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Clinical 2 (Part B) > 1 - Asthma > Flashcards

1 - Asthma Flashcards

1
Q

SABA

A

short acting bronchodilator (beta 2 agonist)

ex. Ventolin (salbutamol)

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2
Q

ICS

A

inhaled corticosteroid

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3
Q

LABA

A

long acting bronchodilator (beta 2 agonist)

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4
Q

LAMA/LAAC

*equivalent

A

long acting muscarinic antagonist

long acting anticholinergic

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5
Q

SAMA/SAAC

*equivalent

A

short acting muscarinic antagonist

short acting anticholinergic

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6
Q

What are the 2 parts to the pathophysiology of asthma and how do we treat them?

A

1) Inflammatory processes and agents to reduce inflammation (“controllers”)
2) Bronchoconstriction and the use of bronchodilators (“relievers”)

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7
Q

How often should you be using a SABA (reliever) if your asthma is controlled ?

A

<4 times per week

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8
Q

What is the main therapy that every asthmatic should be on?

A

ICS - inhaled corticosteroid

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9
Q

Ventolin/SABA is a ______ for asthma

A

bandaid (i.e. it doesn’t fix the problem)

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10
Q

Is it safe to be on inhaled corticosteroids for a long time?

A

Yes

-inhaled corticosteroids do not give you the systemic symptoms that oral corticosteroids (e.g. prednisone)

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11
Q

Are asthma attacks sudden?

A

No. It is a buildup of triggers and then the last trigger causes the attack. (water cup analogy)

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12
Q

Asthma more common in adults or children?

A

children

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13
Q

Can children grow out of asthma?

A

Yes but not everyone does

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14
Q

Can you develop asthma later on in life?

A

Yes - usually occupational or stress-induced

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15
Q

How many of deaths caused by asthma can be prevented?

A

80%-90%

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16
Q

What is the most common cause of death in asthmatics?

A

inadequate assessment of the severity of airway obstruction by the patient or physician & inadequate therapy

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17
Q

Describe the clinical presentation of asthma

A
  • Episodic wheezing, breathlessness, chest tightness, and coughing
  • *most people have these symptoms, but not all (about 6/10)
  • Intervals between symptoms can be days, weeks, months or years
  • Spirometry demonstrates obstruction (decreased FEV1/FVC) with reversibility following inhaled B2 agonist (at least a 12% improvement in FEV1 AND a difference of 200 mL)
  • prob an important exam Q to know that is has to be BOTH and not one or the other
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18
Q

What age can you do spirometry as part of asthma diagnosis?

A

over 6

For those under 6, have to rely on history and symptoms

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19
Q

If a mom/person is looking for cough syrup for a cough that has been going on for a few months, do you give it to them?

A

LMAO NO

a cough shouldn’t last that long so you need to refer for spirometry to determine if it’s asthma or not

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20
Q

If someone has asthma that is controlled with a SABA (ex. salbutamol), do they need additional therapy?

A

Yes - they need an ICS to help with the chronic inflammation of the airways

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21
Q

For asthma to be controlled:

How often should they be having daytime symptoms?

A

<4 days/week

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22
Q

For asthma to be controlled:

How often should they be having night-time symptoms?

A

<1 night/week

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23
Q

For asthma to be controlled:

Should exercise be affected?

A

No - should be normal

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24
Q

For asthma to be controlled:

How often should they be having exacerbations?

A

mild infrequent

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25
Q

For asthma to be controlled:

How often should they be having absence from work or school?

A

never

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26
Q

For asthma to be controlled:

How often should they be needing a SABA (ex. ventolin)?

A

<4 doses/week

NOTE: this used to exclude exercise/pre-exercise.

now this includes exercise/pre-exercise !!

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27
Q

For asthma to be controlled:

What FEV1 or PEF value should they have?

A

> 90% personal best

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28
Q

For asthma to be controlled:

What PEF diurnal variation should they have?

