41. Asthma Flashcards
Common triggers of asthma
Pollution, cigarettes, cold air/changes in weather, pets, dusk, pollen, cockroaches, perfume/cosmetics
Drugs (Aspirin, NSAIDs, non-selective beta-blockers)
Comorbid conditions a/w asthma
Infections (cold/viruses), allergic rhinitis, GERD, obesity, obstructive sleep apnea, anxiety, stress, and depression
An asthma diagnosis is confirmed with ___
spirometry
FEV1 measures ___
how much air can be forcefully exhaled in one second
FVC measures ____
the max volume of air exhaled after taking a deep breath
FEV1/FVS measure ___
% of total air capacity (“vital capacity”) that can be forcefully exhaled in 1 second (speed of exhale)
Asthma diagnostic criteria
Measure baseline FEV1 with spirometry
Give albuterol
Measure post-bronchodilator FEV1
An FEV1 increase >12% post-bronchodilator is consistent with asthma diagnosis (considered “reversible”)
An FEV1 increase >___% post-bronchodilator (albuterol) is consistent with asthma diagnosis (considered “reversible”)
> 12%
What are the 2 major guidelines used for treating asthma?
Global Initiative for Asthma (GINA) - gold standard
NHLBI’s Expert Panel Report (EPR)
How frequent should follow up appointments be for asthma patients?
every 2-6 weeks after starting meds - ensure proper inhaler technique (priming, cleaning) and step up/down treatment
Decrease to 1-6 months once controlled
Vaccines recommended for asthma patients
Annual influenza
Pneumococcal vaccine
2 Primary rescue inhaler regiments
Combo of low-dose ICS + formoterol (preferred)
SABA in addition to ICS
In addition to treating acute asthma symptoms, relievers can be used preventively for ____
exercise-induced bronchospasm (EIB)
___ are the mainstay of maintenance treatment for asthma
ICS
How does combo med ICS + formoterol work as rescue asthma drug?
Formoterol = LABA with fast onset
Combination reduces the risk of exacerbations compared to SABA alone
How does SABA work as rescue asthma drug?
Quickly reverses bronchoconstriction
Note: SABAs do not treat underlying inflammation, should be used with an ICS (taken as needed at the same time as SABA or taken daily as maintenance med)
What is the role of systemic steroids in asthma?
Injections - used during exacerbations
Oral - used during exacerbations or severe asthma that is difficult to control with other drug combos
Note: use should be limited as much as possible d/t adverse effects
What is the role of inhaled epinephrine in asthma?
Not included in asthma guidelines
Available OTC, can be used intermittently for acute treatment for mild asthma only
What is the role of Inhaled short-acting muscarinic antagonists (SAMAs) (anticholinergics) in asthma?
Can be used in combo with SABA during exacerbations
What is the role of ICS in asthma?
First-line treatment for all pts; most effective anti-inflammatory drugs
What is the role of LABA in asthma?
Used in combo with ICS (should NEVER be used alone d/t risk of serious adverse outcomes)
Preferred add-on agents to ICS
What is the role of oral leukotriene receptor antagonist (LTRAs) in asthma?
Most commonly used in children
Alt option to LABA in combo with ICS; can also be added ICS/LABA treatment
What is the role of theophylline (PO or IV) in asthma?
Least desirable option for add-on treatment d/t significant adverse effects, drug interactions and the need to monitor serum drug concentrations
Requires monitoring serum drug conc!!
What is the role of LAMAs in asthma?
Can be used as add-on treatment in pts with hx of exacerbations despite ICS/LABA treatment
What is the role of injectable monoclonal antibodies (SC or IV) in asthma?
Add-on in persistent severe asthma
Omalizumab - severe allergis asthma
Mepolizumab, reslizumab, benralizumab, and dupilumab - severe eostinophilic asthma
Patient complains of s/sx of asthma that occurs <2x/month with no nighttime awakenings. What treatment do you recommend?
Step 1:
Rescue - low-dose ICS/formoterol OR
Rescue - SABA + low-dose ICS (taken together)
Patient complains of s/sx of asthma that occurs ≥2x/month but ≤4-5x/week with no nighttime awakenings. What treatment do you recommend?
