Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

RxPrep > Asthma > Flashcards

Asthma Flashcards

1
Q

What are classic symptoms of asthma?

A
  1. wheezing
  2. chest tightness
  3. coughing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are common asthma triggers?

A
  1. pollution
  2. cigarettes
  3. cold air/weather change
  4. pets
  5. dust/pollen/cockroaches
  6. perfumes/cosmetics
  7. aspirin/NSAIDs/non-selective beta-blockers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What comorbid conditions can trigger asthma?

A
  1. infections
  2. allergies
  3. GERD
  4. obesity
  5. obstructive sleep apnea
  6. anxiety/stress/depression
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How is asthma diagnosed?

A

Spirometry:
1. measure FEV1 at baseline
2. give albuterol
3. measure post-bronchodilator FEV1
4. FEV1increase > 12% post bronchodilator is consistent with asthma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What guidelines are established for treating asthma

A

Global Initiative for Asthma (GINA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is used to assess patient for initial asthma therapy?

A

Clinical Assessment and Treatment Step

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is step 1 symptom severity?

A

Daytime symptoms <2 times per month
No night symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is step 2 symptom severity?

A

Daytime symptoms >2x/month but less than 4-5 days/week
No night symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is step 3 symptom severity?

A

Daytime symptoms most days
≥ 1 night awakening/ week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is step 4 symptom severity?

A

Daytime symptoms every day
≥ 1 night awakening/ week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is a general treatment approach to asthma?

A

assess Q 2-6 weeks:
1. assess adherence
2. assess technique, including priming and cleaning
3. step-up, maintain or step-down treatment
once control is achieved follow up Q 1-6 months; Q 3 months with step-down therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What medication classes are reliever/rescue drugs?

A
  1. inhaled ICS+ formoterol (preferred)
  2. inhaled SABA
  3. systemic steroids
  4. inhaled epinephrine
  5. SAMA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What reliever medication is available OTC?

A

inhaled epinephrine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Why is ICS preferred in all patients for exacerbation and maintenance vs. bronchodilators?

A
  1. most effective antiinflammatory drugs
  2. reduces exacerbations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What drug classes are controller/maintenance?

A
  1. ICS
  2. LABA + ICS
  3. Leukotriene receptor antagonists (LTRA) PO
  4. Theophylline PO/IV
  5. LAMA (Add on)
  6. injectable monoclonal antibodies SC/IV
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What monoclonal antibody is for severe allergic asthma?

A

Omalizumab

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What monoclonal antibodies are for severe eosinophilic asthma?

A
  1. mepolizumab
  2. reslizumab
  3. benralizumab
  4. dupilumab
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What monoclonal antibody is used in severe asthma regardless of eosinophil count/ other markers?

A

Tezepelumab

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is initial therapy for step 1?

A
  1. prn low-dose ICS+ formoterol
    OR
  2. SABA + low-dose ICS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is initial therapy for step 2/ needing SABA > 2 times/month?

A
  1. prn low-dose ICS+ formoterol
    OR
  2. prn SABA + low-dose ICS+ low dose ICS scheduled
    OR
  3. prn SABA + low-dose ICS+ LTRA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is initial therapy for step 3?

A
  1. prn and scheduled low-dose ICS + formoterol
    OR
  2. prn SABA +ICS AND scheduled low dose ICS +formoterol
  3. low-dose ICS + LTRA
  4. Medium-dose ICS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is initial therapy for step 4/ initial presentation is exacerbation?

A
  1. prn low-dose ICS + formoterol AND scheduled medium-dose ICS + formoterol
  2. prn low-dose ICS + formoterol AND scheduled medium-dose ICS + LABA
  3. prn low-dose ICS + SABA AND scheduled medium-dose ICS + formoterol +LRTA/tiotropium
  4. high-dose ICS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is the initial treatment for step 5?

