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PHAR 253 > Asthma > Flashcards

Asthma Flashcards

1
Q

how is asthma characterized?

A

paroxysmal or persistent symptoms
dypsnea, chest tightness, wheezing, sputum production & cough
airway hyper-responsiveness to a variety of stimuli

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2
Q

does asthma alter lifespan?

A

no

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3
Q

in children is there more males or females with asthma?

A

males

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4
Q

environmental factors contributing to asthma

A

tobacco smoke
allergen exposure
infections in infancy
environment
occupational sensitizers
exercise
drugs/preservatives
diet

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5
Q

atopic vs non-atopic asthma

A

atopic - extrinsic - allergy to antigens
non-atopic - intrinsic - secondary to chronic/recurrent infections

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6
Q

effect of age on asthma

A

most diagnosed by age 5

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7
Q

predictors of persistent adult asthma include:

A

atopy
onset during school age
presence of BHR

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8
Q

pathophysiology of asthma

A

bronchial hyper-reactivity of airways to physical, chemical & pharmacologic stimuli is the hallmark of asthma

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9
Q

bronchospasm

A

constriction of the muscles in the walls of the bronchioles

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10
Q

hyper-reactivity

A

an exaggerated response of bronchial smooth muscles to trigger stimuli

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11
Q

airway remodeling

A

refers to structural changes leading to airway obstruction, may eventually become only partially reversible

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12
Q

what causes airway inflammation?

A

CD4+, T lymphocytes, eosinophils, mast cells

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13
Q

types of asthma

A

early asthmatic response - minutes
late asthmatic response - hours
chronic asthma - days

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14
Q

asthma phenotype 1

A

obesity-related
very late onset
smoking related
comorbidities

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15
Q

asthma type 2

A

early onset allergic asthma
later onset eosinophilic asthma
aspirin exacerbated respiratory disease
exercise induced asthma

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16
Q

elements of asthma diagnosis

A

medical history
physical exam
pulmonary function test
other lab tests

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17
Q

symptoms of asthma

A

intermittent episodes of expiratory wheezing, coughing and dypsnea
chest tightness and chronic cough in some

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18
Q

triggers of asthma

A

exercise-induced bronchospasm
time of day
aero-allergens
irritants
respiratory tract infections
weather
psychological factors
hormonal fluctuations
GERD
medications
preservatives

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19
Q

why id a physical exam a poor indicator of asthma?

A

because asthma is a disease of exacerbation and remission, so the patient may not have any signs or symptoms at the time of the exam

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20
Q

what may be observed during a physical exam?

A

expiratory wheezing on ausculation
dry hacking cough
signs of atopy (allergic rhinitis and/or eczema)

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21
Q

why is a pulmonary function test necessary for asthma diagnosis?

A

to establish diagnosis, assess severity and treatment response

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22
Q

adult criteria of pulmonary function in asthma

A

FEV1/FVC < 75-80% predicted
12% improvement in FEV1 & at least 200ml from baseline 15 minutes post quick acting 2-agonist challenge or after a course of controller therapy

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23
Q

preferred criteria for a diagnosis of asthma

A

spirometry showing reversible airway obstruction

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24
Q

lab tests for asthma diagnosis

A

CBC, eosinophil count, IgE concentration, FeNO
allergy skin tests
sputum eosinophils

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25
Q

what is the Canadian thoracic society? (CTS)

A

Canada professional organization which promotes lung health and provides best respiratory practices

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26
Q

what is global initiative for asthma? (GINA)

A

developed in collaboration with experts from many countries
NOT a guidline, but a practical approach to managing asthma in clinical practice - updated yearly

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27
Q

what is the CTS definition of asthma control for each:
daytime symptoms
night symptoms
physical activity
exacerbations
absence from work or school
need for a reliever
FEV1 or PEF
PEF diurnal variation
sputum eosinophils

A

daytime symptoms </= 2 days/week
nighttime symptoms < 1 night/week and mild
physical activity - normal
exacerbations - mild and infrequent
absence from work or school due to asthma - none
need for a reliever - </= 2 doses per week
FEV1 or PEF >/= 90% of personal best
PEF diurnal variation < 10-15%
sputum eosinophils < 2-3%

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28
Q

asthma is well controlled when a patient can:

