Asthma Flashcards
how is asthma dx
measure baseline FEV-1
give albuterol
measure FEV-1
if there is >12% increase in FEV-1 - asthma dx
what are the criteria for step 1
what is/are the recommended treatments for this step?
asthma sx <2x/week
PRN low dose ICS - formoterol
or
low dose ICS - SABA
what are the criteria for step 2
what is/are the recommended treatments for this step?
asthma sx or need for SABA >2x/week
low dose ICS - formoterol for rescue
or
SABA rescue + ICS-LABA maintenance
what dose of ICS is always used in rescue
low dose ICS
what are the criteria for step 3
what is/are the recommended treatments for this step?
sx most days or waking at night 1+ x/week
low dose ICS-formoterol rescue and maintenance
or
SABA rescue + low dose ICS - LABA maintenance
what are the criteria for step 4
what is/are the recommended treatments for this step?
asthma sx daily or waking 1+ night a week or exacerbation upon initial presentation
low dose ICS-formoterol rescue + medium dose ICS - formoterol maintenance
or
SABA rescue + medium dose ICS-LABA maintenance
what are the criteria for step 5
what is/are the recommended treatments for this step?
beyond step 4 management, need referral
low dose ICS-formoterol rescue + high dose ICS - formoterol
or
SABA rescue + high dose ICS-LABA
how do we assess asthma control and when to step up therapy?
4 questions
daytime sx >2x/week?
nighttime awakenings?
SABA >2x/week?
activity limited 2/2 asthma?
0 yes’ = well controlled
1-2 yes’ = partly controlled, inc by 1 step
3-4 yes’ = uncontrolled, inc by 1-2 steps
what are the three main ICS for asthma
budesonide (Pulmicort)
fluticasone (Flovent, Arnuity)
mometasone (Asmanex)
what are the low dose ICS strengths of
budesonide
fluticasone
mometasone
budesonide 200-400mcg
fluticasone 100-250mg (MDI and DPI)
mometasone MDI 200-400mcg
DPI 110-220mcg
what are the low doses of ICS usually used for
rescue in combination with formoterol
budesonide + formoterol =
Symbicort
what are the medium dose ICS strengths of
budesonide
fluticasone
mometasone
budesonide >400-800mcg
fluticasone 250-500 (MDI and DPI)
mometasone MDI 200-400mcg
DPI 220-440mcg
what are the high dose ICS strengths of
budesonide
fluticasone
mometasone
budesonide >800mcg
fluticasone >500 (MDI and DPI)
mometasone MDI >400mcg
DPI >440mcg
what are the medium/moderate ICS doses usually used for
step 4
what are the high ICS doses usually used for
step 5
what are the characteristics of an MDI? what inhalers does this include?
HFA, Respimat, Symbicort, Dulera
shake before using
can use spacer
aerosolized liquid
HFA = propellant
slow, deep inhalation
need to be primed and re-primed after some time
what are the characteristics of an DPI? what inhalers does this include?
Diskus, Ellipta, Handihaler, Respiclick, Flexhaler
do not shake
fine powder
no propellant
need quick, forceful inhalation
no spacer!!
no priming
budesonide =
pulmicort
fluticasone =
Flovent, Arnuity
mometasone =
Asmanex
budesonide + formoterol =
Symbicort
fluticasone + salmeterol =
Advair
fluticasone + vilanterol =
Breo
mometasone + formoterol =
Dulera
what ICS has a neb soln dosage form? why does this help?
budesonide
good for children
counseling points for ICS
rinse and spit after use
inc risk fx, growth retardation, imm supp
SE: dysphonia, thrush, cough
all ICS products are CI as …
monotherapy for asthma exacerbation
albuterol
brands
dosage forms and dosing
SE
Ventolin HFA, Proair Respiclick, Proair HFA, Proventil HFA
MDI/DPI: 1-2 inhalations every 4-6h prn
nebulizer: 1.25-5mg q4-8h prn
SE: tremor, nervousness, palpitaitons, hyperglycemia, hypokalemia
Qvar =
beclometasone
a LABA must always be used with an
ICS
salmeterol =
Serevent
Spiriva =
tiotropium
what ICS/LABA combinations are FDA approved for asthma?
fluticasone/salmeterol = Advair, Airduo
fluticasone/vilanterol = Breo
mometasone/formoterol = Dulera
budesonide/formoterol = Symbicort
are there any LAMA/LABA/ICS products FDA approved for asthma?
yes
Trellegy (umeclidinium/vilanterol/fluticasone)
montelukast
MOA
dosing
BBW
LTD4 receptor antagonist
1-5 yo = 4mg PO HS
6-14 yo = 6mg PO HS
>14 yo = 10mg PO HS
BBW: neuropsychiatric events
theophylline
dosing
DDI
5mg/kg IBW LD
then 100-600mg MD
DDI: major 1A2 substrate
signs of theophylline toxicity
persistent vomiting
arrhythmias
seizures
who would not be a good candidate for theophylline
patients with epilepsy, arrhythmias, PUD
what are the recommended tx for exercise induced asthma? how should the patient use the inhaler(s)?
SABA or low-dose ICS-formoterol
take 5-15 min before activity
SABA will last 2-3 hours
ICS-formoterol will last 12 hours
what therapies are not recommended for asthma in pregnancy?
all are recommended to be continued in pregnancy
what order should patients take their inhalers in? do they have to wait between doses
SABA, wait 60 sec then
LAMA, LABA, wait 60 sec then
ICS
what are the benefits of spacers
increase drug delivery to lungs
dec risk of thrush
good for children or those with low hand-breath coordination
what readings on a peak flow meter indicate what to do for asthma management?
> 80-100% - continue therapies
50-80% - set up asthma action plan, caution
<50% - emergency, go to ED
what inhaler needs 2 sprays to be primed and required priming if not used for 7 days
Symbicort
what inhalers require 4 sprays to prime and should be re-primed if not used for 7 days
Flovent
Dulera
what inhalers require 4 sprays to prime and should be re-primed if not used for 14 days
Flovent
Proair