A

<10-15%

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29
Q

For asthma to be controlled:

What % of sputum eosinophils should they have?

A

<2-3%

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30
Q

What else would indicate poor asthma control?

A

walk-in clinic, ER, hospitalization

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31
Q

What is the actual % of patients with controlled asthma?

A

43%

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32
Q

If someone has very mild asthma, do they need an ICS ?

What exactly should be their treatment?

A

Not necessarily - they do need an SABA or ICS/LABA

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33
Q

What is 2nd line if they can’t use ICS?

NOTE: this is more of an add-on than a replacement for ICS

A

LTRA - Leukotriene receptor antagonist

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34
Q

What is the Flovent equivalent dose for ICS that patients need to be on?

A

250 ug/day

usually dosed as 125 ug BID

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35
Q

Is there any benefit to increasing the Flovent equivalent dose past 250 ug/day long term?

A

No - only increase SE and not any increase in benefit

*think about switching therapy

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36
Q

Is there any benefit to increasing the Flovent equivalent dose past 250 ug/day short term?

A

Yes - can increase it to get it back into control but then should either go back to the minimum dose

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37
Q

What if adults are not controlled with ICS at a low dose ?

A

add LABA

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38
Q

What if children are not controlled with ICS at a low dose ?

A

try medium dose before adding LABA

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39
Q

What are some other questions we should be asking ?

A
  • Feel like you’re getting a cold/flu?
  • Exposure to triggers?
  • Limitation of activities?
  • Referred to action plan?
  • Rule out exacerbation!!!
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40
Q

What symptoms what indicate she is experiencing an asthma exacerbation?

A
  • Unable to speak
  • Shortness of breath at rest
  • Reliever (SABA) is not working
  • Peak Flow < 60% predicted best
  • Patients knows from past experience that they are having a serious attack
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41
Q

What are some triggers?

A
  • Respiratory tract infections
  • Allergens
  • Environment (cold air, fog, smoke)
  • Food additives (sulphites, MSG)
  • Exercise
  • Drugs/preservatives (ASA, NSAIDS, B-Blockers, benzalkonium chloride)
  • Occupational (bakers, farmers, paint)
  • Emotions
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42
Q

Once an individual is sensitized to a pet, ______ is recommended because continued exposure is associated with worsening airway inflammation and deterioration in asthma control.

A

avoidance

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43
Q

If a person doesn’t want to get rid of their pet, what is they key thing they must do?

A

keep it out of the bedroom and don’t spoon with the animal

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44
Q

People with asthma have a high probability of having ?

A

allergic rhinitis

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45
Q

Inflammation is _____

A

chronic

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46
Q

Symptoms are _____

A

episodic

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47
Q

Airway narrowing is ____

A

variable

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48
Q

What causes airway narrowing?

A

Contraction of airway smooth muscle

  • increase responsiveness to certain triggers (aka: bronchospasm)
  • airway edema
  • mucus hypersecretion
  • airway thickening (“remodelling”)
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49
Q

What causes remodelling?

A

When you do not treat with ICS preventatively

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50
Q

Describe airway remodelling

A
  • Repair in response to chronic inflammation
  • Increased airway wall thickness
    • Fibrosis
    • Increased smooth muscle size and number
    • Increased number and size of mucous glands
    • Increased number of blood vessels
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51
Q

What is the trigger for acute asthma?

A

release of inflammatory mediators

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52
Q

Describe the early phase of acute asthma?

A

bronchoconstriction (within 10-20 min), mucous hypersecretion, edema

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53
Q

What is the duration of the early phase of acute asthma?

A

about 1 hr

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54
Q

About ____ hours later, the late phase of acute asthma occurs

A

6-9

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55
Q

Describe the late phase of an acute asthma attack

A
  • Continued inflammation, epithelial damage, intensified hyper responsiveness (triggers are even worse than normal)
  • More severe, more prolonged & more difficult to reverse (may last for weeks)
56
Q

What is the focus of asthma therapy?

