Asthma Flashcards
Define asthma:
Chronic INFLAMMATORY disorder of the airways characterized by:
1) Paroxysmal or persistent symptoms
2) Dypsnea, chest tightness, wheezing, sputum production & cough
3) Airway hyper-responsiveness to a variety of stimuli
Is Asthma’s course throughout life the same?
Course is variable (fluctuates daily)
Asthma onset:
Onset can occur at any age
What is the #1 chronic condition in Canadian children
?
Childhood asthma is the #1 chronic condition in Canada
15% or children between 4 & 11
8.5% > age 12
Leading cause of ER hospitalizations of children
How many people out of 10 do not have their asthma under control?
6 out of 10 people with asthma do not have control of their condition
How many people die per year of asthma in canada?
250
What is the cause of death of asthma? What % is preventable? How?
- Exacerbations
- Most do not die from long-term progression of asthma
- 80% of these deaths can be prevented with proper education
QOL of Asthmatics
- Can maintain all activities of daily living
- QOL measures can be the same as non-asthmatics
What is the etiology of asthma?
Genetic predisposition and environmental interaction
What % of asthma is genetic? Genes may affect:
- 60-80%
- Multiple genes involved
Genes pre-disposing to atopy
Genes pre-disposing to airway hyper-responsiveness
Genes associated with response to treatment
Which sex has a higher prevalence of asthma?
Childhood: male > female (males have a smaller airway size increasing risk of wheezing)
Around age 20: men = women
> age 40: female> male
What encompasses a genetic predisposition to asthma?
Genes, Sex, Obesity
What is atopy in regards to asthma?
The genetic tendency to develop allergic diseases (IgE mediated) such as allergic rhinitis, asthma and atopic dermatitis (eczema)
- # 1 pre-disposition to asthma
What is the #1 pre-disposing factor to asthma?
ATOPY
What are some examples of environmental factors of asthma?
Smoke
Allergen exposure
Airborne pollens (grass, trees, weeds), house-dust mites, animal danders, cockroaches, fungal spores
Infections in infancy
Respiratory syncytial virus (RSV), decreased exposure to common childhood infectious agents (hygiene hypothesis)
Environment
Cold air, fog, ozone, sulfur dioxide, nitrogen dioxide,tobacco smoke, wood smoke
Occupational sensitizers
Wood dust, chemicals etc.
Exercise
Particularly in cold, dry climate
Drugs/preservatives
Aspirin, NSAIDs (cyclooxygenase inhibitors), sulfites, benzalkonium chloride, non-selective beta-blockers
Diet
ODEE SAID
What are the types of asthma? Explain them? W
Atopic (extrinsic)
- Allergy to antigens - IgE mediated
- Offending allergens are suspended in the air (mainl;y environemntal)
- Family hx of asthma
~1/2 children and young adults (most common - usually begins in childhood)
Non-atopic (intrinsic)
- Non-i,mmune response
- Secondary to chronic/ recurrent infections, pollution, exercise induced, hormonal
- Hypersensitivity to bacteria/ viruses causing infection (MOST COMMOn CULPRIT is VIRUSES)
- No fam hx
- Usually adult onset
Mixed
Asthma (in regards to onset) is primarily diagnosed in ________ and is primarily a ________ disease
Childhood, pediatric
What are some predictors of persistent adult asthma?
Atopy
Onset during school age
Presence of BHR (bronchial hyperreactivity)
What is the pathophysiology of asthma? What is the main hallmark?
Bronchial hyper-reactivity (BHR) of airways to physical, chemical & pharmacologic stimuli is the hallmark of asthma
If anti-inflammatory therapy is not prescribed, airway remodelling can occur
HYPER-REACTIVITY IS THE MAIN HALLMARK
Define bronchospasm. WHat causes it?
Constriction of the muscles in the walls of the bronchioles caused by inflammatory mediators
Define hyper-reactivity. What does it relate to? What dx has the highest hyper-reactivity?
an exaggerated response of bronchial smooth muscles to triggering stimuli
Correlates with clinical course of disease
Hyper-reactivity also seen in allergic rhinitis, chronic bronchitis and CF but not to same extent as asthma
Define airway remodelling. Why do we want to prevent this?
refers to structural changes, including a change in the extracellular matrix in the airway wall leading to airflow obstruction
may eventually become only partially reversible
Highlight the basic pathway of asthma pathophysiology
Asthma (sensitizing agent)
V
Airway Inflammation (CD4+, lymphocytes, eosinophils, mast cells)
V
Airflow limitation (reversible)
Highlight the steps in an asthma response. What occurs in each step? How long does it take each step to occur?