A

avoid symptoms during the day and night
need little or no reliever mediaction
have productive, physically active lives
have normal or near-normal lung function
avoid serious asthma flare-ups

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29
Q

goals of therapy for asthma

A

prevent asthma-related mortality
maintain normal activity levels
prevent daytime and nocturnal symptoms
maintain normal spirometry
prevent exacerbations
provide optimal pharmacotherapy and avoid side effects

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30
Q

principles of asthma treatment

A

environmental control
pharmacologic treatment
appropriate use of inhalation therapy
regular consultation with certified asthma educator
graduated approach to therapy
regular follow-up

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31
Q

types of asthma triggers

A

endogenous stimuli - stimuli generated inside the body
exogenous stimuli - stimulie generated outside the body

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32
Q

what is the reliever?

A

short-acting beta-adrenergic agonists (SABA)

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33
Q

what is the controller?

A

long-acting beta-2 agonists (LABA)

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34
Q

MOA of SABAs

A

selective beta 2 adrenergic agonists
- smooth muscle relaxation
onset within 5 minutes peak effect on FEV within 30 minutes

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35
Q

indication of SABAs

A

prevention of exercise-induced or cold air induced bronchospasm
treatment of intermittent episodes of bronchospasm

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36
Q

what does the structure of a SABA determine?

A

the selectivity, potency, duration of action and oral activity

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37
Q

what are the SABAs?

A

salbutamol
terbutaline
metaproterenol
isoproterenol
epinephrine

38
Q

which two SABAs are preferred due to their selectivity for B2?

A

salbutamol and terbutaline

39
Q

adverse effects of SABAs

A

tachycardia, palpitations
skeletal muscle tremor
nervousness, irritability, insomnia, headache
BP changes
cardiac arrhythmias
increased BG
hypokalemia at high doses
tachyphylaxis

40
Q

what drug interactions do SABAs have?

A

beta-blockers: oppose effect
loop or thiazide diretics: increase risk of hypokalemia
tricyclic antidepressants: may increase ADRs of SABA

41
Q

how are SABAs usually dosed?

A

1-2 puffs every 4-6 hours as needed

42
Q

how do LABAs work?

A

work slowly over a 12-hour period to keep airways open and muscles relaxed

43
Q

what are the LABAs?

A

salmeterol - partial agonist
formoterol - full agonist
vilanterol - full agonist
indacaterol - full agonist

44
Q

which LABA is approved for rescue therapy?

A

formoterol

45
Q

which LABAs are available in combo products only?

A

vilanterol
indacaterol

46
Q

what are the DOAs of the LABAs?

A

> 12 hours: salmeterol, formoterol
24 hours: vilanterol, indacaterol

47
Q

what are the most effective anti-inflammatory drugs available for asthma?

A

corticosteroids

48
Q

what is the most common type of controller medication?

A

inhaled corticosteroids

49
Q

how do ICSs work?

A

improve lung function
decrease frequency /severity of attacks
increase QOL
decrease asthma mortality

50
Q

MOA of ICSs

A

inhibit inflammatory response at all levels
inhibits the late asthmatic response & decreases bronchial hyper-responsiveness in asthma

51
Q

what are the ICS drugs?

A

fluticasone propionate
fluticasone furoate
budesonide
ciclesonide
beclomethasone
mometasone

52
Q

when are ICSs preferred?

A

in pregnancy

53
Q

which ICSs are approved for use in all ages?

A

fluticasone propionate

54
Q

which ICSs are approved for use in 6-11 years of age?

A

beclomethasone dipropionate (low)
budesonide (low)
ciclesonide (low)
fluticasone propionate (low and meddium)
mometasone furoate (low)

55
Q

which ICS is only approved for adults 12 and older?

A

fluticasone furoate

56
Q

side effects of ICSs

A

dysphonia, hoarseness, throat irritation, cough
candida oral infections (thrush)
growth retardation in kids
adrenal axis suppression if high doses

57
Q

education points for ICSs

A

regular, daily use; delayed onset
rinse mouth & spit
address steroid phobia
wash face after use if using spacer with mask
efficacy reduced in patients who smoke

58
Q

what drug do ICSs interact with?

A

desmopressin: highly increased risk of hyponatremia

59
Q

when would oral/IV CSs be used?

