{"id":208,"date":"2019-10-07T22:49:01","date_gmt":"2019-10-07T17:19:01","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=208"},"modified":"2019-10-07T22:49:01","modified_gmt":"2019-10-07T17:19:01","slug":"drugs-used-in-bronchial-asthma","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/drugs-used-in-bronchial-asthma\/","title":{"rendered":"Drugs Used in Bronchial Asthma"},"content":{"rendered":"\n<p><strong>Bronchial Asthma<\/strong><\/p>\n\n\n\n<ul><li>Condition of bronchial hyperreactivity associated with inflammation. <\/li><\/ul>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"387\" height=\"246\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-51.png?w=387\" alt=\"\" class=\"wp-image-209\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-51.png 387w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-51-300x191.png 300w\" sizes=\"(max-width: 387px) 100vw, 387px\" \/><\/figure><\/div>\n\n\n\n<ul><li>IgE binds to mast cells on first exposure to antigen. On subsequent exposure, the antigen binds to this IgE (bound to mast cells) and its activation leads to degranulation of mast cells, resulting in the release of mediators. <\/li><li>Important mediators include leukotrienes (LTs), prostaglandins (PGs), platelet-activating factor (PAF), histamine and protease enzymes. <\/li><li>These mediators can lead to bronchoconstriction (and thus acute attack of asthma) as well as inflammation leading to hyperreactivity. <\/li><li>The only drugs effective for the treatment of an acute attack of bronchial asthma are <strong>bronchodilators (sympathomimetics, parasympatholytics, and methylxanthines).<\/strong><\/li><\/ul>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"501\" height=\"407\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-52.png?w=501\" alt=\"\" class=\"wp-image-210\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-52.png 501w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-52-300x244.png 300w\" sizes=\"(max-width: 501px) 100vw, 501px\" \/><\/figure><\/div>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"301\" height=\"263\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-53.png?w=301\" alt=\"\" class=\"wp-image-211\" \/><\/figure><\/div>\n\n\n\n<p><strong>1.\nBronchodilators<\/strong><\/p>\n\n\n\n<p>These are\nthe only drugs useful in terminating acute attack of bronchial asthma. Three groups\nof drugs may act as bronchodilators:<\/p>\n\n\n\n<p><strong>Sympathomimetics<\/strong><\/p>\n\n\n\n<ul><li>Adrenergic\ndrugs <strong>(\u03b22 agonists)<\/strong> act <strong>by stimulating GPCRs<\/strong> that result in the\n<strong>activation of adenylyl cyclase and\nfinally increase in cAMP<\/strong>, which causes <strong>smooth\nmuscle relaxation (<em>bronchodilation<\/em>).<\/strong><\/li><li>cAMP\nalso <em>decreases the mediator release from mast cells<\/em>. <\/li><li>These drugs <em>also inhibit\nmicrovascular leakage and increase mucociliary transport <\/em>by increasing\nciliary activity. <\/li><li>By inhalational route, these are the <strong>fastest\nacting drugs<\/strong>. <\/li><li>Adrenaline\nand isoprenaline produce bronchodilation quickly whereas ephedrine has a slower\nonset of action. Above mentioned drugs are non-selective and thus are not\npreferred (tachycardia and increase in the BP are their side effects).<\/li><li>Selective\n\u03b22 agonists are preferred agents for bronchial asthma. <\/li><li><em>Salbutamol,\nLevalbuterol, pirbuterol, terbutaline, isoetharine, bitolterol, fenoterol, and\nprocaterol are short-acting whereas<\/em><\/li><li><em>salmeterol,\nformoterol, arformoterol, carmoterol, olodaterol, and indacaterol are long-acting\n<\/em>\u03b2<em>2 agonists.<\/em><\/li><li><strong>Salbutamol <\/strong>(<strong>albuterol<\/strong>),\n<strong>metaproterenol, pirbuterol, and terbutaline <\/strong>are fast-acting drugs by\ninhalational route (<em>optimal particle size: 2-5 <\/em>\u03bc<em>m, deposition can be\nincreased by holding the breath in inspiration<\/em>), so they are used for <strong>aborting an attack of acute asthma<\/strong>. <\/li><li>These drugs are <strong>not suitable for\nprophylaxis <\/strong>because of a shorter duration of action. <\/li><li>Chronic use of these drugs may lead to\n<strong>tolerance due to the downregulation of\n\u03b22 receptors.