Asthma - Sensitizing Agent
V
Early Asthmatic Response
- occurs in mins
- bronchospasm
-Mast cells –> Histamine
V
Late Asthmatic response
- Occurs in hours
- Bronchospasm returns, submucosal edema, hyper-responsiveness
- Inflammatory cells
V
Chronic Asthma
- occurs in days
- hyper-reactive airways, epithelial cell damage, mucous hyper-secretion
- inflammatory cells
- leads to airway remodelling
Asthma Phenotypes:
Type 2 –> ATOPY (exercise-induced, allergic asthma, Aspirin enduced respiratory disease)
Type 1 –> Obesity, smoking-related, comorbities
How is asthma diagnosed?
1) Medical history
Symptoms & severity, history
Precipitating factors
2) Physical Exam
Poor indicator of the degree of airflow obstruction
3) Pulmonary Function Tests
Necessary to establish diagnosis, assess severity and treatment response
FEV1/FVC < 75-80% predicted
4) Other laboratory Tests
In the history section of an asthma diagnosis, sx of asthma are? Is everyone the same?
Intermittent episodes of expiratory wheezing, coughing and dypsnea
Chest tightness and chronic cough in some
No - Asthma is not a Heterogeneous disease
To asses symptoms and severity, ASK:
- Assess Symptoms:
In past 12 months have you had:
a) A sudden severe episode or recurrent episode of coughing, wheezing, chest tightness or SOB?
B) Chest colds that take more than 10 days to get over?
C) Coughing, wheezing, or SOB in a particlar season or time of year
D) Coughing, wheezing, or SOB in certain places or when exposed to certain things
To gauge severity:
- Have you used any meds to help you breathe? If so, how often? Have they helped?
- In past 4 weeks, have you had Coughing, wheezing, or SOB when:
i) At night that has awkaned you
ii) Upon awakening
iii) After running, moderate exercise, or physical activity
In regards to conducting a history, one should also ask about?
Family history of asthma/ allergic conditions
–>Positive patient history for allergic conditions
Precipitating factors/Triggers
–>Ask about precipitating factors, variable between patients
What are some triggers of asthma?
Exercise
a drop in FEV1 of 15% or greater from baseline (pre-exercise value)
Most pts with asthma
Time of Day
Worsening during sleep = nocturnal asthma
Associated with endogenous cortisol secretion and circulating epinephrine
Aero-Allergens
Smoke, fumes, pollen, pollutants, mold
Irritants
Perfumes, air fresheners
Respiratory tract infections
Especially less than 10 years old or viral
Weather
Cold, dry OR hot and humid
Psychological factors
Stress? Esp. during an attack
Hormonal Fluctuations
Gastro-esophageal reflux disease (GERD)
Medications
In regards to medication triggers of asthma, what are some common meds that may precipitate an attack?
Medication history is essential!
ASA/NSAIDS
- precipitate an attack in 20% of adults and 5% of children
- Related to recurrent rhinitis and nasal polyps
Radiocontrast media
Beta-blockers
Sulfites, benzalkonium chloride
What is the disadvantage of a physical exam in asthma?
A disease of exacerbation and remission, so the patient may not have any signs or symptoms at the time of exam
Poor indicator of degree of airway obstruction
What may you observe in a physical exam for asthma?
Expiratory wheezing on auscultation
dry hacking cough
signs of atopy (allergic rhinitis and/or eczema)
What are PFT’s necessary to establish?
Necessary to establish diagnosis, assess severity and treatment response
In spirometry, what is the adult criteria to make a diagnosis?
FEV1 /FVC < 75-80% predicted
12% improvement in FEV1 & at least 200 mL from baseline 15 minutes post quick acting 2-agonist challenge or after course of controller therapy
An alternative PFT to diagnose asthma in adults is:
Alternative: Positive challenge test
Assesses level of bronchial hyper-reactivity
Measures the change in PFTs after inhalation of incremental doses of methacholine or exercise (i.e., stimuli known to elicit airway narrowing)
Asthmatics respond with greater degrees of airflow obstruction then normal subjects, at any given dose
When should a healthcare provider reconsider the diagnosis?
a) Frequent sx but normal FEV1:
b) Few Sx but low FEV1:
Reconsider diagnosis if symptoms and lung function don’t match
Frequent symptoms but normal FEV1 = cardiac disease, lack of fitness
Few symptoms but low FEV1 = poor perception, restricted lifestyle?
A low FEV1 is indicative of…….