A

the prevention and suppression of the underlying inflammation

57
Q

What are the major risk factors for severe exacerbations ?

A

Underutilization of anti-inflammatory drugs and excessive reliance on short-acting inhaled B2-agonists are the major risk factors for severe exacerbations

58
Q

How many inhalers per year of the SABA should a person be filling ?

A

1-2

59
Q

Black bos warning for using LABA as ________

A

monotherapy

60
Q

Why are LABA not okay as monotherapy?

A

they are not treating the inflammation and increase the risk for serious adverse events

61
Q

List some reassessments that should be done regularly

A
  • control
  • spirometry or PEF
  • inhaler technique
  • adherence
  • triggers
  • comorbidities
62
Q

What are some benefits of inhaled corticosteroids

A
  • decrease airway hyperresponsiveness
  • decrease airway inflammation
  • improving pulmonary function
  • decrease asthma symptoms
  • decrease exacerbations
  • decrease hospitalizations
  • improving QOL
  • decrease asthma-related deaths
63
Q

How do you choose between different ICS to use?

A

doesn’t matter which one they use as long as they use one

64
Q

What does do you use for an ICS?

A

start low and adjust as needed

65
Q

How much do ICS usually cost?

A

About $30-50 for a 30 day supply

66
Q

Less than __ years old, cannot use dry powdered inhalers or MDIs without spacers

A

5

67
Q

______ does not improve efficacy, use spacers instead

A

nebulization

68
Q

What is the preferred device for a person aged 0-3 years ?

A

Pressurized metered-dose inhaler plus dedicated spacer with FACE MASK

69
Q

What is the preferred device for a person aged 4-5 years ?

A

Pressurized metered-dose inhaler plus dedicated spacer with MOUTHPIECE

70
Q

ICS inhaler options:

What age group can use Alvesco (ciclesonide) ?

A

> 6 years

71
Q

ICS inhaler options:

What age group can use Asmanex Twisthaler (mometasone) ?

A

> 4 years

72
Q

ICS inhaler options:

What age group can use Flovent HFA MDI (fluticasone) ?

A

> 1 years

73
Q

ICS inhaler options:

What age group can use Flovent Diskus (fluticasone) ?

A

> 4 years

74
Q

ICS inhaler options:

What age group can use Pulmicort Tubuhaler (budesonide) ?

A

> 6 years

75
Q

ICS inhaler options:

What age group can use QVAR MDI (beclomethasone) ?

A

> 5 years

76
Q

How long will it take for an ICS response ?

A

Most patients see a decrease in symptoms in days to 1-2 weeks and often achieve minimum improvement in 2-4 weeks and maximum symptomatic improvement within 4-8 weeks.

77
Q

When should we follow up with a patient after starting an ICS ?

A

Should be seen within 1-3 months after starting treatment.

78
Q

When should we follow up with a patient after being stable on an ICS ?

A

Every 3-12 months thereafter (have them call or return if concerned about increased symptoms)

79
Q

Can you consider stepping down to an even lower ICS dose if they are controlled?

A

Can decrease by a 25-50% at 3-month intervals is feasible and safe for most patients or to a once daily ICS.

KNOW THAT IT’S AT THE 3 MONTH MARK

80
Q

Can you ever stop controller treatment ?

A

only if there have been NO symptoms for 6-12 months and patient has no risk factors - request repeat spirometry and if no longer in the “mild” asthma category (i.e. VERY mild) then could consider

**complete cessation of ICS in adults is not advised as the risk of exacerbations is increased

81
Q

Describe “doing it right” for stopping/decreasing ICS

A
  • choose an appropriate time (no respiratory infection, not during allergy season, patient not travelling, not pregnant)
  • provide a written asthma action plan
  • monitor closely and have them report increased reliever use
82
Q

What are the components of an action plan ?