<\/strong><\/li><li><strong>Salmeterol,\nbambuterol (prodrug of terbutaline) and formoterol are long-acting <\/strong>\u03b22\nselective agonists. <\/li><li><strong>Salmeterol <\/strong>is <strong>delayed acting<\/strong>, therefore\nuseful only for prophylaxis whereas <strong>formoterol <\/strong>is <strong>fast-acting also<\/strong>,\nso it is useful in aborting acute attack of bronchial asthma as well as for prophylaxis.\n<\/li><li><em>Bitolterol\nis a prodrug and is activated to form colterol by esterases in the lung. <\/em><strong><\/strong><\/li><\/ul>\n\n\n\n<p><strong>Adverse effects beta-blockers:<\/strong><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"322\" height=\"175\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-54.png?w=322\" alt=\"\" class=\"wp-image-212\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-54.png 322w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-54-300x163.png 300w\" sizes=\"(max-width: 322px) 100vw, 322px\" \/><\/figure><\/div>\n\n\n\n<p><strong>Anticholinergics<\/strong><\/p>\n\n\n\n<ul><li>cause dilation of mainly <strong>large\nairways <\/strong>(\u03b22 agonists cause bronchiolar dilation).<\/li><li><strong>less efficacious and slower acting <\/strong>bronchodilators\nthan sympathomimetics. <\/li><li><strong>more\neffective for COPD <\/strong>than bronchial asthma. <\/li><li><strong>Ipratropium, tiotropium, and umeclidinium\n<\/strong>are anticholinergic drugs (M3 antagonists) that can be used only\nby the inhalational route. <\/li><li><strong>Tiotropium and umeclidinium are longer\nacting <\/strong>than ipratropium. <\/li><li>Tiotropium is used in long-term\nprophylaxis of bronchial asthma (only in combination with corticosteroids)<\/li><li>whereas umeclidinium is used for\nmaintenance treatment of airflow obstruction in COPD.<\/li><li><strong>bronchodilators of choice in patients <\/strong>of\nbronchial asthma <strong>on <\/strong>\u03b2 <strong>blocker therapy <\/strong>(\u03b22 agonists will be\nineffective).<\/li><\/ul>\n\n\n\n<p><strong>Methylxanthines<\/strong><\/p>\n\n\n\n<ul><li>This group includes caffeine, theophylline, and theobromine. <\/li><li><em>act by blockade of adenosine receptors <\/em>(adenosine is a bronchoconstrictor) and by <em>inhibition of <\/em>enzyme <em>phosphodiesterase <\/em>(involved in the breakdown of cAMP). <\/li><li>At a high dose, these drugs can result in the <em>release of Ca++ <\/em>from the sarcoplasmic reticulum in skeletal and cardiac muscles. <\/li><li>These drugs are <em>CNS stimulant drugs <\/em>and at a toxic dose can result in tremors, delirium, and convulsions. <\/li><li>These can lead to vomiting due to gastric irritation and CTZ stimulation. <\/li><li><strong>Theophylline <\/strong>is a potent vasodilator (due to an increase in cAMP) and can cause hypotension which leads to reflex tachycardia. <\/li><li><em>Positive chronotropic and inotropic effects <\/em>may be produced even at low doses due to inhibition of presynaptic adenosine receptors (heteroceptors at sympathetic nerve endings). <\/li><li>At toxic doses, arrhythmias can be produced.<\/li><li>Theophylline is given by oral route and <strong>aminophylline <\/strong>is administered by <strong>slow i.v. infusion<\/strong>. <\/li><li>Kinetics of <strong>theophylline <\/strong>changes from first-order to <strong>zero order <\/strong>within the therapeutic dose range. <\/li><li>It has a <strong>narrow therapeutic index<\/strong>. <\/li><li><em>Smoking <\/em>and enzyme inducers (phenytoin, phenobarbitone, rifampicin, etc.) decrease the plasma levels of theophylline, therefore <em>require an increase in dose<\/em>. <\/li><li>On the other hand, drugs like <em>ciprofloxacin, erythromycin, and cimetidine <\/em>are powerful microsomal enzyme inhibitors, <em>predisposing to the toxicity of theophylline<\/em>. <\/li><li><strong>Children clear theophylline faster than adults <\/strong>(require high dose) whereas clearance of theophylline is <strong>slower in elderly, premature infants and neonates <\/strong>(require less dose). <\/li><li>Further, children are more liable to develop CNS toxicity.