronic obstructive pulmonary disease (COPD) are two of the most common respiratory conditions treated with inhaled medications. Pharmacy technicians encounter inhaler prescriptions daily and must understand the different drug classes, proper device usage, and key dispensing considerations. Respiratory medications are also a significant topic on the PTCB exam.

Short-Acting Beta-2 Agonists (SABAs)

SABAs are rescue inhalers used for quick relief of acute bronchospasm. They work by relaxing the smooth muscles in the airways, opening them within minutes. Every asthma patient should have a SABA available for emergency use, and increased SABA use often signals poorly controlled asthma that needs therapy adjustment.

Common SABAs

Albuterol (ProAir, Ventolin, Proventil) - the most commonly prescribed SABA
Levalbuterol (Xopenex) - the R-isomer of albuterol, marketed as having fewer side effects

Common side effects of SABAs include tremor, nervousness, increased heart rate, and headache. Patients should be counseled to prime new inhalers before first use and to rinse their mouth after use if their inhaler contains a corticosteroid combination.

Long-Acting Beta-2 Agonists (LABAs)

LABAs provide sustained bronchodilation lasting 12 to 24 hours and are used as maintenance therapy. An important safety note is that LABAs should never be used alone for asthma; they must always be combined with an inhaled corticosteroid (ICS) to reduce the risk of severe asthma exacerbations. For COPD, LABAs may be used alone or in combination with other controllers.

Common LABAs

Salmeterol (Serevent Diskus) - twice-daily dosing
Formoterol (Foradil, Perforomist) - twice-daily dosing, faster onset than salmeterol
Olodaterol (Striverdi Respimat) - once-daily, primarily for COPD
Indacaterol (Arcapta Neohaler) - once-daily, ultra-long-acting, for COPD

Inhaled Corticosteroids (ICS)

Inhaled corticosteroids are the cornerstone of long-term asthma control therapy. They reduce airway inflammation and prevent asthma symptoms when used consistently. ICS medications take days to weeks to reach full effectiveness, so patients must understand that these are not rescue medications and should be taken every day as prescribed.

Common Inhaled Corticosteroids

Fluticasone propionate (Flovent HFA, ArmonAir Digihaler)
Budesonide (Pulmicort Flexhaler, Pulmicort Respules for nebulization)
Beclomethasone (QVAR RediHaler)
Mometasone (Asmanex Twisthaler)
Ciclesonide (Alvesco)

The most important counseling point for ICS is that patients should rinse their mouth with water and spit after each use. This prevents oral candidiasis (thrush), which is the most common local side effect of inhaled corticosteroids. Pharmacy technicians should reinforce this message each time an ICS prescription is dispensed.

Combination Inhalers

Combination inhalers contain two or more active ingredients in a single device, improving convenience and adherence. The most common combinations pair an ICS with a LABA. Newer triple therapy combinations include an ICS, LABA, and a long-acting muscarinic antagonist (LAMA).

Popular Combination Inhalers

Fluticasone/salmeterol (Advair Diskus, Advair HFA, AirDuo Digihaler)
Budesonide/formoterol (Symbicort)
Fluticasone furoate/vilanterol (Breo Ellipta) - once daily
Mometasone/formoterol (Dulera)
Fluticasone/umeclidinium/vilanterol (Trelegy Ellipta) - triple therapy, once daily
Budesonide/glycopyrrolate/formoterol (Breztri Aerosphere) - triple therapy for COPD

Long-Acting Muscarinic Antagonists (LAMAs)

LAMAs, also called anticholinergic bronchodilators, block acetylcholine receptors in the airways to produce bronchodilation. They are primarily used for COPD maintenance therapy and are increasingly used as add-on therapy for severe asthma.

Common LAMAs

Tiotropium (Spiriva HandiHaler, Spiriva Respimat) - once daily, available for both COPD and asthma
Umeclidinium (Incruse Ellipta) - once daily, for COPD
Aclidinium (Tudorza Pressair) - twice daily, for COPD
Glycopyrrolate (Lonhala Magnair, Seebri Neohaler) - for COPD

Common side effects of LAMAs include dry mouth, urinary retention, and constipation. Patients with narrow-angle glaucoma should use LAMAs with caution, as anticholinergic effects can increase intraocular pressure.

Inhaler Devices and Technique

One of the biggest challenges with inhaled medications is proper device technique. Studies consistently show that a large percentage of patients use their inhalers incorrectly, which significantly reduces medication effectiveness. While formal inhaler technique counseling is the pharmacist's responsibility, pharmacy technicians should be familiar with common device types.

Common Inhaler Device Types

Metered-dose inhalers (MDIs) - pressurized canisters requiring coordination of actuation and inhalation
Dry powder inhalers (DPIs) - breath-activated devices that do not require coordination (Diskus, Ellipta, Flexhaler)
Soft mist inhalers (SMIs) - the Respimat device creates a slow-moving mist
Nebulizers - machines that convert liquid medication into a fine mist for inhalation through a mask or mouthpiece

Dispensing Considerations for Pharmacy Technicians

When dispensing inhalers, verify the correct device type and strength. Many respiratory medications come in multiple strengths and device forms. Ensure that the prescribed device matches what is being dispensed. Check whether the patient is new to the medication and may need the pharmacist to demonstrate proper technique.

Pay attention to quantity and days supply calculations for inhalers, as these can be tricky. An MDI's canister contains a set number of actuations (puffs), and the days supply depends on the prescribed dosing frequency. For example, a 120-actuation albuterol inhaler prescribed as 2 puffs four times daily would last 15 days (120 puffs / 8 puffs per day). Insurance billing requires accurate days supply to avoid rejection.

Some inhalers have dose counters while others do not. Patients using inhalers without counters should track their usage to know when to refill. Encourage patients to keep their rescue inhalers accessible and to refill maintenance inhalers before they run out to avoid gaps in therapy.