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Pharm N895 > Asthma > Flashcards

Asthma Flashcards

1
Q

Asthma Triggers

A
  • Environment
  • Respiratory infection
  • Allergens
  • Emotions
  • Exercise
  • Drugs/preservatives
  • Occupational stimuli
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2
Q

What are the most important asthma triggers?

A

Environmental:

Cold air, fog, ozone, sulfur dioxide, nitrogen dioxide, tobacco smoke, wood smoke

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3
Q

Define Asthma

A

Widespread, reversible narrowing of bronchial airways w/marked increase in bronchial responsiveness to inhaled stimuli

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4
Q

Asthma: pathophysiology of bronchoconstriction

A
  • Irritant stimulates vagal nerve pathways –> postganglionic fibers release acetylcholine at muscarinic receptors on bronchial smooth muscle cells –> BRONCHOCONSTRICTION
  • Irritant also stimulates release of chemical mediators from mast cells in lungs –> BRONCHOCONSTRICTION
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5
Q

Diagnostic criteria: asthma

A
  • Detailed med Hx
  • PE
  • Spirometry (age ranges, but typically FEV1/FVC <70% is a problem)
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6
Q

Components of severity classification: asthma

A
  • Frequency of symptoms
  • Nighttime awakening
  • Days/wk SABA used for Sx control
  • Interference w/normal activity

*use the highest classification

Intermittent or Persistent (mild, moderate, severe)

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7
Q

Asthma treatment goals

A

Reduce impairment: prevent chronic & troublesome Sx; prevent frequent use of rescue meds, 2+/week; maintain near normal pulmonary function & normal activity

Reduce Risk: prevent hosp, prevent loss lung fx, provide optimal pharm w/minimal AEs

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8
Q

Asthma medications

A

SHORT ACTING B2 AGONISTS

LONG ACTING B2 AGONISTS

INHALED CORTICOSTEROIDS

LEUKOTRIENE INHIBITORS

CROMOLYN (INTAL®)

METHYLXANTHINES

IMMUNOMODULATORS

ORAL CORTICOSTEROIDS (OCSs)

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9
Q

Most effective long-term control medication

A

Inhaled corticosteroids: reduces impairment and risk of exacerbations

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10
Q

B2 Receptor Agonists, Short Acting (SABAs): agents

A
  • Albuterol (ProAir, Proventil)
  • Levalbuterol (Xopenex)
  • Pirbuterol (Maxair)
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11
Q

B2 Receptor Agonists, Short Acting (SABAs): MOA

A

selectively activate β-2 adrenergic receptors in the smooth muscles of the lungs, promoting bronchoconstriction

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12
Q

B2 Receptor Agonists, Short Acting (SABAs)​: indications

A

Indications: acute bronchospasm (“rescue inhaler”) and prevention of exercise-induced asthma

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13
Q

B2 Receptor Agonists, Short Acting (SABAs) and long acting (LABAs): ADRs

A

inhalation –> minimal systemic effects; tremors/shakiness

-oral –> possibility of activated β-1 receptors with high dose –> tachycardia; angina; tremors

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14
Q

significance of albuterol and levalbuterol as enantiomers

A

enantiomers are chemical mirror images; theoretically, levalbuterol may have a lower risk of bronchial hyperresponsiveness because it does not contain the S-isomer; however albuterol is still more frequently rx’ed due to the availability of a generic

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15
Q

Albuterol (ProAir, Proventil): onset & duration

A

Onset: ~10min, duration 3-4h

(SABA)

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16
Q

Albuterol (ProAir, Proventil): formulations

A

MDI, Neb

(SABA)

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17
Q

Albuterol (ProAir, Proventil): available generic?

A

Available generic, least $

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18
Q

SABA w/most and least clinical evidence

A

Most: Albuterol (ProAir, Proventil)

Least: Pirbuterol (Maxair) - least B2 potency

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19
Q

Levalbuterol (Xopenex): onset & duration

A

Onset: ~10min, duration 3-4h

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20
Q

Levalbuterol (Xopenex)​: formulations

A

MDI, Neb

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21
Q

Levalbuterol (Xopenex): available generic?