<\/li><\/ul>\n\n\n\n<p><strong>Interactions of Theophylline<\/strong><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"591\" height=\"189\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-55.png?w=591\" alt=\"\" class=\"wp-image-213\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-55.png 591w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-55-300x96.png 300w\" sizes=\"(max-width: 591px) 100vw, 591px\" \/><\/figure><\/div>\n\n\n\n<p>Apart from\nbronchial asthma, theophylline can also be used to <strong>reduce <\/strong>the frequency\nof <strong>episodes of apnea in premature infants <\/strong>because methylxanthines\nimprove contractility and reverse fatigue of diaphragm.\n<\/p>\n\n\n\n<p><strong>Roflumilast,\ncilomilast and tofimilast <\/strong>are <em>PDE-4 inhibitors <\/em>being\ntried for bronchial asthma.<\/p>\n\n\n\n<p>Recently, it has been found that theophylline at low\ndoses exerts anti-inflammatory action by activating a nuclear enzyme; histone\ndeacetylase-2.<\/p>\n\n\n\n<p><strong>Drug\nInhibiting IgE Action<\/strong><\/p>\n\n\n\n<p><strong>Omalizumab\n<\/strong><\/p>\n\n\n\n<ul><li>monoclonal antibody against IgE and is\nindicated to prevent the attack of bronchial asthma in patients not responding\nto a combination of long-acting \u03b22 agonists and a high dose of inhalational\nsteroid. <\/li><li>It is administered by s.c. route.<\/li><li>Black box warning- anaphylaxis \u00e0 patient\nshould be observed for 2 hours after the first 3 injections and 30 mins after\neach subsequent dose. <\/li><\/ul>\n\n\n\n<p><strong>Mast Cell\nStabilizers<\/strong><\/p>\n\n\n\n<p><strong>Sodium cromoglycate <\/strong>and <strong>nedocromil<\/strong><\/p>\n\n\n\n<ul><li>prevent the degranulation of mast\ncells by trigger stimuli. <\/li><li>These are indicated only for\nprophylaxis of bronchial asthma. <\/li><li>These are given by the inhalational\nroute. <\/li><li><strong>Ketotifen <\/strong>has\nantihistaminic action apart from mast cell stabilizing the property and is\nspecially indicated for patients with multiple disorders (atopic dermatitis, perennial\nrhinitis, conjunctivitis, etc.).<\/li><\/ul>\n\n\n\n<p><strong>Drugs Decreasing the Action of LTs<\/strong><\/p>\n\n\n\n<ul><li>includes the drugs that interfere with\nthe generation of LTs (corticosteroids and lipoxygenase inhibitors) and <\/li><li>interfere with the action of LTs (\nleukotriene receptor antagonists).<\/li><\/ul>\n\n\n\n<p><strong>Corticosteroids<\/strong><\/p>\n\n\n\n<ul><li>potent anti-inflammatory drugs and\nalso decrease bronchial hyperreactivity and mucosal edema.<\/li><li>&nbsp;Anti-inflammatory action is due to decreased\nrecruitment of inflammatory cells as well as decreased production of PGs and\nLTs. <\/li><li>Arachidonic acid (AA) is released from\nthe membrane phospholipids with the help of enzyme phospholipase A2 that is inhibited\nby corticosteroids. <\/li><li>AA is converted to PG and TX by\ncyclooxygenase and to LT with the help of enzyme 5-lipooxygenase (5 LOX). <\/li><li>Thus, these mediators are not\ngenerated when corticosteroid therapy is initiated. <\/li><li>Systemic steroids have a lot of\nadverse effects, therefore are reserved for resistant severe chronic asthma and\nin status asthmaticus. <\/li><li>These are not bronchodilators but\nincrease the sensitivity to \u03b22 agonists. <\/li><li><strong>Inhaled steroids <\/strong>include\n<strong>beclomethasone, budesonide, mometasone, fluticasone, flunisolide, <\/strong>and <strong>triamcinolone<\/strong>.