3 - Asthma & COPD Therapy Flashcards
Identify common risk factors assoc’d w asthma devo
environ: SEC, family sie, second hand smoke allergen exposure urbanization RSV Abx exposure
genetic: polygenic inhertience
Identify risk factors assoc’d w COPD devo
smoking particles (smoke, occupation, indoor pollution) genes (involved in proteases) age/gender lung devo asthma and airways hyperreactivity SEC resp infx
asthma exacerbatinos sx and trgiggers
trigger: pets, exercise, emtoinos, pollution, smoke, dust, fungi, cold, inserts and fecal matter, pollen, aerosols
c/c asthma and COPD pathophys
asthma: chronic inflammx or airways, hypertrophy of BM, mucus plug, hyertrophy of SM
COPD: chronic brnchitis, emphysema, inflammx; exposure to particles/gases–> destroy epithelial cells–> incr T lymhocytes and inflamm cells, incr fibroblases; neutrophils and macrophages –> incr protease
asthma staging
based on freq of sx nighttime awakening SABA use interference w normal activity lung fxn exacerbations requiring oral steroids
What is normal FEV1
> =80%
what is normal FVC
normal adults can empty 80% of air in <6 sec
What is normal FEV1/FVC ratio
normal w/in 5% of predicted range (based on age)
- decr’d in dz
- normal or high in restrictive dz
what is normal PEFR
percent predicted correlates w FEV1
max rate that a person can exhale after a full inspiration
what are sx used for asthma dx
episodic sx of airflow obstruction: chest-tightness, SOB, non-productive cough (worse at night and early morning)
- obstruction is reversible
- often triggered
- signs of atopy-tendency to devo allergic rxn
- decr FEV1/FVC w reversibility following SABA admin
- incr eosinophil count and blood IgE conc
intermittent asthma stage
sx, SABA use <= 2d/wk awake <=2x/mon no interference lung fxn normal btw exacerbation 0-1 exacerbations w oral steroids
persistent mild asthma stage
sx, SABA use >2 d/wk (but no d SABA use) 3-4 x/mo awake minor interference lung fxn normal exac w po steroids >=2/yr
persis mod asthma stage
sx and SABA use d awake >1/wk some limitations FEV 60-80% FEV1/FVC red'd 5% exac w po steroids >=2/yr
persis sev asthma stage
sx, SABA use throughout day awake 7x/wk extremely limited activity FEV1 <60^% predicted FEV1/FVC red'd 5% exac w steroids >=2/yr
def EIB
sx of cough, chest tightness, or endurance prob during exercise
drop of FEV1 by >15% of baseline
BHR
describe emphysema
enlargement of airspaces that is accompanied by destruction of alveolar walls
describe chronic bronchitis
prescence of cough and sputum production for at least 3 mo in each of two consecutive yrs
airayws narrow d/t fibrosis: SM hyperplasia, inflammx, ronchial wall thickening, mucous gland enlargment, ciliary abnromality
decr inflammx in COPD
response to irritants
incr oxidants and decr endogenous antioxidatnts
protease-antiprotease imablance
describe COPD dx
chronic cough, SOB, sputum production
*FEV1/FVC <0.7
consider if >40 yoa w any above sx, hx of exosure to risk factors, family hx
What are signs of COPD
incr resp rate use of acessory muscles to breath hyperinflation (barrel chest) decr breath sounds prolonged expiration lips pursing on expiration
What is the spirometry cutoff for COPD
FEV1/FVC <0.7 –> confirms airflow limitation (ompared to predicted)
Describe GOLD 1 staging
FEV1 >=80% of predicted (post-bronchodilator)
mild COPD
GOLD 2 staging
50% <= FEV1 < 80%
moderate
Gold 3 staging
30% <= FEV1 < 50%
sev
GOLD 4 staging
FEV1 <30%
very sev
GOLD AC symptoms
CAT < 10
mMRC 0-1
GOLD BD sx
CAT >= 10
mMRC 2
GOLD AB
0-1 exac (no hosp)
GOLD CD
> = 2 exacerbations in past year
or 1 exac w hospitalization
What is the moa of BAs?
bronchorelaxation
activation AC, incr cAMP
What are the SABAS? their ooa?
albuterol (Proair, Ventolin, Proventil)
Levalbuterol (Xopenex)
3-5 min
DOG for acute asthma sx
What are the LABAs?