Low FEV1 = predictor of exacerbation
After diagnosis, monitoring of profgress should be done when……
At diagnosis and 3-6 months after starting treatment
At least every 1 – 2 years for most adults
More often if high risk and children
What is the preferred test in asthma diagnosis? Why?
Spirometry –> Shows reversibility of airway obstruction
Spirometry ofAsthma Diagnosis in Children (<6) and Adults
Children + Adults:
Reduced FEV1/FVC ratio –> less than lower limit of normal based on age, sex, height, and ethnicity
AND
Children + Adults: Increase in FEV1 after a bronchodilator or after course of controller tx
Children: Greater than or equal to 12%
Adults: Greater than or equal to 12% (and a minimum greater than or equal to 200 mL)
What are some other labratory tests that may be used to diagnose asthma?
CBC, eosinophil count, IgE concentration
Allergy skin tests
Sputum eosinophils
monitoring tool in moderate to severe asthma
Use in addition to standard parameters
Asthma Control: Daytime Sx
< or equal to 2 days/week
Asthma Control: Nightime Sx
< 1 night/week and mild
Asthma Control: Physical Activity
Normal
Asthma Control: Exacerbation
Mild and infrequent
Asthma Control: Abscence from school/work
None
Asthma Control: Need for reliever (SABA or bud/form)
< or = to 2 doses/week
Asthma Control: FEV1 or PEF
> or = to 90% of personal best
Asthma Control: PEF dirunal variation
<10-15%
Asthma Control: Sputum eisonophils
< 2-3%
GINA Asthma Control:
- Daytime sx more than 2x/week
- reliever > 2x/week
- Nighttime sx?
- Activity limitation
None - Well Controlled
1-2 –> Partly Controlled
3 –> uncontrolled
Asthma is considered well-controlled when:
Avoid symptoms during the day and night
Need little or no reliever medication
Have productive, physically active lives
Have normal or near-normal lung function
Avoid serious asthma flare-ups (exacerbations, severe attacks)
Goals of Therapy of Asthma
Prevent asthma-related mortality
Maintain normal activity levels
Prevent daytime and nocturnal symptoms
Maintain normal (or near normal) spirometry
Prevent Exacerbations
Provide optimal pharmacotherapy and avoid side effects
(MENS attitudes suck so everyone panic)
What are the principle sof asthma tx?
Environmental control – limit exposure to triggers
Pharmacologic treatment – reduce the inflammatory process
Appropriate use of inhalation therapy
Regular consultation with certified asthma educator
Graduated approach to therapy
Regular follow-up
Triggers of asthma can be:
Examples:
Endogenous stimuli:
those stimuli generated inside the body
e.g. stress, gastroesophageal reflux disease (GERD), rhinitis
Exogenous stimuli:
those stimuli generated outside the body
e.g. exercise, allergens, irritants
Is environmental control a substitute for avoidance of exposure?
NO
What is immunotherapy? is it effective tx for asthma?
Administration of allergen in progressively higher doses to induce tolerance
Limited role in adults
Must identify and use a single, well defined, clinically relevant allergen
Consider if strict environmental avoidance and pharmacologic intervention have failed
Risk vs benefit
Inconvenient
In asthma, what is the difference between a reliever medication vs. a controller medication?
Reliever Medication
Patient should have on hand and take only when needed (during an attack, episode of shortness of breath or before exercising).
Controller Medication
Prevents asthma attacks and inflammation
Take every day, even if no symptoms
Acts slowly and works over the long-term
Will not help in an acute asthma attack
Relievers in asthma are often……
Short-Acting Beta-adrenergic agonists (SABA)
SABA MOA, Onset, Inflammation, peak Effect:
Selective Beta 2 adrenergic agonists (beta receptors SNS mimic epinephrine - beat-2 smooth muscle relaxation in lungs)
Little effect on late (inflammatory) phase
Onset within 5 minutes
Peak effect on FEV within 30 minutes
SABA Indications:
Prevention of exercise induced or cold air induced bronchospasm
Treatment of intermittent episodes of bronchospasm
In comparison of SABA agents:
a) Structure
b) Selectivity
c) Equipotent Response
Structure determines the selectivity, potency, duration of action and oral activity
Agents vary in selectivity for the various receptors (α1, β1, β2 )
Equipotent doses of all adrenergic agents will produce the same degree of bronchodilation
What are the SABA’s and rank there selective potencies?
