Asthma Flashcards
what is the most common chronic dz in children?
asthma
is asthma reversible?
Yes
risk factors for asthma
Allergens
Respiratory infections
tobacco smoke, air pollution, occupation, diet
2 phases of asthma
immediate-phase response
late-phase response
what are the most effective drugs in the early phase of an asthmatic attack.
Bronchodilators
What occurs in the late-phase response of asthma?
bronchospasm, vasodilatation, edema and mucous secretion
what is needed for tx of late-phase response asthma?
Anti-inflammatory drug action
what are some environmental triggers of asthma?
Dust mites pet dancer cockroaches pollens molds viral URIs
What are some co-morbid conditions with asthma?
GERD
allergic rhinitis
sinusitis
depression
what drugs can induce asthma?
Cardioselective and non-selective Beta Blockers, Calcium antagonists
Dipyridamole
NSAID’s
Life-threatening acute deterioration of stable asthma
Acute asthma/ status asthmaticus
Acute or subacute onset of progressively worsening asthma symptoms
Asthma exacerbation
how much time does it take for an acute asthma exacerbation to occur
Sudden, less than 6 hours
Physical findings of asthma
Hyperexpansion of the thorax
Sounds of wheezing
Increased nasal secretion, mucosal swelling and nasal polyps
Atopic dermatitis/eczema
what do you use to establish reversibility of the airway?
spirometry
how often should short-acting inhaled beta-2 agonists be used?
<2 days / week
what meds are used for long term controll
Corticosteroid : inhaled and systemic Long-acting beta 2-agonist Leukotriene modifiers Methylxanthines Cromolyn Anti-IgE
What is used for quick relief of asthma
Short-acting beta 2 agonists (albuterol)
anticholinergics
systemic corticosteroids
Advantages of inhaled therapy
deliver drugs directly to the airways
deliver higher drug concentrations locally
minimize systemic side effects.
do you get a lot of systemic absorption with inhaled corticosteroid.
No
what makes it easier to use an inhaler?
Spacers
Convert a solution of drug into aerosol for inhalation
Used to deliver higher doses of drug to the lungs
more efficient than inhalers
Nebulizers
MOA of inhaled corticosteroids
Depress the inflammatory response and edema in the respiratory tract
Diminish bronchial hyper-responsiveness
What do inhaled corticosteroids decrease
Mucous production
Prostaglandins and leukotrienes
what is the most effective long-term control for persistent asthma
corticosteroids
what do you often combine with inhaled corticosteroids?
beta 2 agonist or other asthma agents
when do symptoms of asthma respond to ICS?
1-2 weeks, max 4-8 weeks
when must inhaled corticosteroids be used?
Regularly in order to help
Will not help in an acute setting
Contraindications with ICS?
caution in growing children (wash mouth out after)
ADRs of ICS (local)
Reflex cough and bronchospasm
thrush
Systemic ADRs of ICS
hypothalamic-pituitary-adrenal suppression
impaired growth in children
dermal thinning-dose dependent
in adults what are some concerns with ICS?
bone mineral density
ocular effects- cataracts, glaucoma
How can you decrease systemic absorption with ICS?
use a holding chamber
rinse and spit
lowest dose possible
used in combo w/ long-acting beta 2-agonists
Name the ICS
fluticasone Budesonide Beclomethasone Flunisolide Triamcinolone Mometasone
What are some ICS and LABA combos?
Fluticasone/ salmeterol (Advair)
Budesonid/ formoterol (symbicort)
List some long acting beta 2 agonists
Salmeterol
Formeterol
are LABAs a substitute for anti-inflammatory therapy? or for acute symptoms
No
can you develop tolerance with LABAs?
Yes- with chronic administration
what is the black box warning with long acting Beta 2 agonists?
Increase the chance of severe asthma episodes and death when those episodes occur
what can increase salmeterol plasma levels.
Concomitant use of CYP3A4
what drugs should be avoided with salmeterol
Ketoconazole, ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, saquinavir, telithromycin
if a patient is controlled on a low dose ICS, should you start a LABA?
No
should LABA be used as monotherapy?
No
which LABA as a quick onset of action
Formoterol
what are three leukotriene receptor antagonists
montelukast (singulair)
zafirlukast
zileuton
MOA of leukotriene receptor antagonists
Competitively antagonize leukotriene receptors D4 and E4 in the bronchiolar muscle, antagonizing endogenous leukotrienes causing bronchodilation.
what leukotriene receptor antagonsits also inhibits 5-lipoxygenase?
Zileuton
how are luekotriene receptor antagonists administered?