What is their ooa?
salmeterol (Serevent Diskus) formoterol (Foradil aerolizer) Arformoterol (Brovana Neblizer) Indacaterol (CArcapta Neohaler) Olodaterol (Striverdi Respimat) combo prod w ICS and LAMA
15–30 min
What are the SEs of BAs?
skeletal muscle tremors palpitations tachycardia hypokalemia hyperglycemia
What is the boxed warning for LABAs?
asthma only: monotherapy should b avoided, incr’d risk of death
What is the moa of inhaled antimuscarinics?
no ACh effect on M3 receptors in SM
no neuronal M2 recpeotr activation in lungs (no ACh relese)
–> no bronchoconstriction
What are the SEs of anticholinergics?
dry mouth dizziness blurred vision urinary retention upper RTIs
caution use of AMAs in what conditions?
myasthenia gravis
narrow-angle glaucoma
urinary retention
BPH
What are the SAMAS?
ipratropium (Atrovent)
ipratroium + lbuterol (Combivent)
What are the LAMAs?
tiotropium (Spiriva) umeclidinium (Incruse Elipta) aclinidium (Tudorza Pressair) glycopyrrolate (Seebri Neohaler) combo prods
What is the moa of leukotriene modifiers?
inhibits CysL-1R
OR
5-lipoxygenase inhibitor
What is the normal source and fxn of leukotrienes?
released from mast cells, basophils, eosinophils.
incr mucus, contract SM, incr vascular permeability; attract and act inflamm cells.
What are the leukotriene modifiers?
CysL-1R antag:
Zafirlukast (Accolate)
montelukast (Singular)
5-lipoxygenase inhibitors:
zileuton (Zyflo)
what is the mao of mast cell stabilizers?
prevent mast cel release of histamine, leukotriene, and inhibits degranulation after contact w antigens
–> prevent bronchoconstriction
What are the mast-cell stabilizers?
cromolyn sodium –soln for neb
What are SEs and precautions for mast-cell stabilizers?
cough
unpleasant taste in mouth
arrhythmias
anaphylaxis
what is the moa of ICSs?
decr eosinophils, T cells, mst cells, macrophage, dendritic cells, cytokines
decrease release of cytokines by epithelial cels decr endothelial cell leakages incr B2R decr cytokines decr mucus secr
What are SEs and precautions with ICSs?
oral thrush cough dysphonia (difficulty speaking) hoarse throat incr'd risk of pneumonia
What ar ethe ICS products?
beclomethasone (QVAR) budesonide (Pulmicort) flunisolide (Aeropsan) fluticasone (Flovent, ArmonAir, Arnutiy) mometasone (Asmanex) ciclesonide (Alvesco) combo prods w LABAs and AMAs
What are the mab products?
anti-IgE:
omalizumab (Xolair) SC inj
Anti-IL5
mepolizumab (Nucala)-SC inj
reslizumab (Cinquair)-IV inj
What is the moa of mab products?
anti-IgE: prevents binding of allergen to IgE and activation of mast cell, preventing degranulation.
anti-Ig5:
blocking binding of IL-5 to the alpha chain of the IL-5R compelx which results in reuduced production and survivial of eosinophils
What are the SEs and precutions asoci’d w mabs?
inj site rxn arthralgias dizziness fatigue CVEs (omalizumab) herpes zoster infx (mepolizumab)
BOXED WARNING: anaphylaxis (only precaution w mepolizumab)
What re the effects/moa of theophylline?
decr plasma exudation
incr mucocilliary clearnace
decr neutrophil, T-cell, macrophage fxn
incr resp muscle strength
What are avialable DFs of theophylline?
tab
ER cap
PO soln
IV inj
What are SEs and precautions for theophylline?