A
  1. prn low-dose ICS + formoterol AND scheduled high-dose ICS + formoterol
  2. prn low-dose ICS + SABA AND scheduled high-dose ICS + LABA
  3. prn low-dose ICS + SABA AND scheduled high ICS + formoterol +tiotropium/oral steroid/injectable treatments
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

albuterol

A
  1. ProAir HFA
  2. ProAIr Respiclick (DPI)
  3. Proventil HFA
  4. Ventolin HFA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Salmeterol

A

Severevent Diskus (DPI)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Levalbuterol

A

Xopenex HFA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Beclomethasone

A

QVAR RediHaler

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Budesonide

A

Pulmicort Flexhaler (DPI)
Pulmicort Respules (nebulizer)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Budesonide+ formoterol

A

Symbicort (DPI)
Breyna (DPI)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Fluticasone

A

Flovent HFA
Flovent Diskus (brand D/C)
Arnuity Ellipta (DPI)
ArmonAir Digihaler (DPI)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Fluticasone+salmeterol

A

Advair Diskus
Advair HFA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Fluticasone + vilanterol

A

Breo Ellipta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Mometasone + formoterol

A

Dulera

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Mometasone

A

Asmanex HFA
Asmanex

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Ciclesonide

A

Alvesco

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are SEs of beta-2 agonists?

A
  1. nervousness
  2. tremor
  3. tachycardia
  4. palpitations
  5. cough
  6. hyperglycemia
  7. hypokalemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What are warnings with SABAs?

A

Use caution in:
1. CVD
2. glaucoma
3. hyperthyroidism
4. seizures
5. diabetes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What are monitoring parameters for SABAs?

A
  1. # of days of SABA use
  2. sx frequency
  3. peak flow
  4. pulmonary function tests
  5. BP
  6. HR
  7. blood glucose
  8. K+
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What is an important counseling point for MDI (HFA) use?

A

shake well before use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What is the difference between levalbuterol vs. albuterol?

A

Levalbuterol contains the R-isomer of albuterol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

What are boxed warnings with LABAs?

A
  1. increased risk of asthma-related deaths; should only be used in asthma patients already receiving but not controlled on inhaled corticosteroids
  2. increased risk of asthma-related hospitalization in pediatric and adolescent patients
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What is the MOA of beta-2 agonists?

A

beta-2 agonists bind to beta-2 receptors –> relaxation of bronchial smooth muscle–> bronchodialation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Epinephrine

A

Asthmanefrin Refill

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Why should inhaled epinephrine not be used?

A

non-selective beta-agonist; FDA-approved for mild asthma symptoms in intermittent asthma only

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Albuterol+ budesonide

A

Airsupra

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What is the MOA of ICS?

A

inhibit inflammatory response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What are warnings with ICS?

A
  1. high doses for extended periods of time can cause adrenal suppression
  2. immunosuppression
  3. increased risk of fractures
  4. growth retardation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

What are SEs of ICS?

A
  1. dysphonia (difficulty speaking)
  2. oral candidiasis (thrush)
  3. cough
  4. headache
  5. hoarseness
  6. URTIs
  7. hyperglycemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

What are the monitoring parameters with ICS?

A
  1. use of SABA/ rescue inhaler
  2. sx frequency
  3. peak flow
  4. growth (children)
  5. s/sx of renal insufficiency
  6. s/sx thrush
  7. bone density
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What can be done to decrease the risk of thrush?

A
  1. rinse mouth with water and spit out each time ICS used to prevent thrush
  2. use a spacer with MDI ICS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What is the only ICS available as a nebulizer suspension?

A

Budesonide (Pulmicort Respules)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

How is Pulmicort Respules used?

A

only use with a jet nebulizer connected to an air compressor; DO NOT use an ultrasonic nebulizer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Why should QVAR RediHaler not be shaken or used with a spacer?

A

breath-activated aerosol with characteristics of MDi and DPI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Which ICS contains built-in electronic module that detects, record, and stores data (detects when inhaler is used and measures inspiratory flow)?

A
  1. ArmonAir Digihaler (fluticasone)
  2. AirDuo Digihaler (fluticasone+ salmeterol)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What is a low daily dose of Beclomethasone MDI 40 or 80 mcg/inh?

A

100-200 mcg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

What is a medium daily dose of Beclomethasone MDI 40 or 80 mcg/inh?

A

> 200-400mcg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

What is a high daily dose of Beclomethasone MDI 40 or 80 mcg/inh?

