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PDAT4 > 36/37/38 - Asthma > Flashcards

36/37/38 - Asthma Flashcards

1
Q

Asthma
Classification & Presentation

A

Chronic R_eactive + Obstructive_ airway disease
Characterized by:
airway INFLAMMATION** & **HYPERresponsiveness

Presentation:
Wheezing / SOB / chest Tightness
Cough
+/- Increased mucus Production

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2
Q

Asthma
DIAGNOSIS

A

Requires a combination of:
Medical History**+**Spirometry

Reduced FEV1/FVC ratio = airway obstruction

  • *INCREASE in FEV1 > 12%**
  • *AFTER BRONCHODIALATOR = Reversibility**
  • or bronchoconstriction / HYPERresponsiveness on challenge test*
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3
Q

Phenotype Asthma

A

Clinical Characteristics
based upon:
Genetic makeup / Bio Mechanisms / Environmental Exposures

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4
Q

Endotype Asthma

A

Specific Biologic/Immunologic MECHANISM
that drives the
pathophysiologic cause of Asthma presentation

Eosinophilic Endotypes
HIGH /low TH2

NON-eosinophilic Endotypes
HIGH & low TH1

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5
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-1 / IL-8 / IL-17 / TNF-a / TRL4

Source Cell Types:
TH17 cells - Macrophages - NK/NKT Cells - CD8 TCells

End Result:
↑Neutrophil release of pro-inflammatory chemokines

A
  • *low TH1**
  • *NON-eosinophylic Endotypes**
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6
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-12 / INF-y / 15-Lipooxygenase

Source Cell Types:
TH1 - Goblet Cells

End Result:
↑Neutrophil release of Pro-inflammatory chemokines

A
  • *HIGH TH1**
  • *NON-eosinophilic Endotype**
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7
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-25 / IL-33 / IL-5 / IL-13 / TSLP

Source Cell Types:
TH2 - Mast Cells

End Result:
↑Eosinophil Differentiation & Maturation
↑NO production / ↑Periostin
↑ Mast Cell Degranulation

A

LOW TH2
Eosinophilic Endotype

just different Cytokines and No B-cell Involvement

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8
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-4 / IL-5 / IL-13 / TSLP

Source Cell Types:
TH2 - B Lymphocytes - Mast Cells

End Result:
↑Eosinophil Differentiation & Maturation
↑NO production / ↑Periostin
↑ Mast Cell Degranulation

A

HIGH TH2
EOSINOPHILIC Endytype

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9
Q

Goals of Asthma Therapy

A

Reduce Impairment

  • *<** 2 Daytime Symptoms / WEEK & ↓Reliever meds
  • *<** Nightime awakenings / MONTH from asthma

Reduce RISK of future exacerbations / airflow limitation / ADR
Prevent exacerbations
↓ED Visits or Hospitilzations
↓Loss of lung functions / lung growth
↓Drug ADR

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10
Q

What questions do we ask to

ASSESS ASTHMA SEVERITY & CONTROL?

A

OVER THE PAST 2-4 WEEKS
How much is Asthma Impairing Patient’s Life?

Daytime Asthma Symptoms?

Nighttime Awekenings?

Rescue Medication use?

Lung Function?

PERCEPTION of Limitation

Validated Questionaires
ACT / ATAQ / ACQ

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11
Q

Monitoring & Follow-Up

When to RE-EVALUATE?

A

Recommend to RE-Evaluate:
Within 1 WEEK after an EXACERBATION

  • *1-3 Months after STARTING treatment**
  • full benefit may take ~3 MONTHS+*

Every 3-12 Months once stable​

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12
Q

WHO SHOULD USE CONTROLLER MEDICATION?

A

RULE OF 2

  • *Daytime Symptoms** or Reliever use
  • *>** 2 days per WEEK
  • *Nightime Awakening from Asthma**
  • *>** 2 days per MONTH
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13
Q

When would consider

STEPPING DOWN?

A

STABLE FOR 3+ MONTHS

Aims of stepping down:
Minimum effective treatment Dose
Continue encouraging controller dose

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14
Q

ASTHMA ACTION PLAN

Includes WHAT?

A

Daily Medications

List of TRIGGERS** + **ACTIONS to control

How to RECOGNIZE worsening asthma
based on SYMPTOMS or PEF (peak-flow)

How to RESPOND to worsening asthma
Bronchodilator use & when to INCREASE intnsity of treatment

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15
Q

What Medications

can WORSEN or TRIGGER Asthma?