Epinephrine (a-4, b1- 4, b2 2)
V
Isoproterenol ( a-0, b1-4, b2-4)
V
Metaproterenol (a-0, b1-3, b2-3)
V
Terbutaline (a-0, b1-1, b2-4)
V
Salbutamol (a-0, b1-1,b2-4)
0=none, 1=low potency, 4 = high potency
Every Insecure Man Talks S***
Describe alpha, beta-1, and beta-2 and there effects when stimulated?
Beta-1 –> Iontropic and choronitorpic effects on heart (renin release, increases HR)
Beta-2 –> Smooth muscle relaxation in lungs, GI tract, uterus,
Alpha-1–>Arterial Smooth muscle contraction and vasoconstriction
Adverse Effects of SABA’s
Tachycardia, palpitations
Skeletal muscle tremor
Nervousness, irritability, insomnia, headache
BP changes
Cardiac arrhythmias
Increased blood glucose
Hypokalemia at high doses
Children: excitement / hyperactivity
Tachyphylaxis - Frequent use ↑tolerance and may ↑morbidity/ mortality
- All have beta-1 activity so expect CV A/E
Drug Interactions of SABA’s:
Beta-blockers: Oppose effect of SABAs
Loop or thiazide diuretics: increase risk of hypokalemia
Tricyclic antidepressants: May increase ADRs of SABA
QT prolongation possible
(LESS RISK WITH INHALED TX)
SABA Dosing:
Usually dosed 1-2 puffs every 4-6 hours as needed
Some patients will use their rescue medication 15 minutes prior to exercise/triggers to prevent symptoms
During a serious asthma attack, it is safe to take puffs every few minutes (have them take it as much as needed until they get relief)
When should pt’s using a SABA be refferred to a doctor?
Patients who need their rescue medication more than 2 times per week should be referred to physician for reassessment (not enough, need something more)
Do SABA’s have any inflammation activity?
NO
LABA’s MOA, Onset, Used Alone?
Work slowly over a 12-hour period to keep airways open and muscles relaxed
Require daily use
Mechanism of action and side effects similar to short-acting bronchodilators
Formoterol also approved for rescue therapy
Never to be used alone in any age group; always added to inhaled steroid therapy
Is there a LABA that is approved for rescue tx? if so, which one?
Yes - Formeterol
Do LABA’s control inflammation?
NO
What are some of the LABA’s? Are they partial or full agonsists? WHich ones avilable only in combinations? a, b1, b2 activity?
Salmeterol –> Partial agonist
formoterol –> full agonist (SYMBICORT CAN BE USED AS CONTROLLER AND RELIEVER)
Available in combination products only:
vilanterol –> (full agonist)
Indacaterol –> (full agonist)
ALL HAVE NO ALPHA ACTIVITY, b1= 1, b2=4
So0me females verify it
What is a central part of the pathogenesis of asthma? What is used to manage this?
Chronic inflammation is central to the pathogenesis of asthma. Steroids are the most effective anti-inflammatory drugs available for the management of ASTHMA.
What is the msot common and effective type of controller?
INHALED CORTICOSTEROIDS
ICS Usage, Onset, Effect on Acute Sx relief, and Uses?
Require daily use; onset of effect is days – weeks (maximal months); no effect on acute symptom relief
Improve lung function
decrease frequency/severity of attacks
increases QOL
decreases asthma mortality
When should ICS be initiated in asthma tx? Why?
Early vs late intervention (start early, getting at the pathogenesis)
ICS MOA
Inhibit inflammatory response at all levels
Inhibits the late asthmatic response & decreases bronchial hyper-responsiveness in asthma
ICS Potency
High potency when inhaled, but less systemic effects
ICS Examples and Dosing
Fluticasone Propionate - OD
Fluticasone Furoate - BID
Budesonide - BID
Ciclesonide - OD
Beclomethasone - BID
Mometasone - BID
Family Friends B*** Constantly Before Marriage
Which ICS is preferred in pregancy?
Budesonide –> Think of Birth of a buddy
ICS in Children:
Beclomethasone is approved for children 5 and above
Mometasone is approved for children 4 years of age
Max dose Fluticasone Propionate is 200 mcg/day in children 1-4
Max dose of fluticasone propionate is 400 mcg/day 4-16 yrs old
The potency of a drug (e.g. ICS) can is changed when……
- Drugs are put into a different device
ICS dosing in Asthma:
A low maintenance dose of ICS will be adequate for many pt’s
- ICS have flat response curve. Starting at a low dose, see steroid effect with less side effects
- When stepping up to high dose, less steroid effect and see more side effects/toxicity
What are some side effects of ICS? What are they dependent on?
drug, dose, inhalation technique dependent
Dysphonia, hoarseness, throat irritation, cough
URTI increase
Candida oral infections (thrush)
Use of prodrugs (e.g., Ciclesonide) may reduce
Growth retardation in kids
can occur in low – mod doses; does not seem to affect adult height (0.5 cm, occurs within 1st 6 months-1 yr of tx – benefits outweigh risks)
NOTE: If high doses of inhaled steroids are used, adrenal axis suppression and other side effects may occur.