<\/li><li>These have very little oral absorption\nand thus little systemic activity after inhalation (&gt;90% reaches GIT after\ninhalational route, only 4-5% is retained in the lungs). <\/li><li><strong>Hoarseness of voice <\/strong>and\n<strong>oropharyngeal candidiasis <\/strong>are very common adverse effects. <\/li><li>Candidiasis\ncan be prevented by gargling after each dose and topical nystatin (can be used\nfor treatment also). <\/li><li><em>Systemic corticosteroids should be\navoided in pregnancy but inhaled steroids are safe<\/em>. <\/li><li><strong>Ciclesonide\n<\/strong>is an inhaled corticosteroid that is <strong>metabolized by enzymes in the lungs. Thus, it has the least risk of\ntoxicity from systemic absorption when given inhalational. It is known as a soft\nsteroid.<\/strong><\/li><li><em>Intramuscular\ntriamcinolone acetonide is a depot preparation but proximal myopathy is a major\nproblem with this therapy.<\/em><\/li><\/ul>\n\n\n\n<p><strong>Lipooxygenase\ninhibitors<\/strong><\/p>\n\n\n\n<p><strong>Zileuton <\/strong><\/p>\n\n\n\n<ul><li>inhibits the synthesis of LTB4\n(chemotactic) and LTC4 and LTD4 (bronchoconstrictor).<\/li><li>Limiting features of this drug are the\nshort duration of action and <strong>hepatotoxicity<\/strong>.<\/li><\/ul>\n\n\n\n<p><strong>LT\nreceptor antagonists<\/strong><\/p>\n\n\n\n<ul><li><strong>Montelukast <\/strong>and\n<strong>zafirlukast <\/strong>inhibit the bronchoconstrictor action of LTs at cys LT1\nreceptor.<\/li><li>These are used as prophylactic agents\nfor bronchial asthma. <\/li><li>These are very safe drugs but few\ncases of <strong>Churg Strauss syndrome <\/strong>(vasculitis with eosinophilia) have been\nassociated with their use.<\/li><\/ul>\n\n\n\n<p>Stepwise therapy of asthma<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"595\" height=\"579\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-56.png?w=595\" alt=\"\" class=\"wp-image-214\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-56.png 595w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-56-300x292.png 300w\" sizes=\"(max-width: 595px) 100vw, 595px\" \/><\/figure><\/div>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"465\" height=\"130\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-57.png?w=465\" alt=\"\" class=\"wp-image-215\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-57.png 465w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-57-300x84.png 300w\" sizes=\"(max-width: 465px) 100vw, 465px\" \/><\/figure><\/div>\n\n\n\n<p>GINA 2018<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"463\" height=\"123\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-58.png?w=463\" alt=\"\" class=\"wp-image-216\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-58.png 463w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-58-300x80.png 300w\" sizes=\"(max-width: 463px) 100vw, 463px\" \/><\/figure><\/div>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"397\" height=\"252\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-59.png?w=397\" alt=\"\" class=\"wp-image-217\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-59.png 397w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-59-300x190.png 300w\" sizes=\"(max-width: 397px) 100vw, 397px\" \/><\/figure><\/div>\n\n\n\n<p>\u2022\n<strong>Exercise-Induced Asthma: <\/strong><\/p>\n\n\n\n<p>It\ntypically begins after the end of exercise and recovers spontaneously within 30\nminutes. Treatment is usually not required but can be done by SABA. <\/p>\n\n\n\n<p>The\nbest method to prevent exercise-induced asthma is regular treatment with <strong>inhaled\ncorticosteroids <\/strong>(Ref. Harrison 17th\/1601) which reduces mast cells. <\/p>\n\n\n\n<p>Antileukotrienes,\nmast cell stabilizers, and \u03b22 agonists can also be used for this function.<\/p>\n\n\n\n<p>\u2022\n<strong>Aspirin Induced Asthma: <\/strong><\/p>\n\n\n\n<p>Recently,\nit has been found that aspirin acetylated COX- 2 enzymes can convert\narachidonic acid to 15-HETE (15-hydroxyeicosatetraenoic acid). <\/p>\n\n\n\n<p>In\nWBCs, 15-HETE is converted to epi-lipoxins (15-epi-LXA4 or 15-epi LXB4).<\/p>\n\n\n\n<p>These\nare called <strong>aspirin-triggered lipoxins <\/strong>and have powerful\nbronchoconstrictor action. This finding can explain the induction of asthma\nwith aspirin but not by other COX-inhibitors.