A

ASPIRIN

NSAIDs

  • *BETA-BLOCKERS**
  • OLOLs
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16
Q

What can WORSEN or TRIGGER Asthma?​

A
  • *VIRAL** illnesses
  • *Exercise / Sport / Exertion**

ALLERGIES
mold / dust / animals / pollen / sulfides / cockroaches

  • *Exposure to Irritants**
  • *smoke** / air pollutants / perfumes

Stress / Emotions

Endocrine / Hormonal Changes
pregnancy / thyroid disorders / menses

Environmental Factors
vacuuming / open windows / weather / humidity

Medications
ASPIRIN / NSAIDS / BETA LOCKERS

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17
Q

What COMORBID CONDITIONS

may WORSEN ASTHMA?

A

Atopic Triad
Rhinitis / Sinusitis / Nasal Polypts

GERD

ALLERGIES
food or domestic / allergic bronchopulmonary Aspergillosis

Obesity / Anxiety / Stress

OSA
Obstructive sleep apnea

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18
Q

Role in Therapy:
Reliever / Rescue - Asthma Medications

Inhaled/Oral SABA = Albuterol / Levalbuterol

Inhaled SAMA = Ipratroprium Bromide

A

ALL PATIENTS NEED QUICK RELIEF MEDICATION

As NEEDED for:
Intermittent / Persistant Asthma - Step 1 +

PREVENTATIVE for:
Exercise Induced Bronchospasm = EIB

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19
Q

Albuterol / Levalbuterol

Drug Class / Onset of Action / ADR

A
  • *SAMA =** Quick Onset:
  • *MDI > DPI > Neb > oral**
  • oral is NOT preferred*

ADR:

  • *Tachycardia / Tremor / Excitement / Nervousness**
    rare: Pharyngitis / Rhinitis / Bronchospasm

Precautions:
CV Disease / Arrythmia
HyperThyroidism / Diabetes / Seizures

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20
Q

Ipratropium Bromide
MDI / Neb

Drug Class / Indication / ADR

A

SAMA
NOT appropriate rescue medication ALONE in ASTHMA
used in COMBO + SABA (albuterol) in patients not responding in ER/hospital
less effective bronchodialator than SABA, NOT anti-inflammatory

ADR:
Well tolerated –> HA / Cough / Eye irritation (neb)

Precautions:
AntiCholinergic Precautions: Glaucoma / BPH

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21
Q

What is the:
PREFERRED INITIAL & BACKBONE CONTROLLER MED
for
PERSISTANT ASTHMA
Step 2+

A
  • *INHALED CORTICOSTEROIDS**
  • *-SONE / -NIDE**

Most Effective MONOTHERAPY
only therapy shown to reduce risk of DEATH from ASTHMA

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22
Q

What is the PREFERRED
INHALED CORTICOSTEROID (ICS)
in PREGNANCY?

A

BUDESONIDE
Pulmicort Flexhaler DPI
Pulmicort Respules Nebulizer (only Neb ICS available)

  • *Ok to add LABA**
  • if not well controlled*
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23
Q
  • *Inhaled Corticosteroids**
  • *-SONE / -NIDE**

BENEFITS / USES

A
  • only therapy shown to* REDUCE RISK OF DEATH from ASTHMA
  • *MOST effective MONOTHERAPY - Controller**
  • *Symptom Improvement**
  • *starts @1-2 Days** –> MAX in 4-8 Weeks
  • *BHR/Inflammation Improvement**
  • *starts @1-2 days** –> progressive up to 1 year

LUNG FUNCTION IMPROVEMENT
begins in 3-6 weeks

  • does NOT reduce AIRWAY REMODELING
  • -> discontinuation can cause HIGH RISK for EXACERBATION*
24
Q
  • *Inhaled Corticosteroids
  • SONE / -NIDE**

ADR / DI

A

Local: Thrush / Dysphonia / Cough / reflex bronchospasm

Rare: systemic effects / stunted growth / bruising / cataracts

CYP3A4 INHIBITORS
–> increase SYSTEMIC exposure
DI Risk:
Fluticasone-Budesonide >
Ciclesonide,Flunisolide,Mometasone > Beclomethasone

  • Reduce risk of LOCAL side effects*
  • *RINSE MOUTH / SPACER**
  • Reduce ALL ADRs*
  • *Step down therapy / lowest effective dose**
25
Q

Which ICS Drugs have the

HIGHEST DRUG INTERACTION RISK?

A

Strong CYP3A4 Inhibitors

Fluticasone & Budesonide
>>>
Ciclesonide / FLunisolide / Mometasome
>>
Beclomethasone
least drug ineracton risk

(Ritonavir / Ketoconazole / Protease Inhibitors)

26
Q

LABA = -TEROL

Uses in Asthma Therapy

A
  • *Preferred ADJUNCT to ICS therapy = Step 3+**
  • superior to LTRA / LAMA / cromolyn / theo when ADDED to ICS*
  • NEVER use LABA ALONE in ASTHMA*
  • *ALWAYS COMBINED WITH ICS**
  • not an ALTERNATIVE to ALBUTEROL/ICS*
  • *Formoterol = FASTEST onset of Action (Minutes)**
  • *Vilanterol = slowest (hours)** –> but long duration (22hours)
27
Q

What Asthma drug has a
BLACK BOX WARNING?