A

1) Outline recommended daily preventive management strategies to maintain control
2) When & how to adjust reliever and controller therapy for loss of control
3) Provide clear instructions regarding when to seek urgent medical attention

83
Q

What are some potential reasons for lack of ICS response?

A

1) Erroneous diagnosis of asthma
2) Comorbidities (sinusitis, GERD, vocal cord dysfunction)
3) Poor inhaler device technique
4) Poor adherence to maintenance ICS treatment
5) Ongoing exposure to environmental triggers

84
Q

For a 10 year old:

If after reviewing these factors, asthma remains uncontrolled on low-dose ICS, there are three initial options for escalation pharmacological therapy:

1) Increasing to medium or high doses of ICS
2) Adding a LABA
3) Adding an LTRA

What do you pick for the 10 year old?

A

1) Increasing to medium or high doses of ICS

85
Q

The 10 year old’s mom is concerned that using higher-dose steroids will stunt Jack’s growth. How do you respond?

A

Effects of ICS on growth:

  • Seems to be maximal during the first year of therapy and less pronounced during subsequent years
  • For budesonide ug/d for a mean of 4.3 years during prepubertal age there was a mean decrease of 1.2 cm in adult height vs placebo

-in children who had long term treatment with budesonide attained normal adult height

Keep in mind: uncontrolled or severe asthma also adversely affects growth and final adult height

86
Q

How does the DOSE of ICS affect growth?

A

higher ICS dose stunts growth more than lower ICS dose

87
Q

What do the findings support for the use of ICS regarding growth ?

A

findings support the use of the minimal effective ICS dose in children with asthma

*but measure height at least yearly in kids on ICS

88
Q

What are some other ICS cons?

A
  • Thrush (candidiasis)
  • Dysphonia (change in voice)

If dysphonia occurs you can switch to an MDI with a spacer

89
Q

Thrush and dysphonia are ____-dependent

A

dose

90
Q

How do you minimize thrush and dysphonia ?

A
  • Spacer (for MDI) with mouthpiece vs mask

- Rinse with water “swish, swish, spit”

91
Q

For a 13 year old:

If after reviewing these factors, asthma remains uncontrolled on low-dose ICS, there are three initial options for escalation pharmacological therapy:

1) Increasing to medium or high doses of ICS
2) Adding a LABA
3) Adding an LTRA

What do you pick for the 13 year old?

A

2) Add a LABA

92
Q

What is the benefit of doing ICS/LABA instead of increasing dose of ICS?

**we do this in kids >12

A
  • decreases rate of exacerbations
  • increase morning and evening PEF
  • decrease time taken to achieve well-controlled asthma
  • improve exercise response
93
Q

Why do we increase dose of ICS instead of use ICS/LABA combo for those under 12?

A

little evidence is available to guide use of LABA for children

94
Q

LABA+ICS options:

What age can you use Advair MDI (Salmeterol/Fluticasone) ?

A

> 12

95
Q

LABA+ICS options:

What age can you use Advair Diskus (Salmeterol/Fluticasone) ?

A

> 4

96
Q

LABA+ICS options:

What age can you use Breo Ellipta (Fluticasone/Vilanterol) ?

A

> 18

97
Q

LABA+ICS options:

What age can you use Symbicort Turbuhaler (Budesonide/Formoterol) ?

A

> 12

98
Q

LABA+ICS options:

What age can you use Zenhale MDI (Mometasone/Formoterol) ?