In regards to drug selection, how can one reduce the risk of thrush?
Candida oral infections (thrush)
Use of prodrugs (e.g., Ciclesonide) may reduce
Important Education Counselling Tips on ICS:
Regular, daily use; delayed onset
Spacer/ rinse mouth & spit
Address “steroid phobia”
Wash face after each dose (if use spacer with mask)
Efficacy reduced in patients who smoke
Drug Interactions of ICS:
Desmopressin: Highly increased risk of hyponatremia
Contraindications of ICS:
Initiation during untreated respiratory tract infection
What are some precautions of ICS’s that a pharmacist should be aware of? (Long term consequences)
HPA-axis suppression upon withdrawal (high doses)
Long-term steroid effects at high doses
Increase URTIs (more likely in COPD)
When would it be necessary to use oral/IV CS’s? Duration of use?
Short periods of time in ACUTE, SEVERE asthma (1-2 weeks max)
In what populations would s/e of oral/IV CS’s for asthma be noticed?
Increased with long term or IV administration
Children/elderly more susceptible
Must taper after long-term use
Examples of oral/Iv CS’s used in asthma?
Prednisone
Prednisolone (PediPred®)
Dexamethasone
Leukotriene Recepter NAtagonists (LTRA) MOA. What do they do?
Antagonizes the effects of leukotrienes , which are formed by the breakdown of arachadonic acid in mast cells, eosinophils and other inflammatory cells
Reduces airway inflammation, small variable bronchodilation
LTRA Side Effects
Headache, dizziness, heartburn, nausea, drowsiness
LTRA Example. Side effects?
Montelukast
Side effects – minimal & non-specific
Can LTRA’s be used for an acute asthma attack?
NOT for reversal of acute bronchospasm:
Must be taken regularly
LTRA Patient Response
Variable patient response
Can an LTRA be substituted for inhaled/oral?
Do not abruptly substitute for inhaled or oral steroids
What age should a LTRA be used?
2-5: 4mg QD hs
6-14: 5mg QD hs
15+ 10mg QD hs
When is an LTRA used?
Alternative to increasing dose of inhaled steroids in patients who remain symptomatic
Very mild asthmatics who cannot / will not use an inhaled steroid (LTRAs can be an initial treatment choice)
Suboptimal adherence to inhaled steroid
Dose of inhaled steroid required to maintain control is very low(e.g. Exercise induced asthma)
ASA / NSAID induced asthma Allergic rhinitis ± asthma
Are combinations of LABA and CS’s available? Are they just effective?
Combinations of LABA & corticosteroids
As effective as separate medication
What are the advantages of combination products?
More convenient
enhanced adherence
ensures the patient receives their dose of inhaled corticosteroid
Avoids SABA dependence
What is special about symbicort? Dosing? Max puffs per day?
formoterol + budesonide
BID, maintenance & relief (up to 8 puffs per day)
What is an example of methylxanthine? What is structurally similar too?
Theophylline
- Structurally related to caffeine
Is theophylline as effective as bronchodilators?
Less effective brochodilators than beta-adrenergic agonists
What is the MOA of theophyllines?
Non-specific inhibition of phosphodiesterase, which causes mild bronchodilation
Increases diaphragmatic contractility and enhances mucociliary clearance
What is the therapeutic role of theophylline?
Use as an ‘add on’ in patients that require high dose corticosteroid
Used only in severe asthma cases
Does theophylline have a role in rescue therapy? Why or why not?
No role as rescue therapy (delayed onset)
Is theophylline commonly used?
Availability of safer, more effective agents has minimized use
Theophylline monitoring, s/e, and D.I.”s?
Extreme care required due to risk of side effects, drug-drug, and drug-disease state interactions
Diarrhea, nausea, heartburn, anorexia, headaches, nervousness, tachycardia, upset stomach
Significant DI potential (3A4 and 1A2 substrate)
Omalizumab MOA, Dosage Form, Use?
Anti-immunoglobulin E antibody
S/C injection (150mg vial)
150-375 mg S/C q 2-4 weeks
Use (>6 years):
Atopic asthma poorly controlled despite high-dose inhaled steroids and appropriate add-on therapy, with or without oral prednisone.