A

> 400 mcg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

What is a low daily dose of Budesonide DPI 90 or 180 mcg/inh?

A

200-400 mcg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

What is a medium daily dose of Budesonide DPI 90 or 180 mcg/inh?

A

> 400-800 mcg

60
Q

What is a high daily dose of Budesonide DPI 90 or 180 mcg/inh?

A

> 800 mcg

61
Q

What is a low daily dose of Ciclesonide MDI 80 or 160 mcg/inh?

A

80-160 mcg

62
Q

What is a medium daily dose of Ciclesonide MDI 80 or 160 mcg/inh?

A

160-320 mcg

63
Q

What is a high daily dose of Ciclesonide MDI 80 or 160 mcg/inh?

A

> 320 mcg

64
Q

What is a low daily dose of Fluticasone MDI/DPI?

A

100-250 mcg

65
Q

What is a medium daily dose of Fluticasone MDI/DPI?

A

> 250-500 mcg

66
Q

What is a high daily dose of Fluticasone MDI/DPI?

A

> 500mcg

67
Q

What is a low daily dose of Mometasone MDI 100/200 mcg/inh?

A

200-400 mcg

68
Q

What is a medium daily dose of Mometasone MDI 100/200 mcg/inh?

A

200-400 mcg

69
Q

What is a high daily dose of Mometasone MDI 100/200 mcg/inh?

A

> 400 mcg

70
Q

What is a low daily dose of Mometasone DPI 110/220 mcg/inh?

A

110-220 mcg

71
Q

What is a medium daily dose of Mometasone DPI 110/220 mcg/inh?

A

> 220-440 mcg

72
Q

What is a high daily dose of Mometasone DPI 110/220 mcg/inh?

A

> 440

73
Q

How can MDIs be identified by brand name?

A

HFA, Respimat, or no suffix (ex. symbicort, dulera)

74
Q

How can DPIs be identified by brand name?

A

Diskus, Ellipta, Pressair, HandiHaler, RespiClick, Flexhaler

75
Q

Which MDIs can a spacer not be used with?

A
  1. QVAR RediHaler
  2. Respimat products
76
Q

Which MDIs do not need to be shaken before use?

A
  1. QVAR RediHaler
  2. Alvesco
  3. Respimat products
  4. Atrovent HFA
77
Q

Which DPI requires priming?

A

Flexhaler

78
Q

What is the MOA of montelukast?

A

inhibits leukotriene D4 (LTD4)–> reduce airway edema, constriction, and inflammation

79
Q

What is the MOA of zafirlukast?

A

inhibits leukotriene D4 and leukotriene E4

80
Q

What is the MOA of Zileuton?

A

inhibits 5-lipoxygenase–> inhibits leukotriene formation

81
Q

What are boxed warnings with montelukast?

A

neuropsychiatric events (serious behavior/mood changes including suicidal thoughts and actions)

82
Q

What are indications for montelukast?

A
  1. asthma
  2. allergic rhinitis
  3. exercise-induced bronchospasm
83
Q

Montelukast

A

Singular

84
Q

Zafirlukast

A

Accolate

85
Q

Zileuton

A

Zyflo

86
Q

What are warnings with all leukotriene modifying agents?

A
  1. neuropsychiatric events: monitor for signs of aggressive behavior, hostility, agitation, hallucinations, depression, suicidal thinking
  2. systemic eosinophilia (montelukast, zafirlukast)
87
Q

What are SEs with all leukotriene modifying agents?

A
  1. headache
  2. dizziness
  3. abdominal pain
  4. elevated LFTs
  5. URTIs
88
Q

What is dosing for montelukast ages 1-5?

A

4 mg daily in the evening

89
Q

What is dosing for montelukast ages 6-14?

A

5mg daily in the evening

90
Q

What is doing for montelukast age 14+?

A

10 mg daily in the evening

91
Q

What is the dosing of montelukast for exercise-induced bronchospasm?

A

5 mg (6-14 y/o) or 10 mg (≥15y/o) 2 hours before exercise

92
Q

What dosage forms does montelukast come in?

