Asthma Flashcards
Rescuers or agents commonly used in asthma exacerbation
Short acting Beta two agonist, systemic steroids (injectable or oral), anticholinergics
Common triggers
- Allergens
- Drugs: aspirin, NSAIDs, sulfites, beta blockers
- Environmental
- Exercise: cold air or humid hot air
- Occupational
- Respiratory infections
Controller or long-term maintenance therapy medications for asthma
Inhaled steroids, long-acting Beta two agonist, leukotriene modifying agents, theophylline, omalizumab (xolair)
Beta-2 agonist
MOA: find to beta-2 receptors causing relaxation of bronchial smooth muscle resulting in bronchodilation – and hail route is the preferred route of administration
Drugs: albuterol (Ventolin, Proventil, proair), levalbuterol (Xopenex, Xopenex HFA), pirbuterol (Maxair autohaler)
Side effects: charmer, shakiness, lightheadedness, cough, palpitations, hypokalemia, tachycardia, hyperglycemia
Monitoring: number of days of use of short acting beta agonist, symptom frequency, peak flow, BP, HR, BG, and K
Note: candy used in pregnancy, prefer a beta-2 selected agent and the inhaled route. These rescue medications used as needed but if using more than two days per week then need to increase maintenance therapy
Long acting beta two agonist
Drugs:
- Salmeterol (serevent), + fluticasone (advair diskus and HFA)
- Formoterol (foradil aerolizer), + budesonide (Symbicort)
Blackbox warning: increased risk of asthma related death, do not use as monotherapy in patients with persistent asthma, should only be used as adjunct of therapy, what’s asthmas control try to step down therapy and discontinue LABA if possible
Notes: pregnancy category C, refrigerate foradil capsules
Corticosteroids
MOA: inhibit the inflammatory response, depressed migration of leukocytes, fibroblast; reverses capillary permeability at the cellular level to prevent or control exclamation
Drugs: beclomethasone (Qvar), budesonide(Pulmicort), budesonide plus Formoterol (Symbicort), Ciclesonide (Alvesco), flunisolide (aerospan-built in spacer), fluticasone (Flovent), fluticasone plus salmeterol (advair), mometasone (asmanex twisthaler), mometasone plus formoterol (Dulera)
Contraindication: not for relief of acute bronchospasm
Side effect of inhaled steroid: dysphonia, oral candidiasis, cough, hoarseness, upper respiratory tract infection, increased risk of fracture and pneumonia
Monitoring: frequency of use, septum frequency, growth of adolescents and signs and symptoms of adrenal insufficiency or oral candidiasis
Note: to prevent oral candidiasis rinse mouth and throat with warm water and spit out or use a spacer device; first-line for long-term control for all ages with persistent asthma; do not need to shake Qvar and Alvesco
Oral steroids
Long-term effects of systemic steroids: Cushing’s syndrome (moon face, Buffalo hump, impaired wound healing, dermal thinning, psychiatric disturbances as a result of the pituitary gland producing large amounts of endogenous cortisol), hypokalemia, immunosuppression, amenorrhea (hirsutism in women), acne, insomnia/nervousness
Does equivalents of oral steroids
- short acting: Cortisone 25 mg, hydrocortisone 20 mg
- Intermediate acting: methylprednisolone/triamcinolone 4 mg, prednisones/prednisolone 5 mg
- Long-acting: betamethasone 0.6 mg, dexamethasone 0.75 mg
- Mineralocorticoids: fludrocortisone (no anti-inflammatory effect)
Oral corticosteroids
Drugs: Cortizone, hydrocortisone (Cortef or Solu-Cortef), methylprednisolone (Medrol, Medrol Dosepak, Solu-Medrol), prednisone, prednisolone (MilliPred and Orapred), triamcinolone (Kenalog)
Contraindication: live vaccines, systemic fungal infections, Varicella
Side effects: increased appetite, weight gain, fluid retention, emotional instability, insomnia, better taste and with high doses increased BP and BG
Monitoring: BP, weight, appetite, mood
Notes: Cortizone is a pro drug for cortisol. Prednisone is a pro drug for prednisolone. Steroids should be given between 7 and 8 AM to limit the body’s normal release of cortisol. If taking longer than 10 to 14 days must take her slowly due to suppression as a pituitary adrenal axis
Relative anti-inflammatory potency
Betamethasone/dexamethasone> fludrocortisone> methylprednisolone/triamcinolone> prednisones/prednisolone> hydrocortisone> Cortisone
Leukotriene modifying agent
MOA: help to decrease airway edema, constriction and inflammation (Zafirlukast and Montelukast are receptor antagonist whereas Zileuton is a inhibitor of leukotriene formation)
Drugs: Zafirlukast (Accolate), Montelukast (Singulair), Zileuton (Zyflo, Zyflo CR)
Contraindications: hepatic impairment and active liver disease or LFTs greater than or equal to three times ULN
Warning: neuropsychiatric event, hepatotoxicity, vasculitis
Side effects: headache, dizziness, abdominal pain, increased LFTs, URT eyes, pharyngitis, sinusitis
Monitoring: liver function
NOTE: SINGULAIR IS FOR ADULTS AND CHILDREN 12 MONTHS OF AGE AND OLDER WITH ASTHMA (can be used two hours before exercise for exercise-induced asthma)
Theophylline
MOA: blocks phosphodiesterase causing increased cAMP which promotes release of epinephrine from adrenal Maduell cells. This results in bronchodilation, diuresis, Cenis and cardiac stimulation and gastric acid secretion. Used as add-on as it is not most effective and has many drug interactions
Therapeutic range: 5 – 15 mcg/mL (measure peak level after three days)
Warning: caution in patients with CV disease, hyperthyroidism, peptic ulcer disease and seizure disorder
Side effects: nausea, loose stools, headache, tachycardia, insomnia, tremor and nervousness
Signs of toxicity: persistent and repetitive vomiting, ventricular tachycardia, seizure
Theophylline drug interactions
- Increase theophylline levels: ciprofloxacin, fluvoxamine, propranolol, zafirlukast, Zileuton, clarithromycin, erythromycin
- Drugs that increase theophylline levels due to other mechanisms: alcohol, allopurinol, anti-thyroid ages, estrogen, methotrexate, verapamil, Propafenone
- Drugs that decrease theophylline levels: carbamazepine, fosphenytoin, phenobarbital, phenytoin, primidone, rifampin, tobacco, St. John’s wort, levothyroxin, high protein diet
- Theophylline will decrease lithium levels
Omalizumab (Xolair)
MOA: IgG antibody that inhibit IGE binding on mast cells. Is indicated for moderate to severe persistent, allergic asthma in patients with a positive skin test for an allergen were in adequately controlled on inhaled steroids
Administration: SHOULD ALWAYS BE GIVEN IN THE DOCTORS OFFICE
Blackbox warning: anaphylaxis
Side effects: injection site reactions, arthralgia, pain, dizziness, fatigue, leg, arm pain, dermatitis, bone fracture
MONITORING: IGE, FEV1, PEAK FLOW
Notes: pregnancy category B, doses greater than 150 mg should be divided over more than one injection site
Pregnancy and asthma
Albuterol is the preferred short acting beta agonist, budesonide is the preferred inhaled corticosteroid