Step 2:
Rescue - low-dose ICS/formoterol OR
Rescue - SABA // Maintenance low-dose ICS
Alternatives: PO leukotriene receptor antagonist (LTRAs) OR low-dose ICS taken whenever SABA is taken
Patient complains of s/sx of asthma that occurs most days and night time awakenings ≥1x/week. What treatment do you recommend?
Step 3:
Rescue - Low-dose ISC/Formoterol // Maintenance - low-dose ICS/formoterol OR
Rescue - SABA // Maintenance - low-dose ICS/LABA
Alternatives: low-dose ICS + LTRA OR medium-dose ICS
Patient complains of s/sx of asthma that occurs every day and night time awakenings ≥1x/week. What treatment do you recommend?
Step 4:
Rescue - low-dose ICS/Formoterol // Maintenance - Medium-dose ICS/formoterol OR
Rescue - SABA // Maintenance Medium-dose ICS/LABA
Alternatives: high-dose ICS or add on tiotropium or LTRA
Patient still complains of s/sx of asthma that occurs every day and night time awakenings ≥1x/week despite step 4 treatment regimen. What treatment do you recommend?
Step 5:
Rescue - low-dose ICS/Formoterol // Maintenance - High-dose ICS/formoterol OR
Rescue - SABA // Maintenance - high-dose ICS/LABA
Consider adding tiotropium, oral steroid, or injectable treatments (e.g. omalizumab, mepolizumab, reslizumab, tezepelumab)
When would a provider consider stepping down for treatment algorithm for asthma?
If well-controlled for ≥3 months
SABAs and LABAs should be used only in combination with ___
ICS
Albuterol (ProAir HFA, ProAir RespiClick, Proventil HFA, Ventolin HFA) strength and dosing
90 mcg/inh
1-2 inhalations q4-6 hrs prn
Note: PO forms available but NOT recommended
Epinephrine (Asthmanefrin Refill) OTC should NOT be used since it is ____
non-selective
Boxed Warnings for Salmeterol (Serevent Diskus)
Increased risk of asthma-related deaths; only use in pts currently receiving but not adequately controlled on ICS
Increased risk of asthma-related hospitalizations in pediatric and adolescent pts
Which beta-2 agonists is a maintenance inhaler only, not for acute bronchospasm?
Salmeterol (Serevent Diskus) - LABA
Side effects of SABAs
Nervousness, tremor, tachycardia, palpitations, cough, hyperglycemia, decreased K
Which types of SABA products require shake well before use?
MDIs (HFA products)
Levalbuterol contains __-isomer of albuterol
R-isomer
Most albuterol inhalers contain __ inh/canister
Exception: ____ which is available as ___inh/canister as well
200 inh/canister
Ventolin HFA - available in 60 inh/canister and 200 inh/canister
When using SABAs for exercise induced bronchoconstriction, use 2 inhalations ___ prior to exercise
5 min prior
Warnings for ICS
Increased risk of fractures, growth retardation (in children) and immunosuppression
Others: high doses for prolonged periods of time can cause adrenal suppression
Side effects for ICS
Dysphonia (difficulty speaking), oral candidiasis (thrush), cough
Others: HA, hoarseness, URTIs, hyperglycemia
Which type of inhaler requires rinsing mouth with water to prevent thrush?