A
  • *LABA_ _= -terol**
  • *ON ITS OWN** –> INCREASE in ASTHMA RELATED DEATHS

LABA should ALWAYS be in COMBO with ICS

28
Q

LAMA = -IUMs

Asthma Therapy / ADR

A

ADD-ON
to Med/High dose ICS + LABA = Step 4 or 5

Cause bronchodilation + reduce mucus secretion by:

  • inhibiting* muscarinic cholinergic receptors
  • *4-8 Week benefit**

ADR:
Dry Mouth / Metallic Taste / AUR
Caution:
NAG / Bladder Obstruction

29
Q

Which Phenotypic Guided Asthma Therapy?

Can be administered AT HOME?

A
  • *DUPILUMAB = Dupixent**
  • *IL-4R / IL-13** Target
  • *SUBQ every other week**

>12 y/o

Requires:
Blood EOS > 300 cells/uL

30
Q

Which Phenotypic Guided Asthma Therapy?

Is indicated for

ALLERGIES** & **HIGH IgE Levels?

A
  • *OMALIZUMAB** = Xolair
  • *IgE target** // >6 y/o

IgE has to be 30-700 IU/mL & ALLERGIES

  • *SUBQ every 2-4 weeks**
  • *DOSED BY WEIGHT & BASELINE IgE**
31
Q

Which Phenotypic Guided Asthma Therapy?

ONLY IV DRUG

A
  • *RESLIZUMAB** = Cinqair
  • *IL-5**

Also 18 y/o+
(others are >12yo)

Requires BLOOD EOS > 400 cells/uL

32
Q

Which Phenotypic Guided Asthma Therapy?

Biomarker targets are

IL-5

& what are their INDICATIONS?

A

MEPOLIZUMAB = Nucala
12yo // Blood EOS >150 (90 days) // >300 (1year)

  • *RESLIZUMAB** = Cinqair
  • *> 18 y/o** // IV // >400 EOS
  • *BENRALIZUMAB** = Fasenra
  • *IL-5R** // 12yo // >300
33
Q

Which Phenotypic Guided Asthma Therapy?

Anti-TSLP Antibody

good for BOTH
HIGH & LOW TH2

A

TEZEPULUMAB

not yet FDA approved

34
Q

Phenotypic Guided Asthma Therapy

ADR / Requirements

A

ADR:

  • *Nasopharyngitis / HA / Back Pain / Fatigue+Myalgias**
  • *INJECTION SITE REACTIONS**

Anaphylaxis / Hypersensitivity
VV
ALL PATIENTS MUST HAVE EPINEPHRINE

  • *All ADMIN in healthcare setting**:
  • EXCEPT for DUPILUMAB*
35
Q

Leukotriene Receptor Antagonist = LTRA

Asthma Uses / ADR / DI

A

Montelukast / Zariflukast / Zileuton
ORAL

  • Less effective than ICS* & LABA + ICS
  • Safer**, but *no more effective than adding Theophylline

Zileuton = Monitor LFTs

36
Q

Oral Corticosteroids

Asthma Uses

A
  • *Prednisolone** > Prednisone
  • *FOR ORAL SOLUTION, TASTE**
  • *Add-On therapy in STEP 6**
  • low daily dose*

Asthma EXACERBATIONS
Short course = burst

37
Q

Methylxanthines

Asthma Uses / ADR

A

Theophylline = IV/PO —- Aminophylline = IVonly

  • *Only modest Asthma Effects**
  • not for use in SEVERE asthma*

NARROW THERAPEUTIC WINDOW
life-threatening side effects

  • *DRUG INERACTIONS**
  • *CYP1A2** & CYP3A4
38
Q

Mast Cell Stabilizer = Cromolyn Sodium

Asthma Use

A

Inhibits early/late
Asthma Response&EIB (exercise induced)
not very effective compared to other agents

  • *20mg QID** –> 4 weeks
  • *2-4 weeks for effectiveness**

NEEDS DAILY CLEANING
hard to use
NEBULIZER SOLUTION

39
Q

Macrolide Antibiotics

ASTHMA USE?

A

Azithromycin = AZISAST trial

Beneficial for:

NON-EOSINOPHILIC ASTHMA

Blood Eos < 200 cell/uL

40
Q

Vitamin D

Asthma Use?