What are the side effects of omalizumab?
Pain at injection site, anaphylaxis
Rash, headache
Fatigue
What biologics are used in severe asthma? Role in asthma?
IL-5 inhibitors:
Mepolizumab (>6) –> EDS coverage
Reslizumab (>18)
Benralizumab (>18)
IL 4 and 13 inhibitor:
Dupilumab (>12
Role in those with severe eosinophilic asthma who experience recurrent asthma exacerbations in spite of high doses of ICS in addition to at least one other controller
Big Men Relax Before D**
Is tiotropium used in astham? When?
Tiotropium may be considered as an add-on therapy for individuals 12 years of age and over with severe asthma uncontrolled despite combination ICS/LABA therapy
Are macrolides used in asthma? When?
Chronic use of macrolides may decrease asthma exacerbations in individuals 18 years of age and over with severe asthma independent of their inflammatory profile
Biggest difference in asthma guidelines:
Use of ICS with SABA early on
OR
ICS + LABA (budesonide + formoterol =Symbicort) use prn
Rationale against SABA monotx?
Even those with intermittent, mild asthma symptoms still have severe or fatal exacerbations
ICS + LABA vs. SABA alone = 2/3 reduction in exacerbations with a lower ICS dose
What are some risks of SABA + ICS only tx rather than (SABA, LABA + ICS)?
Poor adherence to daily ICS
Patients that start on SABA only associate it with symptom relief
When deciding on treatment and evalautaing asthma control, a pharmacist should also assess…..
Risk of asthma excaerbation
A higher risk for an excarebation is defined by:
history of a previous severe asthma exacerbation
poorly-controlled asthma as per CTS criteria
overuse of SABA (defined as use of more than 2 inhalers of SABA in a year)
current smoker
A severe asthma exacerbation is classified as a situation that requires:
requires systemic steroids
an ED visit
Hospitalization
A mild asthma exacerbation is classified as a situation that requires:
an increase in asthma symptoms from baseline that does not require systemic steroids, ED visit or hospitalization
DESCRIBE THE ASTHMA GUIDELINE CONTINUUM
STUDY CHART
What is the criteria for when to start an ICS?
12 and older:
If on PRN SABA with well-controlled asthma at lower risk for exacerbations:
–> Continue PRN SABA or switch to either daily ICS + PRN SABA or PRN bud/ form (based on patient preference). (Strong recommendation)
If on PRN SABA with well-controlled asthma at higher risk for exacerbations:
–> Switch to either daily ICS + PRN SABA or PRN bud/form.
–> In individuals with poor adherence to daily medication despite substantial asthma education and support, we recommend PRN bud/ form over daily ICS + PRN SABA. (Strong recommendation)
-
<12 years of age
If on PRN SABA well-controlled asthma at lower risk for exacerbations:
–> Continue PRN SABA or switch to daily ICS + PRN SABA (based on patient preference). (Strong recommendation)
If on PRN SABA well-controlled asthma on at higher risk for exacerbations
–> Switch to daily ICS + PRN SABA. (Strong recommendation)
What is severity classification of asthma?
WHEN CONTROLLED ON:
Very mild
PRN SABA only
Mild
Low dose ICS (or LTRA) + prn SABA OR
PRN Bud/form
Moderate
Low dose ICS + second controller + PRN SABA OR
Moderate doses of ICS +/- second controller medication and PRN SABA
OR
Low-moderate dose bud/form + PRN bud/form
Severe
High doses of ICS + second controller for the previous year or systemic steroids for 50% of the previous year to prevent it from becoming uncontrolled, or is uncontrolled despite this therapy
In severe asthma, what do we monitor?
- Monitor the exact same things (sx and severity)
- May need biologics
- Other tests may be used
What is the diffference between uncontrolled asthma and severe asthma? How can they be adressed?
Uncontrolled asthma:
Previously asymptomatic patient intermittently develops symptoms
can be addressed with self-management education and action plan
Severe asthma:
remains poorly controlled despite best practices
5% population, but up to 50% of direct costs
requires treatment with high-dose ICS + and a second controller for the previous year, or systemic corticosteroids for 50% of the previous year to prevent it from becoming “uncontrolled”
How should one investigate uncontrolled asthma?
Watch patient use their inhaler
Assess adherence
Remove risk factors and assess / manage comorbidities
Confirm diagnosis of asthma
Consider step-up therapy
Asthma Monitoring Timwframes (IMPORTANT)
1-3 months after treatment started, then every 3-12 months
During pregnancy, every 4-6 weeks
After an exacerbation, within 1 week
How can one step up asthma treatment?