ICS; can use a spacer device with an MDI to decrease risk
___ is a metered dose inhaler (MDI) ICS that does NOT need to be shaken before use
Alvesco (Ciclesonide)
___ is the only ICS available as a nebulized solution
Budesonide, commonly used in children
___ is a ICS breath-activated aerosol with characteristics of DPI and MDI; do NOT shake or use with spacer, does not need priming or activation
QVAR RediHaler (Beclomethasone)
____ are preferred for asthma whereas ____ are preferred for COPD
ICS and ICS/LABA for asthma
LABA, LAMA, LAMA/LABA for COPD
Common ICS inhalers for asthma
Beclomethasone (QVAR RediHaler)
Budesonide (Pulmicort Flexhaler)
Fluticasone (Flovent HFA, Flovent Diskus, Arnuity Ellipta)
Others: Ciclesonide (Alvesco), Mometasone (Asmanex HFA, Asmanex)
Common LABA inhalers for asthma
Salmeterol (Serevent Diskus)
Common LAMA inhalers for asthma
Tiotropioum (Spiriva Respimat only)
Common ICS/LABA inhalers for asthma
Budesonide/formoterol (Smybicort)
Fluticasone/salmeterol (Advair Diskus, Advair HFA)
Mojmetasone/formoterol (Dulera)
Fluticasone/vilanterol (Breo Ellipta)
Common LAMA/LABA/ICS inhalers for asthma
Umeclidinium/vilanterol/fluticasone (Trelegy Ellipta)
Key differences between MDIs vs DPIs: Brand name identifiers
MDIs - HFA, Respimat, or no suffix (e.g. Symbicort, Dulera)
DPIs - Diskus, ellipta, Pressair, HandiHaler, RespiClick, Flexhaler
Key differences between MDIs vs DPIs: Dose delivery
MDIs - aerosolized liquid
DPIs - fine powder
Key differences between MDIs vs DPIs: Administration
MDIs - slow, deep inhalation while pressing canister (hand-breath coordination)
DPIs - quick, forceful inhalation (breath activated dose delivery; no need to press anything)
Key differences between MDIs vs DPIs: Spacer
MDIs - spacers can be used; helpful in pts incapable of hand-breath coordination and decreases risk of thrush with ICS
DPIs - cannot be used
Key differences between MDIs vs DPIs: Shaking prior use
MDIs - required for all products except: QVAR RediHaler, Alvesco, and Respimat products
DPIs - do not shake
Key differences between MDIs vs DPIs: Priming
MDIs - prime before first use and if not used for a certain period of time
DPIs - not needed except for Flexhaler prior to first use
Montelukast (Singulair) MOA
Inhibits leukotriene D4 (LTD4) to reduce airway edema, constriction, and inflammation
Zileuton (Zyflo) MOA
5-lipoxygenase inhibitor, inhibits leukotriene formation
Zafirlukast (Accolate) MOA
Inhibits both LTD4 and LTE4
Boxed warning for montelukast
Neuropsychiatric events (e.g. serious behavior and mood-related changes, including suicidal thoughts or actions)
Warnings for leukotriene modifying agents
Neuropsychiatric events - monitor for signs of aggressive behavior, hostility, agitation, hallucinations, depression, suicidal thinking
How are montelukast granules administered
Directly in mouth, dissolved in small amount (5mL) of breast milk or formula, or mixed with a spoonful of applesauce, carrots, rice, or ice cream
Use within 15 min of opening packet
Which leukotriene modifying agent requires dispensing in original container?
Zafirlukast (Accolate)
Which leukotriene modifying agent is also approved for allergic rhinitis and exercise-induced bronchoconstriction?
Montelukast
Montelukast (Singulair) dosing
10 mg daily in the evening
Age 6-14yo: 5mg daily in the evening
Age 1-5yo: 4mg daily in the evening
Zafirlukast is a major substrate and moderate inhibitor of CYP___
Zafirlukast can increase levels of ____ and other substrates (e.g. ____)
2C9
Theophylline, warfarin
Zileuton is a minor substrate of CYP1A2, 2C9, and 3A4, and weak inhibitor of 1A2
It can increase levels of ___,___,and ___
Theophylline, propranolol, and warfarin
Theophylline MOA
Blocks phosphodiesterase, causing increase in cAMP and release of epinephrine from adrenal medulla cells»_space; bronchodilation (but also causes diuresis, CNS/cardiac stimulation, and gastric acid secretion
Why is theophylline use limited in asthma?
Decreased effectiveness, drug interactions, and adverse effects
Active metabolized of theophylline are ___ and 3-methylxanthine
Caffeine
Theophylline oral loading dose
5 mg/kg IBW (of TBW if < IBW)
Therapeutic range of theophylline
5-15 mcg/mL
Measure peak level at steady state, after 3 days of oral dosing
Side effects of theophylline
Toxicity - persistent vomiting, arrhythmias, seizures
Others: N/V, HA, insomnia, increased HR, tremor, nervousness
Converting Aminophylline to Theophylline
ATM - aminophylline to theophylline = multiply by 0.8
Theophylline has saturable kinetics. What does that mean?
In the higher end of the therapeutic range, small dose increases can result in large increases in drug conc
Theophylline is a major substrate of CYP___. What are some inhibitors that increase theophylline levels?
1A2
Ciprofloxacin, zileuton (others: cimetidine, fluvoxamine, propranolol)
What are drugs that decrease thophylline levels?
