Asthma Flashcards
What is asthma?
Reversible inflammation
Asthma Pathophysiology
Mast cells, eosinophils, epithelial cells, macrophages, active T cells induce inflammation
inflammation is present between flare-ups.
Triggers of Asthma
Upper respiratory tract viral infections
Allergens, exercise, stress
Changes in the weather, laughter
Exposure to inhaled irritants (e.g., smoke, vehicle exhaust fumes, strong smells)
Gastroesophageal reflux disease (GERD)
Aspirin (in individuals sensitive to aspirin)
Exposure to sulfites
Diagnostic Criteria
Wheeze, shortness of breath, cough, and chest tightness
A hyper-responsiveness to an allergen or situation leads to these symptoms
The presence of variable airflow limitation:
Measured by spirometry
Airflow obstruction reversibility
Asthma Treatment Goals
Reduce impairment
Prevent chronic symptoms.
Reduce use of inhaled short-acting beta agonists.
Maintain normal or near-normal pulmonary function.
Maintain normal activity levels.
Meet patient/family expectations of asthma care.
Reduce risk
Prevent recurrent exacerbations and minimize emergency department (ED) visits and hospitalizations.
Prevent loss of lung function.
Provide optimal therapy with minimal adverse drug reactions (ADRs)
Rule of twos for asthma treatment
have asthma symptoms/attacks more than twice a week.
wakes up due to asthma symptoms more than twice a month
needs to take prednisone by mouth more than twice a year
Drug Therapy for Asthma
Beta 2 agonists
Short Acting Beta Agonist (SABA) for rescue
Long Acting Beta Agonist (LABA) for control
Glucocorticoids (ICS)
Leukotriene modifiers
Methylxanthines
Anticholinergics
Short Acting Methylxanthines
Anticholinergics (SAMA)
Long Acting Methylxanthines
Anticholinergics (LAMA)
Anti-IgE treatment
Short acting Beta2-AdrenergicAgonists drug examples
Albuterol (AccuNeb, Proventil HFA, ProAir HFA, Ventolin HFA) and Levalbuterol (Xopenex, Xopenex HFA)
Short acting Beta2-AdrenergicAgonists Side effects
SE: tachycardia, skeletal muscle tremor, nervousness, dizziness, hypokalemia, hyperglycemia
Short acting Beta2-AdrenergicAgonists mechanism
Beta2-adrenergic agonists stimulate beta2-adrenergic receptors, increasing the production of cyclic 3’5’ adenosine monophosphate (cAMP).
Increased cAMP relaxes airway smooth muscle and increases bronchial ciliary activity.
Inhaled Corticosteriod (ics) drug examples
Beclomethasone HFA (Qvar)
Budesonide DPI (Pulmicort)
Fluticasone propionate HFA (Flovent HFA)
Mometasone HFA (Asmanex HFA).
Inhaled corticosteroids side effects
Adverse effects: oral candidiasis & dysphonia, sodium and water retention, edema, hyperglycemia, ^appetite and weight gain.
Inhaled corticosteroids mechanism
Corticosteroids reduce airway inflammation by inhibiting or inducing the production of end-effector proteins.
LONG acting Beta2-Adrenergic Agonists (laba) description
Beta2-adrenergic agonists stimulate beta2-adrenergic receptors, increasing the production of cyclic 3’5’ adenosine monophosphate (cAMP).
Increased cAMP relaxes airway smooth muscle and increases bronchial ciliary activity.
Patient
LONG acting Beta2-Adrenergic Agonists Drugs
Salmeterol, Formoterol,Aformoterol, Vilanterol
LONG acting Beta2-Adrenergic Agonists side effects
SE: tachycardia, skeletal muscle tremor, nervousness, dizziness, hypokalemia, hyperglycemia
LONG acting Beta2-Adrenergic Agonists Black Box Warning
BBW: LABA’s assoc. with increased risk of asthma related deaths
**Must be used with an ICS-never solo therapy
Leukotriene modifiers
C0mbined ICS and LABA
Symbicort and Advair are maintenance inhalers that combine an inhaled corticosteroid (ICS) with a long-acting beta agonist (LABA). These inhalers are used daily to help control inflammation in the lungs and keep the airways open.
main differences between Symbicort and Advair
Symbicort: budesonide, 6 and up, formoterol
Advair: fluticasone, 4 and up, salmeterol
Mast Cell Stabilizers Asthma
Cromolyn:
Solution for nebulization (20 mg/2 Ml)-initial dose is 20 mg QID.
Once asthma symptoms controlled, dose may be tapered to lowest effective dose (e.g., 20 mg three to four times a day).
2-4 weeks to achieve maximum benefit.
Methylxanthines mechanism
Methylxanthine bronchodilators (theophylline, aminophylline) relax bronchial smooth muscle, enhance diaphragmatic contractility, and have a slight anti-inflammatory effect
Methylxanthines dose
Theophylline & aminophylline - dosed to target plasma drug concentration. Therapeutic theophylline serum drug concentration range -10–20 mg/L.
Methylxanthines delivery methods
PO tablets, elixir, solution, IV
Methylxanthines side effects
Many drugs interact with Theophylline
Adverse effect: tachycardia, tremor, n/v, GI, seizures if serum conc. > 35mg/L
Monoclonal Drugs example
Omalizumab (Xolair) is the only recombinant humanized monoclonal drug.
Monoclonal drug dosage
Omalizumab is indicated for treatment of persons with severe persistent allergic asthma with total serum IgE levels from 30 to 700 IU/mL. The dose is based on the total serum IgE and patient weight.