A

> 12

99
Q

Zehale is technically for ______ only

A

asthma (off-label for COPD)

100
Q

OOA of formoterol

A

5 mins, making it a FABA (like salbutamol) with max effect in 2 hours

101
Q

Describe “SMART” dosing

A

The combination of rapid-onset LABA (formoterol) and low dose ICS (budesonide) in a single inhaler as both the controller and the reliever medication is effective in improving asthma control, and in at-risk patients, reduces exacerbations requiring OCS and hospitalizations

102
Q

What is SiT

A

Single-inhaler therapy

103
Q

Describe the “SMART” dosing concept

A
  • Asthma exacerbations evolve slowly over a few days with a fall in PEF and increase symptoms and reliever medication use
  • Recent evidence that ICS begins reducing airway inflammation in as early as 6 hours
  • So by using “as needed” ICS and formoterol (instead of a SABA) you have an immediate intervention with one inhaler to control symptoms and prevent exacerbation
  • Most likely benefit from TIMING (early administration) of higher ICS dose relative to worsening in symptoms as opposed to higher total dose
  • Long-acting effects of formoterol also contribute to improved benefit over SABA
104
Q

Other advantages of SMART dosing

A
  • Even with max doses, you get a lower corticosteroid exposure overall compared to traditional protocols
  • Use of one inhaler may be an advantage for adherence
105
Q

Max dosing of “SMART” dosing practical points ?

A

Maximum daily dose: 8 inhalations - if more needed, contact physician

*Recall that 4 doses of reliever/week = poor control (this counts towards that)

106
Q

Who can we consider Single inhaler therapy in? (budesonide/formoterol)

A

In those > 12 with asthma uncontrolled on fixed dose ICS/LABA combination therapy in lieu of increasing the ICS dose of the combination therapy.

107
Q

What are the most common adverse effects of Beta 2 agonists ?

A
  • tremor
  • excitement, nervousness
  • palpitations, tachycardia
108
Q

75% of asthmatics have ______ ________

A

allergic rhinitis

109
Q

List 3 of the 2nd gen antihistamines

A
  • reactine
  • claritin
  • aerius
110
Q

What are some less common adverse effects of Beta 2 agonists ?

A
  • headache
  • prolonged QT
  • decreased K+
  • increased insulin secretion
  • increased glucose esp. diabetic
111
Q

Is it better to add LABA or LTRA to ICS ?

A

addition of LABA to ICS is modestly superior to the addition of LTRA

112
Q

Don’t forget about the ________ and _____.

A

antihistamines and INCS’s

113
Q

What is the “September Spike” and how does it contribute to asthma attacks?

A
  • farmers are burning stubble
  • kids go back to school and may get viruses from other kids

*both of these are triggers for asthma attacks

114
Q

What is PEF (peak expiratory flow) ?

A
  • maximal flow produced during forced expiration (expressed as L/min)
  • sometimes used to quickly assess effectiveness of bronchodilators (in ED/clinic) during acute attack
  • it is compared to patient’s own previous best measurements using the same peak flow meter
  • measurements are effort dependent
  • CTS recommends for “poor perceivers”
115
Q

PEFM readings:

What is green zone ?

A

85-100% of predicted best

116
Q

PEFM readings:

What is yellow zone ?

A

60-85% of predicted best

117
Q

PEFM readings:

What is red zone ?

A

<60% of predicted best

118
Q

What is the Personal (predicted) best ?

A
  • Greatest peak flow achieved over a 2 week period when asthma well controlled
  • Take 3 times (record highest one) - twice daily for 2 weeks (using same meter)
119
Q

When to use PEFM ?

A
  • PEF monitoring should also be considered in patients who are poor symptom perceivers or those with a history of severe exacerbations
  • Long-term peak expiratory flow (PEF) monitoring is now generally only recommended for patients with severe asthma, or those with impaired perception or airway limitation
120
Q

What are the 3 primary early therapies for exacerbations?

A

1) Repetitive administration of rapid-acting inhaled B2 agonist
- 4-10 puffs q20minutes x 1 hr, then if stable, 2-4 puffs prn (ex. q1-4hrs)

2) Early introduction of systemic glucocorticoids
3) Oxygen supplementation

121
Q

Describe systemic glucocovrticosteroids for acute exacerbation

A

-May be in action plan if history of recent severe exacerbations and do not respond to inhaled SABAs within 6-8 hours
-Burst of systemic glucocorticosteroid orally
Kids: Prednisone 1-2 mg/kg/day for 3-5 days
Adults: Prednisone 50 mg daily x 5-7 days

  • tapering is not required for short term steroids
  • Continue ICS
122
Q

Benefits of systemic glucocorticosteroids ?