Carbamazepine, fosphenytoin, phenobarbital, phenytoin, primadone, rifampin, ritonavir
Others: levothyroxine, St. John’s wort and tobacco/marijuana smoking
What are some conditions/foods that increase theophylline levels (d/t decrease theophylline clearance)?
CHF, liver disease (cirrhosis)
Others: acute pulmonary edema, cor pulmonale, fever, hypothyroidism, shock and high carbohydrate/low protein diet
What are some conditions/foods that decrease theophylline levels (d/t increased theophylline clearance)?
Low carb/high-protein diet
Others: daily consumption of charbroiled beef, cystic fibrosis, and hyperthyroidism
Anticholinergics MOA in asthma
Inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of the airway, leading to bronchodilation
Anticholinergics should not be used alone in asthma; they are add-on treatments to be used with ___
ICS
Omalizumab MOA
Monoclonal antibody that inhibits IgE binding to the IgE receptor on mast cells and basophils
Omalizumab (Xolair) indication
Moderate-severe persistent, allergic asthma in pts ≥6yo who have a positive skin test to a perennial aeroallergen and inadequate symptom control on Step 5 treatment
How is Omalizumab (Xolair) administered and how frequently
SC every 2 or 4 weeks
T/F: Omalizumab (Xolair) is a SC injection that is self administered at home, does not require medical supervision
False - needs to be initiated in healthcare setting under medical supervision (≥3 doses) and then self-administration given no anaphylaxis after ≥3 doses, can recognize/manage anaphylaxis, and proper injection technique
Boxed warning for Omalizumab (Xolair)
Anaphylaxis
___,___, and ___ are IL-5 receptor antagonists. ___ is an IL-4 and L-3 receptor antagonist. All are indicated for severe asthma with an eosinophilic phenotype. Should be added to maintenance inhaler treatment.
Mepolizumab, reslizumab, benralizumab = IL-5 antagonists
Dupilumab = IL-4 and IL-3 antagonist
How is reslizumab (Cinqair) administered and how frequently
IV every 4 weeks
Boxed warning for anaphylaxis
How is Mepolizumab (Nucala) administered and how frequently
SC once every 4 weeks
How is Benralizumab (Fasenra) administered and how frequently
SC once every 4 weeks for 3 doses and then every 8 weeks
How is dupilumab (Dupixent) administered and how frequently
SC every other week
___ or ____, taken ___ before exercise, is preferred to prevent exercise-induced bronchospasm.
SABA or low-dose ICS/formoterol
2-3 hrs
When using SABA or low-dose ICS/formoterol in EIB, SABA will last ___ while ICS/formoterol can last up to ____
2-3 hrs
up to 12 hrs
___ can be used as an alternative to a SABA in EIB if a longer duration of symptom control is needed; should be taken 30 min before exercise.
Salmeterol (LABA)
Note: should never be used alone for persistent asthma if taking for asthma maintenance
___ can be taken 2 hrs prior to exercise and lasts up to 24 hrs for EIB. It is effective only in 50% of patients. Patients taking this medication for asthma or any other indication should not take an additional dose to prevent EIB.
Montelukast
If pts are using more than 1 inhaler, what is the timing and order of use?
Bronchodilators first and wait 60 seconds between
Ex. SABA»_space; 60 second wait»_space; LABA or LAMA»_space; 60 seconds»_space; ICS
How often should spacers be cleaned?
At least once a week
Zones of an Asthma Action Plan: Green indicates >___% of personal best
80-100%
Zones of an Asthma Action Plan: Yellow indicates >___% of personal best
50-80%
Zones of an Asthma Action Plan: Red indicates <___% of personal best
<50%
How often should peak flow meters be cleaned?
at least once a week
Which MDIs should be taken apart to rinse the mouth piece under water and airdry?
Which MDIs should NOT be put into water?
Ventolin HFA, ProAir HFA - mouth piece should be rinsed airdried
Flovent HFA - Do not take canister out of plastic actuator, wipe inside of mouthpiece with damp tissue and air dry
Symbicort, Dulera - do NOT put into water
For RespiClick Inhalers (ProAir RespiClick and AirDuo RespiClick), what is the risk of opening the cap when a dose is not needed?
Opening and closing the cap without inhaling a dose will waste medication and damage your inhaler
Budesonide (Pulmicort Respules) Ampules should be used within ___ of opening the aluminum package
2 weeks
Which inhaler should not be washed?
Advair Diskus (fluticasone/salmeterol)