Monoclonal drug dosing considerations
Half life 20 days
Assess response to treatment after 16 weeks
Monoclonal black box warning
BBW: may induce anaphylaxis
Injection for
Moderate to Severe Persistent Asthma
XOLAIR
Xolair precautions
Allergic reactions can occur; therefore, first dose is always administered in the provider’s office.
Xolair candidates
moderate to severe persistent asthma in people 6 years of age and older
nasal polyps in people 18 years of age and older
chronic idiopathic urticaria (CIU, chronic hives without a known cause) in people 12 years of age
Xolair administration
Patients may inject themselves with prefilled syringe once they’ve been taught proper technique.
1 or more injections administered subq every 2-4 weeks
Bad Xolair side effects
Cancer
Inflammation of your blood vessels.
Fever, muscle aches, and rash.
Parasitic infections
Heart and circulation problems.
Xolair Black Box Warning by FDA
WARNING: ANAPHYLAXIS up to 1 year after administration
Common side effects of Xolair
12 years of age and older with asthma: joint pain in arms and legs, dizziness, feeling tired, itching, skin rash, bone fractures, and ear pain.
6 to less than 12 years of age with asthma: swelling inside nose, throat, or sinuses, headache, fever, throat infection, ear infection, abdominal pain, stomach infection, and nose bleeds.
In adults with nasal polyps: headache, injection site reactions, joint pain, upper abdominal pain, and dizziness.
In people with chronic idiopathic urticaria: nausea, headaches, swelling of the inside of your nose, throat or sinuses, cough, joint pain, and upper respiratory tract infection.
National asthma education and prevention program (NAEPP)
Step 1 Asthma Treatment
SABA PRN
National asthma education and prevention program (NAEPP)
Step 2 asthma Treatment
Low dose ICS
Alternative :
cromolyn, anti leukotriene, methyxanthines, or Nedocromil
National asthma education and prevention program (NAEPP)
Step 3
Low dose ICS + LABA
Or medium dose ICS
Alternative
Low dose ICS + antileukotriene, methyxanthine, or zileuton
Global Initiative for asthma (GINA)
Step 1-2 controller and preferred reliever
As needed low dose ICS - formoterol
Reliever: low dose ICS - formoterol
Global Initiative for asthma (GINA)
Step 3 controller and preferred reliever
Low dose maintenance ICS - formoterol
Reliever: low dose ICS - formoterol
Global Initiative for asthma (GINA)
Step 1 controller and alternative reliever
Take ICS whenever SABA needed
reliever: SABA
Global Initiative for asthma (GINA)
Step 2 controller and alternative reliever
Low dose maintenance ICS
reliever: SABA
Global Initiative for asthma (GINA)
Step 3 controller and alternative reliever
Low dose maintenance ICS + LABA
reliever: SABA
Why not treat with SABA alone?
Regular use of SABA, even for 1–2 weeks, is associated with increased airway hyperresponsiveness (ahr), reduced bronchodilator effect, increased allergic response, increased eosinophils (e.g. Hancox, 2000; Aldridge, 2000)
Can lead to a vicious cycle encouraging overuse
Over-use of SABA associated with exacerbations and mortality
Starting treatment with SABA trains the patient to
regard it as their primary asthma treatment
The only previous option was daily ICS even when
no symptoms, but adherence is extremely poor
GINA changed its recommendation once evidence for
a safe and effective alternative was available
Children 5 and younger GINA
Children 6-11 GINA
First-Line Treatment for Asthma
A short-acting rescue bronchodilator to be used as needed is required for all persons with asthma.
Inhaled Corticosteroids are the mainstay for patients with asthma
Chronic maintenance therapy with an asthma controller medication is indicated for persistent asthma:
Low-dose ICS are indicated for persons with mild persistent asthma (Step 2).
Medium-dose ICS are indicated for persons with moderate persistent asthma (Steps 3 and 4).
High-dose ICS are indicated for persons with severe persistent asthma (Steps 5 and 6).
Managing Exacerbations
Treat with oral steroids to regain control.
Use a short burst of prednisone
Adults: 40 to 60 mg/day for 5 to 10 days
Children: 1 to 2 mg/kg daily (maximum 60 mg/day) for 3 to 10 days
Educate on early recognition of sx of decreased lung function and know the action plan for exacerbations
Medication Monitoring
Once control is achieved, the patient is seen every 1 to 6 months to determine if a step up or step down in therapy is indicated.
The Expert Panel 3 Guidelines recommend the dose of inhaled corticosteroids be reduced about 25% to 50% every 2 to 3 months to lowest possible dose to maintain control.
Stepwise approach 0-4
Step 1
SABA PRN
Stepwise approach 0-4
Step 2
Preferred: Low Dose ICS
Alternative: Cromolyn or montelukast
Stepwise approach 0-4
Step 3
Medium Dose ICS
Stepwise approach 0-4
Step 4
Medium dose ICS + LABA or montelukast
Stepwise approach 0-4
Step 5
High dose ICS + LABA or montelukast
Stepwise approach 0-4
Step 6
High dose ICS + LABA or montelukast
Also oral steroids
Stepwise approach 5-11
Step 1
SABA PRN
Stepwise approach 5-11
Step 2
Preferred: Low dose ICS
Alternative: cromolyn, nexocromil, LTRA, or Theophylinw
Stepwise approach 5-11
Step 3
Low dose ICS + LABA, LTRA, or theophylline
Or
Medium dose ICS
Stepwise approach 5-11
Step 4
Preferred: Medium Dose ICS + LABA
Alternative: medium dose ICS + LTRA or theophylline
