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NAPLEX 2024 > 41. Asthma > Flashcards

41. Asthma Flashcards

1
Q

Common triggers of asthma

A

Pollution, cigarettes, cold air/changes in weather, pets, dusk, pollen, cockroaches, perfume/cosmetics
Drugs (Aspirin, NSAIDs, non-selective beta-blockers)

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2
Q

Comorbid conditions a/w asthma

A

Infections (cold/viruses), allergic rhinitis, GERD, obesity, obstructive sleep apnea, anxiety, stress, and depression

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3
Q

An asthma diagnosis is confirmed with ___

A

spirometry

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4
Q

FEV1 measures ___

A

how much air can be forcefully exhaled in one second

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5
Q

FVC measures ____

A

the max volume of air exhaled after taking a deep breath

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6
Q

FEV1/FVS measure ___

A

% of total air capacity (“vital capacity”) that can be forcefully exhaled in 1 second (speed of exhale)

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7
Q

Asthma diagnostic criteria

A

Measure baseline FEV1 with spirometry
Give albuterol
Measure post-bronchodilator FEV1

An FEV1 increase >12% post-bronchodilator is consistent with asthma diagnosis (considered “reversible”)

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8
Q

An FEV1 increase >___% post-bronchodilator (albuterol) is consistent with asthma diagnosis (considered “reversible”)

A

> 12%

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9
Q

What are the 2 major guidelines used for treating asthma?

A

Global Initiative for Asthma (GINA) - gold standard
NHLBI’s Expert Panel Report (EPR)

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10
Q

How frequent should follow up appointments be for asthma patients?

A

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

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11
Q

Vaccines recommended for asthma patients

A

Annual influenza
Pneumococcal vaccine

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12
Q

2 Primary rescue inhaler regiments

A

Combo of low-dose ICS + formoterol (preferred)
SABA in addition to ICS

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13
Q

In addition to treating acute asthma symptoms, relievers can be used preventively for ____

A

exercise-induced bronchospasm (EIB)

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14
Q

___ are the mainstay of maintenance treatment for asthma

A

ICS

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15
Q

How does combo med ICS + formoterol work as rescue asthma drug?

A

Formoterol = LABA with fast onset
Combination reduces the risk of exacerbations compared to SABA alone

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16
Q

How does SABA work as rescue asthma drug?

A

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)

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17
Q

What is the role of systemic steroids in asthma?

A

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

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18
Q

What is the role of inhaled epinephrine in asthma?

A

Not included in asthma guidelines
Available OTC, can be used intermittently for acute treatment for mild asthma only

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19
Q

What is the role of Inhaled short-acting muscarinic antagonists (SAMAs) (anticholinergics) in asthma?

A

Can be used in combo with SABA during exacerbations

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20
Q

What is the role of ICS in asthma?

A

First-line treatment for all pts; most effective anti-inflammatory drugs

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21
Q

What is the role of LABA in asthma?

A

Used in combo with ICS (should NEVER be used alone d/t risk of serious adverse outcomes)
Preferred add-on agents to ICS

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22
Q

What is the role of oral leukotriene receptor antagonist (LTRAs) in asthma?

A

Most commonly used in children
Alt option to LABA in combo with ICS; can also be added ICS/LABA treatment

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23
Q

What is the role of theophylline (PO or IV) in asthma?

A

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!!

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24
Q

What is the role of LAMAs in asthma?

A

Can be used as add-on treatment in pts with hx of exacerbations despite ICS/LABA treatment