Sustained step-up, for at least 2-3 months if asthma poorly controlled
Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
Day-to-day adjustment
For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen
Stepping Down Tx? COnsider? What is the goal?
Consider in stable patients without history of severe asthma, exacerbations, or risk factors for exacerbations
Only consider if >3 months of control
Goal is to find lowest effective dose
General Principles of Stepping Down Controller Tx - What should the pharmacist tell the pt to do? What should the pharmacist do?
Prepare for step-down
Record the level of symptom control and consider risk factors
Make sure the patient has a written asthma action plan
Book a follow-up visit in 1-3 months
Step down through available formulations
Discontinuing ICS or LABA is not recommended in adults with asthma because of risk of exacerbations
In regards to education, all asthmatics should work with ________ to dvelop a _________ that includes?
Should work with an HCP to develop an action plan
Action plans should include:
How to monitor and measure their symptoms
Daily preventive management strategies
When and how to adjust medications (ex changing ICS, how/when to add OCS)
When to seek urgent care
What are the benefits of action plans?
Written action plans have been shown to decrease hospitalizations, ER and physician visits, missed days at work/school and increase pulmonary function in children and adults
What populations should use of a peak expiratory flow meter?
Use: moderate-severe asthmatics or asthmatics who are poor perceivers of airway obstruction
A peak expiratory flow meter may be used by an asthmatic to:
What does it allow the pt to do?
Monitor treatment course / response
Determine when emergency care is necessary
Identify allergens
Detect asymptomatic deterioration in lungs
Allow the patient to assume more responsibility & control in disease management
A pharmacist could use this system to help a patient self-manage their asthma using a peak flow meter?
Traffic light system
Green - good control, no change required (80-100% of best)
Yellow - worsening asthma, consult action plan (70-80% of personal best)
Red - danger zone, seek emergency medical care (less than 60%)
What should patients be educated on in regards to asthma?
What is asthma?
Definition
role of inflammation in the airways
signs / symptoms
common triggers and management
Goals
Self management
WHy is self-management important? What are its components?
Highly effective in improving asthma outcomes
Consists of 3 components:
1) self monitoring
2) written asthma action plan
3) regular medical review
In regards to medications, a pharmacist should explain:
how they work, long-term control, quick relief, beneficial and adverse effects
“Reliever” versus “controller”
“PRN” vs. “regular
Skills:
educate patient regarding inhaler technique – review frequently
Instruct patient on medications to avoid
A key way to identify asthma exacerbations in asthmatic pts in a community pharmacy is to:
Watch for individuals who purchase cold suppressants / expectorants frequently
What is a good sign to indicate whetehr someone is uncontrolled?
Monitor medication use and refill frequency
- More than 2 containers of salbutamol/ year = sign that they are uncontrolled
When gauging adherence, what are some things that may lead to uncontrolled asthma?
Poor adherence:
Contributes to uncontrolled asthma symptoms, risk of exacerbations and asthma-related death
- ARE THEY USING THE DEVICE CORRRECTLY
Contributory factors:
Unintentional (e.g. forgetfulness, cost, confusion)
Intentional (e.g. no perceived need, fear of side-effects, cultural issues, cost)
How to identify patients with low adherence:
Ask an empathic question
Will a patient always recognize an asthma exacerbation?
NO
What are some of the first signs (not sx)
of an asthma exacerbation?
Worsening pattern of symptoms
Exercise intolerance
Unusual fatigue
Nocturnal awakening
What is a useful tool for patients to gauge whether they are having an exacerbation?
Peak expiratory flow measurement useful to gauge status
Decline of ~20% from patient’s personal best is likely exacerbation
What are some risk factors for exacerbations?
Poor adherence
Suboptimal ICS use
High SABA use
Obesity
Chronic rhinosinusitis
GERD
Pregnancy
Allergen / pollution / smoking exposure
Low FEV
Previous exacerbation in last 12 months
Define a severe exacerbation.
Prolonged, severe episode of asthma unresponsive to usual treatment, develops over hours to days
What should be avoided in a severe exacerbation?
AVOID sedatives / hypnotics!
What are some sx of an asthma exacerbation?