A

Treatment of severe acute exacerbations:

  • Prevent progression of exacerbation
  • Reduce need for ER visit/hospitalization
  • Prevent early relapse after emergency treatment

Acute effects after 4-6 hours:
-PO preferred over IV - convenience

123
Q

Harms of systemic glucocorticosteroids ?

A
  • Dose and duration-dependent adverse effects

- No serious toxicity with short-term “bursts”

124
Q

Short term adverse effects of systemic glucocorticosteroids ?

A
  • Hyperglycemia
  • Increased appetite
  • Fluid retention
  • Weight gain
  • Rounding of the face ?
  • Mood alteration
  • Hypertension
  • Peptic ulcer
  • Aseptic necrosis of the femur
125
Q

Why not use oral prednisone long term ?

A
  • Osteoporosis
  • Hypertension
  • Diabetes
  • Hypothalamic-pituitary-adrenal axis suppression
  • Obesity
  • Cataracts
  • Glaucoma
  • Skin thinning
  • Easy bruising
  • Muscle weakness
  • Risk of adrenal failure with withdrawal
  • Immunosuppressant
  • Peptic ulcers
126
Q

Describe the stability treatment post-exacerbation

A
  • May continue SABA 2-4 puffs q1-4 hours until symptoms resolve
  • Won’t likely be discharged home until not needing SABA more than q2-3h and PEF/FEV1 is > 70-80% personal best/predicted

-Set up treatment (add LABA) and monitor over 1-3 months, then may consider reducing ICS to lowest effective dose

  • AND, especially if associated with gradual loss of control
    • Check inhaler technique
    • Adherence to ICS
    • Trigger avoidance
127
Q

What is EIB ?

A

Exercise-induced bronchoconstriction:

  • Physical activity may be the only common trigger in some asthma patients
  • Develops 5-10 minutes after completing exercise (rarely during)
  • More common in cold, dry climates
  • Typical asthma symptoms or troublesome cough
  • Resolves spontaneously within 30-45 minutes
128
Q

How is EIB diagnosed?

A
  • Rapid improvement after inhaled B2 agonist
  • Prevention was by pretreatment with inhaled B2-agonist before exercise
  • Fall in FEV of >15% following 6-8 minutes of near maximal exercise
129
Q

What do you do for EIB if there is underlying asthma ?

A

May indicate asthma is poorly controlled so step-up controller therapy

130
Q

What do you do for EIB if there is no underlying asthma yet?

A

they will require SABA prior to exercise and recommend they have a spirometry test

*if patient needs to use SABA more that 3 times a week INCLUDING for exercise then they NEED and ICS! They are not considered well controlled

131
Q

Both LABAs and regular use of SABAs provide ___ effective protection against EIB than intermittent prophylactic use of B2 agonist ?

A

less

132
Q

List some biologics that are used as second to last resort

A 
Omalizumab - IgE
Mepolizumab - IL-5
Reslizumab - IL-5
Benralizumab - IL-5R
Tralokinumab - IL-13
Dupilamab - IL-4
133
Q

What is the absolute last resort for asthma therapy ?

A

prednisone taken orally

134
Q

When is Tiotropium recommended ?

A

as add-on therapy for individuals 12 years of age and over with severe asthma, who remain uncontrolled despite combination ICS/LABA therapy

135
Q

Who is tiotropium bromide not currently approved for by HC ?

A

those aged 6-17 years old

136
Q

What immunizations should asthmatics be getting?

A
  • pneumococcal vaccine

- influenza vaccine

137
Q

Is education better done by a doctor, pharmacist or nurse?

A

doesn’t matter who educates patient as long as they get the education

Clinical 2 (Part B) (30 decks)

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