GS, a 29-year-old female, presents to the pharmacy to pick up medications for her chronic conditions. She was recently prescribed a new inhaler called Airsupra for her asthma and has some questions that she wanted to clarify with the pharmacist.

PMH: Asthma, Hypertension, Migraines

Allergies/ADRs: Lisinopril (angioedema), sulfa antibiotics (rash)

Current medications:

Diovan HCT 160/25 mg PO QD

Topamax 25 mg PO QD

Zomig 2.5 mg PO PRN

Which of the following statement(s) is/are correct regarding Airsupra? Select all that apply.

A. It is approved as maintenance/controller therapy for asthma

B. Up to 8 doses (16 inhalations) can be administered in a 24-hour period

C. Always rinse mouth with water and spit out after use

D. Airsupra could potentiate GS's risk of an electrolyte abnormality with her current regimen

E. It is indicated for use in the pediatric population (12 years of age and older)

Answer with Rationale

Asthma is a chronic condition that causes inflammation and swelling of the airways. It is principally a pediatric disease but can persist in about 30-40% of patients. Asthma is one of the most common diseases in the United States with high economic burden. About 25 million people in the US were diagnosed with asthma in 2021 according to CDC reports. Allergens, like seasonal pollen, mold spores, dust, or pet dander, are common triggers. Increased prevalence is seen in groups of people with low-income, senior adults, African American patients, Hispanic patients, and American Indian/Alaska Native patients. These groups account for the highest asthma rates, deaths, and hospitalizations. On average, about 10 people in the US die from asthma each day, but majority of these deaths are avoidable if on appropriate therapy. While there is no cure for asthma, with appropriate education and treatment, asthma attacks can be prevented to improve patients’ quality of life.

Recent treatment guidelines have advocated for using an inhaled corticosteroid with a short acting beta agonist for acute shortness of breath associated with asthma. While there are a number of ways to accomplish this with multiple inhalers, Airsupra combines albuterol and budesonide to accomplish this with one inhalation. Let's see how each answer is correct or incorrect!

Answer A is incorrect. Airsupra is only indicated for the as-needed-treatment or prevention of bronchoconstriction and to reduce the risk of exacerbations in patients with asthma. Short-acting beta agonists are only to be used as needed and if a patient is using these frequently, would be an indication that their controller medication would need adjusting. 

Answer B is incorrect. Clinically significant cardiovascular effects and fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs. Do not exceed 6 doses (12 inhalations) in a 24-hour period.

Answer C is correct. Airsupra contains budesonide, an inhaled corticosteroid, which is known to cause localized infections of the mouth and pharynx with Candida albicans. Patients (or caregivers) should rinse mouth with water without swallowing following administration to help reduce the risk of oropharyngeal candidiasis.

Answer D is correct. ECG changes and/or hypokalemia, resulting from administration of loop or thiazide diuretics, can be acutely worsened by beta-agonists, especially when the recommended dose of the beta-agonist is exceeded. Our patient is on Diovan HCT containing 25mg of HCTZ so she would be at risk. Consider monitoring potassium levels while on therapy.

Answer E is incorrect. Orally inhaled corticosteroids, including budesonide, may cause a reduction in growth velocity when administered to pediatric patients. However, chronic inhaled corticosteroid therapy is the cornerstone of chronic asthma management, as patients who aren't controlled often receive systemic steroids for flares which can provide equal or significantly more corticosteroid exposure.  Airsupra is not indicated for use in this population most likely as it hasn't been evaluated to date but could be in the future. 

Generic/Brand: Albuterol/Budesonide (Airsupra), Valsartan (Diovan), Topiramate (Topamax), Zolmitriptan (Zomig)

NAPLEX Core Competencies Covered:

• 1.2 – From patients: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
• 2.2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied
• 3.4 – Drug dosing or dosing adjustments; duration of therapy
• 3.5 – Drug route of administration, dosage forms, or delivery systems
• 3.8 – Drug interactions
• 5.5 – Instructions or techniques for drug administration