A

for short periods of time in ACUTE, SEVERE asthma

60
Q

short term effects of oral/IV CS

A

insomnia
increased activity
mood changes
water retention
hyperactivity in children

61
Q

long term effects of oral/IV CS

A

increased appetite
weight gain
stomach irritation
cataracts osteoporosis
HPA axis supression

62
Q

MOA of leukotriene receptor antagonists (LTRA)

A

antagonizes the effects of leukotrienes, which are formed by the breakdown of arachidonic acid in mast cells, eosinophils and other inflammatory cells
- reduces airway inflammation, small variable bronchodilator

63
Q

side effects of LTRAs

A

headache
dizziness
heartburn
nausea
drowsiness

64
Q

what drug is a LTRA

A

montelukast

65
Q

when are LTRA given?

A

at night because their peak activity can occur at night

66
Q

what are the advantages to combo products?

A

more convenient
enhanced adherence
ensures the patient receives their dose of inhaled corticosteroid
avoids SABA dependence

67
Q

can you use a LABA alone?

A

no must be used with a corticosteroid

68
Q

what combo product is for maintenance or relief?

A

symbicort - formoterol + budesonide

69
Q

MOA of methylxanthines (theophylline)

A

non-specific inhibition of phosphodiesterase, which causes mild bronchodilation
increases diaphragmatic contractility and enhances mucociliary clearance

70
Q

when is theophylline used?

A

as an ‘add on’ in patients that require high dose corticosteroid
used only in severe asthma cases
no role is rescue therapy

71
Q

side effects of theophylline

A

diarrhea
nausea
heartburn
anorexia
headaches
nervousness
tachycardia
upset stomach

72
Q

what is omalizumab?

A

a biologic that is an anti-immunoglobulin E antibody
it inhibits inflammatory response

73
Q

when is omalizumab used?

A

when atopic asthma is poorly controlled despite high-dose inhaled steroids and appropriate add-on therapy, with or without oral prednisone

74
Q

what are the new IL-5 inhibitors?

A

mepolizumab (>6)
reslizumab (>18)
benralizumab (>18)

75
Q

what is the IL 4 and 13 inhibitor?

A

dupilumab (>12)

76
Q

what are two other therapies for severe asthma?

A

tiotropium (>12)
macrolides - azithromycin (>18)

77
Q

a higher risk for an exacerbation is defined by any of the following:

A

history of a previous severe asthma exacerbation
poorly-controlled asthma as per CTS criteria
overuse of SABA
current smoker

78
Q

in what order are the drugs used to treat asthma?

A

start with SABA and ICS
increase ICS
add LABA
add LTRA

79
Q

very mild asthma is well controlled on:

A

PRN saba only

80
Q

mild asthma is well controlled on:

A

low dose ICS (or LTRA) + prn SABA OR
PRN bud/form (symbicort)

81
Q

moderate asthma is well controlled on:

A

low dose ICS + second controller + prn SABA OR
moderate doses of ICS +/- second controller and PRN SABA OR
low-moderate dose bud/form + prn bud/form

82
Q

severe asthma is well controlled on:

A

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 therapy

83
Q

what is the difference between uncontrolled asthma and severe asthma?

A

anyone can have uncontrolled asthma and it is when a previously asymptomatic patient intermittently develops symptoms and can be addressed with self-management education and an action plan. severe asthma remains poorly controlled despite best practices.

84
Q

how often should asthma be reviewed?

A

1-3 months after starting treatment and then every 3-12 months

85
Q

when can you consider stepping down treatment?

A

in stable patients
>3 months of control
goal is to find the lowest effective dose

86
Q

what should be included in an asthma action plan?

A

how to monitor and measure their symptoms
daily preventative management strategies
when and how to adjust medications
when to seek urgent care

87
Q

when is a peak expiratory flow meter used?

A

for moderate-severe asthmatics or asthmatics who are poor perceivers of airway obstruction

88
Q

when following an action plan when should someone seek emergency medical care?

A

when their expiratory flow is <60% of best

89
Q

risk factors of exacerbations

A

poor adherence
suboptimal ICS use
high SABA use
obesity
GERD
pregnancy
Low FEV

90
Q

what is the first line treatment for ASA/NSAID induced asthma

A

leukotriene antagonists

91
Q

if a b-blocker must be used which one should you choose?

A

a cardio-selective

PHAR 253 (8 decks)

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