A
  1. tablet
  2. chewable tablet
  3. packet (granules)
93
Q

How can Montelukast granules administered?

A
  1. directly in the mouth
  2. dissolved in a small amount (~5mL) of breast milk or formula
  3. mixed with a spoonful of applesauce, carrots, rice, or ice cream (nothing else)
    USE WITHIN 15 MINUTES OF OPENING PACKET
94
Q

How must zafirlukast be dispensed?

A

in original container –> protect from moisture and light

95
Q

What should be monitored when taking zafirlukast/zileuton?

A

LFTs

96
Q

What should be monitored when taking montelukast?

A

behavior changes

97
Q

How is montelukast affected by CYP metabolism?

A
  1. minor substrate of CYP3A4, CYP2C8, and CYP2C9
  2. weak inhibitor of CYP2C8, and CYP2C9
  3. gemfibrozil will increase the concentration of montelukast
  4. lumacaftor can decrease levels of montelukast
98
Q

How is zafirlukast affected by CYP metabolism?

A
  1. Major substrate of CYP2C9
  2. moderate inhibitor of CYP2C9 and weak inhibitor of CYP2C8
  3. can increase levels of theophylline
  4. increase levels of CYP2C9 substrates (warfarin)
99
Q

How is zileuton affected by CYP metabolism?

A
  1. minor substrate of CYP1A2 and CYP3A4
  2. weak inhibitor of CYP1A2
  3. can increase levels of theophylline, propranolol, and warfarin
100
Q

What is the MOA of theophylline?

A

blocks phosphodiesterase–> increase in cAMP and increased epinephrine from adrenal medulla –> bronchodilation

101
Q

What are the active metabolites of theophylline?

A
  1. caffeine
  2. 3-methylxanthine
102
Q

What is a therapeutic level of theophylline and how is it measured?

A

5-15mcg/mL; measure peak level at steady state (after 3 days of oral dosing)

103
Q

What is dosing for theophylline?

A

LD: 5 mg/kg (IBW; unless TBW<IBW)
Maintenance: 300-600 mg QD

104
Q

What are warnings with theophylline?

A

can exacerbate cardiovascular arrhythmias, PUD, and seizure disorders

105
Q

What are SEs with theophylline?

A
  1. N/V
  2. headache
  3. insomnia
  4. increased HR
  5. tremor
  6. nervousness
106
Q

What are signs of toxicity from theophylline?

A
  1. persistent vomiting
  2. arrhythmias
  3. seizures
107
Q

What should be monitored when taking theophylline?

A
  1. theophylline levels
  2. HR
  3. CNS symptoms (insomnia, irritability)
  4. use of rescue inhaler
108
Q

How much theophylline is in aminophylline?

A

2:1 –> theophylline: ethylenediamine

109
Q

How are theophylline and aminophylline interconverted?

A

aminophylline x 0.8= theophylline
theophylline / 0.8= aminophylline
ATM (Aminophylline to Theophylline Multiply)

110
Q

Theophylline has first-order kinetics followed by zero-order kinetics, what does this mean for dosing?

A

in the higher end of the therapeutic range, small dose increases can result in large concentration increases

111
Q

How is theophylline affected by CYP metabolism?

A
  1. Major substrate of CYP1A2
  2. Minor substrate of CYP 3A4 and CYP2E1
112
Q

What medications increase theophylline levels?

A

inhibitors of CYP1A2:
1. ciprofloxacin
2. zileuton
3. fluvoxamine
4. propranolol
Other drugs:
5. zafirlukast
6. alcohol
7. allopurinol
8. disulfiram
9. estrogen-containing OCs
10. methotrexate
11. pentoxifylline
12. propafenone
13. verapamil

113
Q

Which CYP3A4 inhibitors can increase levels of theophylline?

A
  1. clarithromycin
  2. erythromycin
114
Q

What drugs can decrease theophylline levels?

A
  1. carbamazepine
  2. phenytoin
  3. fosphenytoin
  4. phenobarbital
  5. primidone
  6. rifampin
  7. ritonavir
  8. marijuana smoking
  9. st.johns wart
  10. levothyroxine
115
Q

What drug can theophylline decrease levels of due to increased renal excretion?