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25
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
26
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)
27
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
28
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
29
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
30
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)
31
When would a provider consider stepping down for treatment algorithm for asthma?
If well-controlled for ≥3 months
32
SABAs and LABAs should be used only in combination with ___
ICS
33
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
34
Epinephrine (Asthmanefrin Refill) OTC should NOT be used since it is ____
non-selective
35
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
36
Which beta-2 agonists is a maintenance inhaler only, not for acute bronchospasm?
Salmeterol (Serevent Diskus) - LABA
37
Side effects of SABAs
Nervousness, tremor, tachycardia, palpitations, cough, hyperglycemia, decreased K
38
Which types of SABA products require shake well before use?
MDIs (HFA products)
39
Levalbuterol contains __-isomer of albuterol
R-isomer
40
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
41
When using SABAs for exercise induced bronchoconstriction, use 2 inhalations ___ prior to exercise
5 min prior
42
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
43
Side effects for ICS
Dysphonia (difficulty speaking), oral candidiasis (thrush), cough Others: HA, hoarseness, URTIs, hyperglycemia
44
Which type of inhaler requires rinsing mouth with water to prevent thrush?
ICS; can use a spacer device with an MDI to decrease risk
45
___ is a metered dose inhaler (MDI) ICS that does NOT need to be shaken before use
Alvesco (Ciclesonide)
46
___ is the only ICS available as a nebulized solution
Budesonide, commonly used in children
47
___ 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)
48
____ are preferred for asthma whereas ____ are preferred for COPD
ICS and ICS/LABA for asthma LABA, LAMA, LAMA/LABA for COPD
49
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)
50
Common LABA inhalers for asthma
Salmeterol (Serevent Diskus)
51
Common LAMA inhalers for asthma
Tiotropioum (Spiriva Respimat only)
52
Common ICS/LABA inhalers for asthma
Budesonide/formoterol (Smybicort) Fluticasone/salmeterol (Advair Diskus, Advair HFA) Mojmetasone/formoterol (Dulera) Fluticasone/vilanterol (Breo Ellipta)
53
Common LAMA/LABA/ICS inhalers for asthma
Umeclidinium/vilanterol/fluticasone (Trelegy Ellipta)
54
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
55
Key differences between MDIs vs DPIs: Dose delivery
MDIs - aerosolized liquid DPIs - fine powder
56
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)
57
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
58
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
59
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
60
Montelukast (Singulair) MOA
Inhibits leukotriene D4 (LTD4) to reduce airway edema, constriction, and inflammation
61
Zileuton (Zyflo) MOA
5-lipoxygenase inhibitor, inhibits leukotriene formation
62
Zafirlukast (Accolate) MOA
Inhibits both LTD4 and LTE4
63
Boxed warning for montelukast
Neuropsychiatric events (e.g. serious behavior and mood-related changes, including suicidal thoughts or actions)
64
Warnings for leukotriene modifying agents
Neuropsychiatric events - monitor for signs of aggressive behavior, hostility, agitation, hallucinations, depression, suicidal thinking
65
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
66
Which leukotriene modifying agent requires dispensing in original container?
Zafirlukast (Accolate)
67
Which leukotriene modifying agent is also approved for allergic rhinitis and exercise-induced bronchoconstriction?
Montelukast
68
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
69
Zafirlukast is a major substrate and moderate inhibitor of CYP___ Zafirlukast can increase levels of ____ and other substrates (e.g. ____)
2C9 Theophylline, warfarin
70
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
71
Theophylline MOA
Blocks phosphodiesterase, causing increase in cAMP and release of epinephrine from adrenal medulla cells >> bronchodilation (but also causes diuresis, CNS/cardiac stimulation, and gastric acid secretion
72
Why is theophylline use limited in asthma?
Decreased effectiveness, drug interactions, and adverse effects
73
Active metabolized of theophylline are ___ and 3-methylxanthine
Caffeine
74
Theophylline oral loading dose
5 mg/kg IBW (of TBW if < IBW)
75
Therapeutic range of theophylline
5-15 mcg/mL Measure peak level at steady state, after 3 days of oral dosing
76
Side effects of theophylline
Toxicity - persistent vomiting, arrhythmias, seizures Others: N/V, HA, insomnia, increased HR, tremor, nervousness
77
Converting Aminophylline to Theophylline
ATM - aminophylline to theophylline = multiply by 0.8
78
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
79
Theophylline is a major substrate of CYP___. What are some inhibitors that increase theophylline levels?
1A2 Ciprofloxacin, zileuton (others: cimetidine, fluvoxamine, propranolol)
80
What are drugs that decrease thophylline levels?
Carbamazepine, fosphenytoin, phenobarbital, phenytoin, primadone, rifampin, ritonavir Others: levothyroxine, St. John's wort and tobacco/marijuana smoking
81
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
82
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
83
Anticholinergics MOA in asthma
Inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of the airway, leading to bronchodilation
84
Anticholinergics should not be used alone in asthma; they are add-on treatments to be used with ___
ICS
85
Omalizumab MOA
Monoclonal antibody that inhibits IgE binding to the IgE receptor on mast cells and basophils
86
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
87
How is Omalizumab (Xolair) administered and how frequently
SC every 2 or 4 weeks
88
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
89
Boxed warning for Omalizumab (Xolair)
Anaphylaxis
90
___,___, 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
91
How is reslizumab (Cinqair) administered and how frequently
IV every 4 weeks Boxed warning for anaphylaxis
92
How is Mepolizumab (Nucala) administered and how frequently
SC once every 4 weeks
93
How is Benralizumab (Fasenra) administered and how frequently
SC once every 4 weeks for 3 doses and then every 8 weeks
94
How is dupilumab (Dupixent) administered and how frequently
SC every other week
95
___ or ____, taken ___ before exercise, is preferred to prevent exercise-induced bronchospasm.
SABA or low-dose ICS/formoterol 2-3 hrs
96
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
97
___ 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
98
___ 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
99
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 >> 60 second wait >> LABA or LAMA >> 60 seconds >> ICS
100
How often should spacers be cleaned?
At least once a week
101
Zones of an Asthma Action Plan: Green indicates >___% of personal best
80-100%
102
Zones of an Asthma Action Plan: Yellow indicates >___% of personal best
50-80%
103
Zones of an Asthma Action Plan: Red indicates <___% of personal best
<50%
104
How often should peak flow meters be cleaned?
at least once a week
105
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
106
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
107
Budesonide (Pulmicort Respules) Ampules should be used within ___ of opening the aluminum package
2 weeks
108
Which inhaler should not be washed?
Advair Diskus (fluticasone/salmeterol)

NAPLEX 2024 (74 decks)

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