<\/p>\n\n\n\n<p><strong>Note:<\/strong><\/p>\n\n\n\n<p>\u2022 <em>LABA should not be given\nin the absence of ICS therapy <\/em>as they do not control the underlying inflammation. Recently, the FDA\nhas issued a black box warning for this combination due to a slightly increased\nrisk of mortality from asthma attacks.<\/p>\n\n\n\n<p><strong>\u2022 In pregnancy; <\/strong><strong><em>SABA, ICS and theophylline\n<\/em><\/strong><strong>are considered safe. <\/strong><\/p>\n\n\n\n<p><strong>Albuterol \u2013 preferred SABA<\/strong><\/p>\n\n\n\n<p><strong>Budesonide \u2013 preferred ICS<\/strong><\/p>\n\n\n\n<p>If oral corticosteroids are required prednisone should\nbe used. Because for action it needs to be converted to prednisolone and fetal\nliver cannot carry out this reaction. <\/p>\n\n\n\n<p>The fetus is thus protected from the systemic effects of corticosteroids.<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"465\" height=\"305\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-60.png?w=465\" alt=\"\" class=\"wp-image-218\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-60.png 465w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-60-300x197.png 300w\" sizes=\"(max-width: 465px) 100vw, 465px\" \/><\/figure><\/div>\n\n\n\n<p><strong>Respiratory\nSystem<\/strong><\/p>\n\n\n\n<p><strong>Aerosol\nDelivery of Drugs<\/strong><\/p>\n\n\n\n<ul><li>Four classes of\nanti-asthma drugs (\u03b2<strong>2 agonists, anticholinergics, sodium cromoglycate, and steroids<\/strong>)\ncan be administered by the inhalational route. <\/li><li>This route is aimed to\ndecrease the systemic side effects of these drugs. <\/li><li>Two types of aerosols can\nbe used.<\/li><\/ul>\n\n\n\n<p><strong>\u2022 <em>Aerosols using the drug in solution:<\/em><\/strong><em> <\/em><\/p>\n\n\n\n<ul><li>These include <em>metered-dose\ninhaler <\/em>(MDI) and the <em>nebulizer<\/em>.<\/li><li><strong>MDI <\/strong>use chlorofluorocarbons (less preferred due to their effect on the\nozone layer) or hydrofluoroalkane propellants. <\/li><li>These deliver the drug in spray form. <\/li><li>The disadvantage of these\ndevices is that they <em>require proper coordination <\/em>between deep\ninspiration and inhaler activation which many patients (especially children and\nelderly) are unable to do. <\/li><li>Use of a spacer decrease the\nrequirement of this co-ordination<\/li><li><strong>Nebulizers <\/strong>produce a mist of drug solution generated by pressurized air. <\/li><li>These <em>do not require\nhand-inspiration co-ordination <\/em>and are therefore preferred in children,\nelderly and very severe episodes of asthma.<\/li><\/ul>\n\n\n\n<p><strong>\u2022 <em>Aerosols using drugs as dry powder:<\/em><\/strong><em> <\/em><\/p>\n\n\n\n<ul><li>These include <strong>spinhaler and rotahaler<\/strong>.<\/li><li>The disadvantage of these devices is that they <em>require +high-velocity inspiration <\/em>(not suitable for children, elderly and very sick patients) and <\/li><li>these can cause <em>irritation of the air passage <\/em>(leading to cough and bronchoconstriction).<\/li><\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Bronchial Asthma Condition of bronchial hyperreactivity associated with inflammation. IgE binds to mast cells on first exposure to antigen. On subsequent exposure, the antigen binds to this IgE (bound to mast cells) and its activation leads to degranulation of mast cells, resulting in the release of mediators. Important mediators include leukotrienes (LTs), prostaglandins (PGs), platelet-activating[&#8230;]\n","protected":false},"author":3,"featured_media":214,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/208"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=208"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/208\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media\/214"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=208"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=208"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=208"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}