Orally
Who is ziluton NOT indicated w/?
patients with active liver dz
who are luekotriene receptor antagonist contraindicated with?
pregnancy
elderly
ADRs with leukotriene receptor antagonists
GI disturbances
HA
What are 2 methylxanthines?
Theophylliline (oral)
Aminophylline (oral and iv form)
MOA of methylxanthines?
to increase cAMP levels in the bronchial smooth muscle cells by inhibiting phosphodiesterase, an enzyme which catalyses the hydrolysis of cAMP to AMP.
What does increased cAMP lead to?
relaxes smooth muscle, causing bronchodilation.
Indications for methylxanthines
refractory patients
monotherapy and combo with ICS
Contrindications of methylxanthines
Children <4
cardiac dz
HTN
hepatic impairment
Problems with methylxanthinesN
narrow therapeutic window
significant interactions
Name some mast cell stabilizers
cromolyn sodium (inhaled) nedocromil (inhaled)
MOA of mast cell stabilizers
stabilize mast cells preventing the release of inflammatory mediators
Indications for mast cell stabilizers
Patients <20 w/ allergic dz; pregnancy
which mast cell stabilizer is bitter?
Neocromil
How long must mast cell stabilizer be used for effects?
Several weeks
Reserved for moderate-to-severe persistent asthma in patients 12 years of age or older who are not controlled on other therapies (not first line therapy)
SQ injection
Omalizumab (Xolair)
Black box warning for omalizumab
anaphylaxis
MOA os systemic corticosteroids
Decrease inflammation by suppression of migration of leukocytes and reversal of increased capillary permeability.
what route is preferred for systemic corticosteroids?
Oral over IV
when do you see effects of systemic corticosteroids?
after 4-6 hours
what are quick relief therapies for asthma?
Short acting beta2-adrenoceptor agonists
name some bronchodilators
Albuterol
Pibuterol
Metaproternol
Levalbuterol
MOA of beta 2 adrenoceptor agnoist
: β2-adrenoceptors are located on the airway smooth muscles and respond to epinephrine.
indications of beta adrenoceptor agonist?
relieve bronchospasm during acute exacerbations
pretreatment exercise induced
ADRS of beta 2 adrenoceptor agonist
fine tremor
tachycardia
hypokalemia w/ high doses
____________ are the only inhaled agents indicated for acute asthma attacks therefore also used as rescue inhalers.
Short-acting beta agonist such as albuterol
list some anticholinergics used for relief of acute bronchospasm (not chosen over albuterol)
Ipratropium
Tiotropium
what anticholinergic may provide additive effects to B2-agonists, in acute setting
Ipratropium
Are anticholinergics good for maintenance?
No
Anticholinergics are an alternative for patients with what type intolerance?
B2-agnoist intolerance
2 contraindications with anticholinergics
Glaucoma
Pregnancy
what do systemic corticosteroids do?
prevent progression of asthma exacerbation
reduce morbidity of the illness
If systemic corticosteroids are used more than how many times in a year should you re-evaluate their asthma treatment.
3 courses a year
every patient diagnosed w/ asthma should get what?
SABA (rescue albuterol inhaler)
for mild intermittent asthma what should they be given?
No daily meds
quick relief only
If patient has mild persistent asthma what meds should they get?
Low dose inhaled steroids
PRN SABA
alternative tx- cromolyn or nedocromil, leukotriene modifier or theophylline
What meds do you give for moderate persistent asthma
Low dose ICS and LABA; PRN SABA
Alternative- med/high dose ICS or low dose ICS + leukotriene modifier or theophylline
Meds for severe persistent asthma
Medium or high dose ICS and LABA or if needed glucocorticosteroid
Is COPD reversible?
No
what do COPD patients get some relief from (not as well as asthmatics though)
Bronchodilators
Anti-inflammatory agents
what is a hugely important therapy in COPD patients
Oxygen
Associated with chronic or recurrent excess mucous secretion into the bronchial tree
Cough that occurs on most days during a period of at least 3 months of the year for at least 2 consecutive years.
Chronic bronchitis
Abnormal, permanent enlargement of the airspaces distal to the terminal bronchioles
Accompanied by destruction of their walls, without obvious fibrosis
Emphysema
how does oxygen work with COPD
It increases alveolar oxygen tension and decreases the work of breathing necessary to maintain arterial oxygen tension.
what COPD patients shouldn’t receive oxygen?
patient who retain CO2, will depress their respiratory drive
what is the gold standard in COPD meds?
anticholinergics (can add beta 2 agonist, improves better combined)
Who should inhaled steroids be reserved for in COPD
Moderate to severe reduction in airflow that failed bronchodilator therapy
when are anitbiotics used with COPD?
When at least 2 of the following 3 are present
increased dyspnea
increased sputum volume
increased sputum purulence