Tachycardia, tachypnea, diaphoresis, severe dyspnea, ± wheeze,
(hyperinflated chest with accessory muscle use, anxiety, altered level of consciousness, pulsus paradoxus, nasal flaring)
Treatment goals of asthma exacerbation:
Correction of significant hypoxemia
Rapid reversal of airflow obstruction
Reduction of the likelihood of relapse
Development of a written asthma action plan in case of a further exacerbation
Treatment of Acute Sveere Asthma:
Short Acting Beta-2 Agonist + Short Acting Anticholinergic Agent (Ipratropium)
—> Nebulized or MDI + spacer
—>:Dose is titrated according to clinical and objective measurements
—> Regular + prn administration initially
Corticosteroids
Early use of systemic corticosteroids is an important treatment choice
Route: oral or IV
IV if: Too breathless, intubated or unable to tolerate oral medication (vomiting, dehydration, concerns with absorption); severe asthma, unresponsive to treatment.
Improves symptoms within 2 hours, maximal in 6
7-10 days courses most common
Oxygen – correct hypoxemia
Maintain O2S ≥ 90%
Magnesium IV – moderately potent bronchodilator
Mechanical Ventilation / Intubation
Asthma Exacerbation Home Managament Criteria:
Can follow their action plan
Mild to moderate exacerbation (PEF is >60% personal best)
Symptoms are bothersome but not disabling
No comorbidities that place them at higher risk
Should see MD if partial response to treatment (on going symptoms, PEF 61-79%) after 1-2 days
Admit to hospital for asthma exacerbation if:
PEF is <60% personal best
Breathlessness at rest, severe drowsiness, cannot speak full sentences
Comorbidities:
Recent exacerbation and prednisone course taken
Angioedema, Chest pain, fever, mylagias, purulent sputum
Symptoms worsen despite increased SABA/ controller use
In an acute asthma exacerbation, can one switch an ICS to montelukast? What should happen?
IF UNCONTROLLED ON ICS, INCREASE DOSE (DO NOT ADD ON MONTELUKAST
What is exercise induced bronchoconstriction? How does it occur? Treatment?
Magnitude correlates with degree of BHR in the airways; occasionally the only manifestation
Body attempts to warm/ humidify increased volume of air. Can result in release of mediators (leukotrienes & histamine)
Treatment:
Scarf/ mask
Enhance level of physical fitness
Optimize asthma treatment to decrease BHR
Prophylactic therapy – quick acting beta-2 agonist 5-10 minutes pre exercise
Leukotriene receptor antagonist
Warm-up for about 10 minutes
What % of asthmatics will experience ASA/NSAID induced asthma?
7-10% of asthmatics will experience
ASA/NSAID insuced asthma takes _____ to develop.
Develops in phases over months to years
ASA/NSAID Induced Asthma is more common in people with:
Chronic rhinitis
Chronic nasal congestion, anosmia, nasal polyps, mucosal thickening
Inflammation in lower airway
Acute sensitization to NSAIDs
Acute Phase RXn of ASA/NSAID induced asthma:
Nasal symptoms
Worsening asthma symptoms
Allergic symptoms (hives, angioedema)
ASA/NSAID Induced Asthma TX
Leukotriene antagonists first-line
Generally avoid NSAIDs in the future
Low doses of acetaminophen may be tolerated (HIGH DOSES MAY PRECEIPATE A RXN)
Aspirin desensitization
Must regularly use aspirin once desensitized
Why are beta-blockers cautioned ina atshma? Which ones should be used?
A decreased response to beta-agonists
Increased airway hyper-responsiveness
Non-cardioselective (AVOID) – ACT ON BETA 1 AND BETA-2
Poses the greatest risk in asthma or COPD
Ocular β-blockers still a risk
Cardio-selective – Act on Beta-1
Low to moderate doses appear to present limited risk
If compelling indication, use cardioselective cautiously
What is occupational asthma? Common offendors? Sx?
Asthma secondary to workplace exposures
Common offenders: car painting, hair dressing, domestic/commercial cleaning, health care professionals, bakers
Worse at work or after work hours
go away when away from work or while on vacation
may keep patient up at night
may start after working with a new substance.
Co-workers may have similar symptoms.
Why is asthma control in preganncy important? TX?
Uncontrolled asthma can lead to complications:
Premature birth
Low birth weight
Maternal blood pressure changes (i.e. pre-eclampsia)
Benefits of medication outweigh risks
Inhaled corticosteroids: all probably ok, budesonide best studied
Salbutamol, LABAs seem to be safe
Leukotriene antagonists: no known issues
Theophylline: keep low end of therapeutic range
Newer biologics: unknown
What meds are ok in breastfeeding?
Inhaled medications for asthma are ok
Po corticosteroids ok
Theophylline: keep low end of therapeutic range
Montelukast: transferred into breastmilk, but indicated for kids as young as 6 months