A

low VIT D –> INCREASED risk of Asthma Exacerbations

Vitamin D:
Inhibits production of IL-17

  • good for:*
  • *NON-EOSINOPHILIC ASTHMA**
41
Q

Bronchial Themoplasty

Asthma Use?

A

Add-on Therapy
for select patients with unconctrolled ASTHMA

Thermal Energy (150*F)

  • Reduces:*
  • *Bronchial airway smooth muscle MASS** // Airway Narrowing
42
Q

Which ICS is preferred in CHILDREN?

A

BUDESONIDE

because it is the
NLY ICS available via NEBULIZER

43
Q

When to consider

REFERRAL to ASTHMA SPECIALIST?

A

2+ Exacerbations in 1 Year
that was TREATED with SHORT COURSE STEROIDS

ICU admission** or **Intubation

Unresponsive to Therapy
Uncontrolled on STEP 4+ or STEP 3+ for Children

Atypical Presentation / difficult diagnosis

Phenotypic Guided Therapy

Presence of SEVERAL Comorbidities

44
Q

SINGLE INHALER THERAPY?

A

FORMOTEROL** + **ICS

Used as:
Maintenance AND RELIEVER

  • reduces EXACERBATIONS*
  • *cheaper / mixed results**
  • limited evidence*
45
Q

Which DOSAGE FORM?

Highly dependent on:
TIMING of ACTUATION & BREATH

Hand-Breath Coordination

  • SLOW &* DEEP BREATH
  • tilt head back to open up airways*
A
  • *MDI**
  • *Metered Dose Inhaler**

If coordination is bad:
Use DPI or Breath-Activated MDI or SPACER

MDI + Spacer
has EQUAL EFFICACY to NEBULIZER

46
Q

Which DOSAGE FORM?

Has an Activation Step (differs for each one)

  • *Breath Activated / Actuated**
  • less dependent on hand-breath coordination*

DEEP / FORCEFUL BREATH
requires sufficient inspiratory force

A
  • *DPI**
  • *DRY POWDER INHALER**

can NOT use spacer or holding chamber

Requires:
clean with DRY cloth when dirty

47
Q

Spacers & Holding Chambers

For use with WHICH INHALER?

Recommended for WHO?

A

ONLY (not breath actuated MDI nor DPI)

  • *MDI** = METERED DOSE INHALER
  • decreases the need for:*
  • *Hand-Breath Coordination**

Recommended for:

  • *Young Children <4y/o + MASK**
  • poor MDI technique*
  • *Poor Response to SABA MDI**

should be cleaned with:
soap + water

48
Q

Asthma Exacerbations

How do we GRADE them?

A

Mild-Moderate
Talks in PHRASES / Prefers SITTING/LAYING
RESPIRATORY RATE < 30bpm
PULSE 100-120
O2 SAT
PEF >50%

SEVERE

LIFE THREATENING

49
Q

RISK FACTORS
for

Asthma Exacerbations & Death

A
  • Uncontrolled Asthma Symptoms*
  • *OVER-USE of SABA** (>1 /month)

Inadequate ICS Use

Low FEV (<60% predicted

Psychiatric Disease // Trigger Exposure

Pregnancy // Uncontrolled Comorbidities
allergies / obesity / GERD

EOSINOPHILIA** or **Elevated IgE
blood / sputum

>1 Exacerbation in past YEAR

50
Q

Outpatient Management of EXACERBATIONS

Early +/- Mild Symptoms

Reduction in PEF/FEV (60-80%)

A

INCREASE
FREQUENCY or # of ALBUTEROL PUFFS
or
NEBULIZER TREATMENT
or
ADD SPACER if MDI

51
Q

Outpatient Managment of Exacerbations

Late / Severe Symptoms

Reduction in PEF/FEV <60%

A
  • *SYSTEMIC STEROIDS**
  • *Prednisone 40-60mg PO 3-7 Days**

Continue rescue / maintanence meds

52
Q

What Dosage forms are considered

  • *DPI’s**
  • *Dry Powdered Inhalers**
  • *Deep & Forceful Breath**
  • less coordination*
A

DISKUS

  • *TWIST / FLEX / TURBO / NEO** - HALERS
  • EXCEPT for REDIHALER = BREATH ACTIVATED MDI*

Ellipta / Respiclick

53
Q

Which drug is considered a

BREATH ACTIVATED MDI?

A
  • REDIHALE*R
  • *Beclamethasone = ICS**

easier to use than MDI

54
Q

Which drug types can cause / should be cautioned with:

BPH / Bladder Neck Obstruction?

A

MUSCARINICS

SAMA / LAMA
Ipratropium / -iums

55
Q

Which Drugs should we be cautioned with

GLAUCOMA ?

A
  • *LAMA_ / _SAMA**
  • iums

ICS / Oral Corticosteroids

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