insomnia GI upset tremor nervousness hyperactivity in children
catuion in pts w CVD
What are important monitoring points for theophylline?
drug intxn:
substrate of CYP 1A2( major)
3A4, 2E1 (minor)
steady-state serum conc target: 5-15 mcg/mL
signs of tox: N/V tachyarrhythmia HA Sz
Describe Gold A tx
bronchodilators –> alternate class
Gold B tx
LABA or LAMA –> LABA + LAMA
GOLD C Tx
LAMA –> LAMA + LABA
OR –> LABA + ICS (not preff’d, d/t infx risk)
GOLD D Tx
LAMA + LABA –> LABA + LAMA + ICS –>
–> consider roflumilast if FEV1 <50% predicted and chronic bronchitits
OR
–> consider macrolide (azitrhomycin) for former smokers
Step 1 of asthma Tx
no controller
SABA prn
alt: low ICS
Step 2 of asthma Tx
low ICS
SABA prn
alt:
- leukotriene modifier
- theophylline
Step 3 of asthma Tx
low ICS + LABA
SABA prn
alt:
- med/high ICS
- low ICS + leukotriene mod
- add theophylline
Step 4 of asthma Tx
med ICS + LABA
SABA prn
alt:
- + tiotropium
- high ICS + leukotriene mod
- add theophylline
Step 4 of asthma tx
add:
- tiotropium
- anti-IgE
- anti-IL5
SABA prn
alt: low dose po CS
well-controlled asthma
sx & SABA use <= 2d/wk
awake <= 2x/mo
no ointerference
PEV1 or peak flow >80% pred or personal best
not well-controlled asthma
sx & SABA use >2 d/wk
awake 1-3x/wk
some interference w normal activities
FEV1 or peak flow 60-80% predicted/best
very poorly controlled asthma
sx and SABA use throughout day
awake>4x/wk
extremely limited activities
FEV1 or peak flow <60% predicted or personal best
When to step down asthma therapy?
3 mo of controlled symptoms!
when initiating a controller tx, follow up at
2-3 mo
What should be assessed at each COPD follow-up visit?
functional capacity
sx (CAT, mMRC)
smoking
PT
What should be assessed for COPD at annual follow-up?
spiromety
exacerbations
Wht are the causes of COPd exacerbations?
RTIs
air pollution
unknown
What is the tx for COPD exacerbations?
SABDs:
- albuterol +/- ipratropium
- MDI or neb
systemic CS:
prednisone 40 mg po d for 5 d
+/- Abx
- must have cardinal sx present or req mech vent
- macrolides (azithromycin)
- amoxicillin/clavulanate
- tetracyclines
- 5-7 d
What are the cardinal sx for infection in COPD exacerbation?
sputum purulence
sputum volume
dyspnea
–> for Abx therapy must have all three or 2 including purulence
What are non-pharm tx for COPD exacerbation?
O2: target sat 88-92%
ventilator support: invasive or non
What are discharge criteria for COPD exacerbations
understands corect use of an can admin meds
SABA req’d no more than q4h
walk across room
eat and sleep w/o freq awakening
stable for 12-24 h
follo-up and home care arrangement have been completed
What is first-line therapy for status asthmaticus
systemic OCs (po or IV) -methylprednisolone/prenisone/prednisolone: 2 mg/kg/d, max 60 mg/d
inh’d intermitt alb+ipratropium
supportive: O2, fluids
What is second line therapy for status asthmaticus?
continue systemic CSs
transition to continuous SABA nebulization
albuterol: 0.5 mg/kg/h, max 20 mg/hr **
or scheduled intermittend dosing (Q2h)
monitor HR and K+
-mag sulfate (IV or inh’d)
IV: 25-75 mg/kg/d, max 2 g/d
What therapy should be avoided in status astmaticus tx?
LABA: competition for betaR
What are non-pharm or prev considerations for asthma/COPD?
-vaccin: flu, pneumo
smoking cess
asthma: decr trigger (ASA)
physical ativity
COPD:
O2
pulm rehab
surgery