A

lithium

116
Q

What conditions or food can increase theophylline (by reducing clearance?

A
  1. CHF
  2. cirrhosis/ liver disease
  3. fever
  4. acute pulmonary edema
  5. cor pulmonale (pulmonary heart disease)
  6. hypothyroidism
  7. shock
  8. high carb/low protein diet
117
Q

What conditions or food can decrease theophylline (by increasing clearance?

A
  1. low carb/ HIGH PROTEIN diet
  2. daily consumption of charbroiled beef
  3. cystic fibrosis
  4. hyperthyroidism
118
Q

Omalizumab

A

Xolair

119
Q

Mepolizumab

A

Nucala

120
Q

Reslizumab

A

Cinqair

121
Q

Benralizumab

A

Fasenra
Fasenra pen

122
Q

Dupilumab

A

Dupixent

123
Q

Rezepelumab

A

Tezspire

124
Q

How is omalizumab administered?

A
  1. initiated in a healthcare setting under medical supervision (≥3 doses)
  2. SC every 2 to 4 weeks based on body weight and pretreatment IgE levels
  3. must have documented allergic asthma with a positive skin test or in vitro reactivity to an aeroallergen
125
Q

What boxed warnings does omalizumab have?

A

anaphylaxis( can occur at any time during treatment); must be observed after administration

126
Q

What is the MOA of omalizumab?

A

IgG monoclonal antibody; inhibitors IgE binding to the receptor on mast cells and basophils

127
Q

What is the MOA of interleukin receptor antagonist?

A

blocks interleukins (cytokines responsible for growth, differentiation, recruitment, activation, and survival of eosinophils) to reduce inflammation; block IL-5 (except dupilumab)

128
Q

What is the MOA of dupilumab?

A

blocks interleukins (cytokines responsible for growth, differentiation, recruitment, activation, and survival of eosinophils) to reduce inflammation; block IL-4 and 13

129
Q

Which agents are interleukin receptor antagonists?

A
  1. mepolizumab
  2. reslizumab
  3. benralizumab
  4. dupilumab
130
Q

How is mepolizumab administered?

A

SC Q 4 weeks

131
Q

How is reslizumab administered?

A

IV Q 4 weeks

132
Q

How is benralizumab administered?

A

SC Q 4 weeks x 3 doses then Q 8 weeks

133
Q

How is dupilumab administered?

A

SC every other week

134
Q

Which monoclonal antibodies can be administered at home by the patient/ caregiver?

A
  1. mepolizumab
  2. dupilumab
  3. Faserna pen (benralizumab)
  4. tezepelumab
135
Q

Which interleukin receptor antagonist has a boxed warning for anaphylaxis?

A

Reslizumab (IV)

136
Q

How is exercise-induced bronchospasm treated?

A

SABA or low-dose ICS+ fomoterol 5-15 minutes before exercise

137
Q

How long will effects of a SABA last?

A

2-3 hours

138
Q

How long will effects of ICS+ formoterol last?

A

up to 12 hours

139
Q

What agent can be beneficial if a longer duration of exercise is expected with EIB?

A

salmeterol +ICS

140
Q

How should Salmeterol+ ICS be administered for EIB?

A

take 30 minutes before exercise

141
Q

How is montelukast used for EIB?

A
  1. can be taken 2 hours before exercise and lasts up to 24 hours
  2. DO NOT take additional doses for EIB if already taking for another indication
142
Q

How is asthma treated in pregnancy?

A
  1. keep control, do not escalate
  2. ICS prn or daily
143
Q

How long should an albuterol inhaler last with good asthma control?

A

12 months (3-4 months with Ventolin 60 inhalations/canister)

144
Q

How long should a patient wait if prescribed multiple doses of inhaled medications?

A

wait 60 seconds between each inhaled dose

145
Q

What order should asthma medications be given in?

A
  1. SABA
  2. LABA/LAMA
  3. ICS
    waiting 60 seconds in between each inhalation
146
Q

What are the types of nebulizers?

A
  1. jet
  2. ultrasound
  3. mesh

RxPrep (63 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions