Ass-thma (Chronic) Flashcards
SABA agents for asthma
- albuterol
- levalbuterol - more potent
ICS agents for asthma
- Ciclesonide
- Fluticasone - higher risk of sore throat/hoarseness
- Beclomethasone - smaller particles → better lung penetration
- Mometasone
- Budesonide
LABA agents for asthma
- Salmeterol
- Formoterol
- Vilanterol
LAMA agents for asthma
- Tiotropium
Leukotriene modifiers for asthma
Leukotriene D4 antags
- Montelukast
- Zafirlukast - DDI warfarn, theophylline
5-lipooxygenase inhibitor
- Zileuton - DDI theophylline
Biologics for asthma
- Omalizumab
- Mepolizumab
- Reslizumab
- Benralizumab
- Dupilumab
SABA application in asthma therapy
- short acting beta agonists
- Rescue therapy
Inhaled corticosteroid application in asthma therapy
First line maintenance - dosed BID (except for Arnuity QD and mometasone QD OR BID)
AVOID in aute bronchospasm and status asthmaticus
LABA application in asthma therapy
- long acting beta agoists
Maintenance therapy - must be used in COMBO with ICS ← has a BBW of asthma-related death if used as monotherapy
ICS/formoterol (speficially, budesonide/formoterol), can be used as a rescue
LAMA application in asthma therapy
Maitenance therapy
Leukotriene modifier application in asthma therapy
Maintenance for persistent asthma
If using montelukast for exercise, take 2hrs prior
Theophylline application in asthma therapy
Not frequetly used d/t high risk of AE, DDI (CYP3A4), and narrow window (5-15mcg/mL)
- also less effective than ICS
Biologics application in asthma therapy
- In pts with severe allergic or eosinphilic asthma
- Admined in healthcare setting
SABA MOA
stimulate beta 2 receptor in lungs → relaxation of bronchial smooth muscle → bronchodilation (does NOT address inflammation)
Inhaled corticosteroid MOA (asthma)
- Reduce chronic airway inflammation; decrease airway hypersensitivity
- Reduce risk of exacerbations → reduced hospital admissions and death
- Improve lung function → peak expiratory flow rate increases
- Reduce symptoms
LABA MOA
stimulate beta 2 receptor in lungs → relaxation of bronchial smooth muscle → bronchodilation (does NOT address inflammation)
- same as SABA
LAMA MOA
Inhibit the action of ACh at the M3 muscarinic receptor in bronchial smooth muscle → bronchodilation
Leukotriene modifiers MOA (asthma)
Block pro-inlammatory leukotrienes at receptor sites → reduce airway constriction and mucus secretion
Theophylline MOA
Block phosphodiesterase, increase cAMP → release of epinephrine from adrenal medulla cells → brochodilation, CNS and cardiac stimualtion, diuresis, gastric acid secretion
Caffeine is an active metabolite
Biologics for asthma MOA
Targets
- IgE: allergic response
- IL-4: inflammation
- IL-5: eosinophils
SABA AE
- Tremor, shakiness
- Lightheadedness
- Cough
- Palptations
- Hypokalemia
- Tachycardia
- Hyperglycemia
Inhaled corticosteroids for asthma AE
USE LOWEST DOSE POSSIBLE
- step down when asthma is well controlled, decrease dose 25-50% after 3 months of stability
Oropharyngeal candidiasis
Dysphonia
Growth concerns in children (not clinically significant)
Hyperglycemia
Increased risk of fractures
Leukotriene modifiers for asthma AE
- HA
- URI
- GI
- Psych - montelukast only
- aggressive behavior
- AMS
Theophylline AE
Nausea
Loose stools
HA
Tachycardia
Insomnia
Tremor, Nervousness
AVOID in: CV hx, hyperthyroid, PUD, seizures
Clinical pearls regarding inhaler types
- Avoid DPIs in children <4
- Shake MDIs
- Do NOT shake DPI
- Avoid DPI in milk protein allergies (except budesonide)
- DPI may contain lactose
Systemic corticosteroids use in assthma
Can be used for management of exacerbation ← short course that does NOT need to be tapered off
Epinephrine inhlaer in asthma
OTC epinephrine inhaler is nonselective → AE for tachycardia, HTN → DO NOT USE
Cromolyn in asthma
Neb exists but is not preferred
Asthma
characterized by intermittent or persistent presence of highly variable degrees of airflow obstruction from airway wall inflammation and bronchial smooth muscle constriction
Asthma signs/symptoms
- dyspenea
- wheezing
- SOB
- chest tightness
- dry, hacking cough
- variable expiratory airflow
- signs of atopy
- reduced O2 saturation
s/s tend to worsen at night and early morning and vary over time in intensity
Asthma triggers
- viral infections
- allergens
- tobacco smoke/enviroment
- exercise
- stress/emotions
- drugs/preservatives (asa, nsaids, sulfites, non-selective beta blockers, bezalkonium chloride) - occupational stimuli
Asthma risk factors
- higher exposure to residential allergens
- socioeconomic disparities(shortage of PCPs in minority communities; language and literacy barriers)
- underuse of asthma medications
- second hand tobacco somke
- allergen exposure
- urbanization
- RSV
- family size (smaller family, higher risk)
- decreased exposure to common childhood infectious agents
Atopy risk factors
- eczema
- allergic rhinitis
- allergic asthma
Mild asthma
Asthma that is controlled by step 1 or 2
Moderate asthma
Asthma that is controlled by step 3 or 4
Severe asthma
Asthma that is controlled by step 5
Asthma symptom assessment (the checklist)
In the past 4 weeks, has the patient had:
- daytime asthma s/s more than 2x a week
- any night waking d/t asthma
- SABA use for s/s more than 2x a week (EXCLUDE if using before exercise)
- activity limitation d/t asthma
Asthma comorbidities
- obesity
- chronic rhinusinusitis
- GERD
- confirmed food allergy
- anx
- depression
- preggers
Risk factors for developing fixed airflow limitation
- low birth weight
- lack of ICS treatment
- exposure to tobacco smoke, etc.
- low FEV1
- chronic mucus hypersecretion
- sputum or blood eosinophilia
Long term goals of astha management care
- symptom control
- risk reduction for future exacerbations
Why ICS instead of SABA alone?
- pts with mild asthma can have severe exacerbations - ICS is preventative
- SABA only increases risk for exacerbations
- Low dose ICS reduces asthma related hospitalzations and death
- Patients who experience severe exacerbations have better long-term lung function if on an ICS
What is the first thing we do when a patient comes in with partly controlled or uncontrolled asthma
CHECK INHALER TECHNIQUE and adherence
Stepping down asthma therapy
- Appropriate time for step down: >3 months of good asthma control
- Reduce CIS dose by 25-50% at 2-3 month intervals (can go all the way down to PRN ICS/formoterol)
- Do NOT completely stop ICS unless needed to temporarily confirm dxx
Non-pharm interventions for asthma
- smoking cessation
- physical activity
- remove sensitizers
- avoid medications that may worsen asthma (NSAIDs or beta blockers)
- Remediation of dampness or mold in homes
- sulingual immunotherapy