A

no

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22
Q

Pirbuterol (Maxair): onset & duration

A

Onset: ~30min, duration 5h

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23
Q

Pirbuterol (Maxair): formulations

A

MDI

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24
Q

Pirbuterol (Maxair): available generic?

A

no!

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25
Q

LONG-ACTING BETA-2 RECEPTOR AGONISTS (LABAs): agents

A

Salmeterol (Serevent)

Formoterol (Foradil)

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26
Q

LABAs: indication

A

indicated for long term control of asthma; preferred adjunctive therapy in combination with ICS

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27
Q

LABAs: BBW

A

LABA use alone can increase the risk of asthma-related death!; should ALWAYS be combined with an ICS

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28
Q

Salmeterol (Serevent): onset/peak, duration

A

up to 2h, Duration: 12h

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29
Q

Best clinical evidence for LABAs

A

Salmeterol (Serevent)

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30
Q

Salmeterol (Serevent): generic available?

A

Yes!

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31
Q

Formoterol (Foradil): onset/peak & duration

A

Onset/Peak: up to 2h, Duration: 12h

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32
Q

Formoterol (Foradil)​: formulations

A

Aerosol powder for inhalation

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33
Q

Formoterol (Foradil)​: generic available?

A

no

34
Q

inhaled corticosteroids: agents

A
  • beclomethasone dipropionate
  • fluticasone
  • mometasone furoate

Advair®, Symbicort® and Dulera® are combination corticosteroid + β-2 adrenergic agonist formulas

-SONE

35
Q

inhaled corticosteroids: MOA

A

direct local anti-inflammatory activity; reduce airway hyperresponsivenes; inhibit inflammatory cell migration and activation

36
Q

Inhaled/Oral corticosterois: ADRs

A
  • inhalation –> oral candidiasis (use spacer and gargle afterwards); dysphonia
  • intranasal –> drying; itching; sore throat; epistaxis
  • systemic effects –> cataracts; glaucoma; hyperglycemia; PUD (oral only); bone loss; adrenal suppression
  • slowed growth in children and adolescents
37
Q

ICS: considerations for effectiveness

A
  • Consider lung delivery % if delivery to site of action is an issue (think pediatric pts.) –> beclomethasone and flunisolide have highest lung delivery %
38
Q

ICS: Special administration instructions

A
  • Oral rinse with water after use
  • Onset of improvement within 1 week of initiation –> tell pt. not to d/c after a few days of use
39
Q

ICS: concerns w/systemic availability

A
  • Systemic adverse effects
  • ?Decreased growth velocity
40
Q

ICS: monitoring parameters?

A

growth velocity in pediatrics – may ↓ GV if systemic absorption

41
Q

LEUKOTRIENE INHIBITORS: MOA

A

interfere with the production of chemical mediators by eosinophils and mast cells –> ↓ plasma exudation, mucus secretion, bronchoconstriction and eosinophil recruitment

42
Q

LEUKOTRIENE INHIBITORS: Indications

A

Indications: moderate to severe persistent asthma;

43
Q

LEUKOTRIENE INHIBITORS: recommendations - when and with what

A

recommended in combination with high-dose ICS + LABA;

**considered prior to initiation of chronic corticosteroid therapy

44
Q

LEUKOTRIENE INHIBITORS: agents

A

Leukotriene Receptor Antagonist:

  • Montelukast (Singulair®)

Leukotriene Receptor Antagonist:

  • Zafirlukast (Accolate®)

5-Lipooxygenase Inhibitor:

  • Zilueton (Zyflo CR®)
45
Q

Montelukast (Singulair®): dosing

A

4-10 mg PO QHS

Leukotriene Receptor Antagonist:

46
Q

Montelukast (Singulair®): ADRs

A

*H/A (up to 25%)

Leukotriene Receptor Antagonist

47
Q

Zafirlukast (Accolate®): dosing

A

10-20 mg PO BID

Leukotriene Receptor Antagonist

48
Q

Zafirlukast (Accolate®): ADRs

A

transaminitis

Leukotriene Receptor Antagonist

49
Q

Zafirlukast (Accolate®): C/Is

A

Hepatic impairment

Leukotriene Receptor Antagonist

50
Q

Zilueton (Zyflo CR®): dosing

A

1200 mg PO BID

5-Lipooxygenase Inhibitor

51
Q

Zilueton (Zyflo CR®): ADRs

A

transaminitis

5-Lipooxygenase Inhibitor

52
Q

Zilueton (Zyflo CR®): C/Is

A

C/I: Hepatic impairment

also $$$

5-Lipooxygenase Inhibitor:

53
Q

CROMOLYN (INTAL®): indication

A

alternative agent for mild persistent asthma –> effective in providing symptom control for exercise induced bronchospasm (EIB); inferior to ICS in improving outcomes

54
Q

CROMOLYN (INTAL®): dosing & formulations

A

MDI or nebulizer; 20 mg inhalation up to 4 times daily

55
Q

CROMOLYN (INTAL®): MOA

A

MOA: mast cell stabilizer

56
Q

CROMOLYN (INTAL®): Onset of response to therapy

A

2 to 6 weeks

57
Q

CROMOLYN (INTAL®): ADRs

A

Good tolerability and safety profile

58
Q

METHYLXANTHINES: Agents

A

only theophylline (Elixophyllin ®)

59
Q

METHYLXANTHINES: Indications

A

alternative step up therapy for mild persistent asthma or as adjunctive therapy with ICS

60
Q

theophylline (Elixophyllin ®):​ dosing

A

**narrow TI drug, with goal serum concentration of 5-15 mcg/mL (30 min after loading dose)

  • Initial loading dose generally required
  • Time to peak serum concentration 1-2 h for PO, within 30 min for IV

METHYLXANTHINE

61
Q

theophylline (Elixophyllin ®): Dosage forms

A

ER tablet (Theo-Dur®), capsule (Theo-24®), oral solution, IV solution

METHYLXANTHINE

62
Q

theophylline (Elixophyllin ®): MOA

A
  • Bronchodilation*: non-selective phosphodiesterase (PDE) inhibitors –> ↑ cAMP and cGMP concentrations
  • Anti-inflammatory*: activation of histone deacetylase –> ↓ proinflammatory gene expression

METHYLXANTHINE

63
Q

Factors that ↓ theophylline clearance

A

cimetidine; macrolides; quinolones; systemic viral illness; zileuton; propranolol

METHYLXANTHINE

64
Q

Factors that ↑ theophylline clearance:

A

*phenytoin; rifampin; carbamazepine; smoking; phenobarbital; high protein diet

METHYLXANTHINE

65
Q

theophylline (Elixophyllin ®): ADRs

A

Dose-related adverse effects: tachycardia; H/A; hypotension; N/V; hematemesis; hyperglycemia; hyperkalemia; seizures

66
Q

IMMUNOMODULATORS: agents

A

only omalizumab (Xolair ®)

67
Q

omalizumab (Xolair ®): indications

A

alternative agent for patients with sensitivity to relevant allergens in severe persistent asthma

IMMUNOMODULATOR

68
Q

omalizumab (Xolair ®): dosing and administration

A

solution for subcutaneous injection [$1000 per dose]; dosing based on pre-tx IgE levels and body weight; 150-300 mg Q4 weeks; must be adjusted if significant weight change

IMMUNOMODULATOR

69
Q

omalizumab (Xolair ®): pathophysiology

A

IgG monoclonal antibody that inhibits IgE receptor binding on mast cells and basophils; long-term use shows ↓ exacerbations and corticosteroid use

IMMUNOMODULATOR

70
Q

omalizumab (Xolair ®): ADRs

A

anaphylaxis reported in < 0.2% patients; injection site RXNs

IMMUNOMODULATOR

71
Q

ORAL CORTICOSTEROIDS (OCSs): Indications

A

last resort!; short course (up to 2 weeks) indicated for pts. w/ poor asthma control; reduces sx duration, prevents hospitalizations and ↓ likelihood of relapse post-exacerbation

72
Q

Metered Dose Inhalers (MDI): how to use

A
  • Shake the inhaler well before use; remove cap
  • Exhale away from inhaler
  • Bring the inhaler to your mouth.
  • Place it in your mouth between your teeth and close you mouth around it.
  • Start to breathe in slowly.
  • Press the top of you inhaler once and keep breathing in slowly until you have taken a full breath.
  • Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
73
Q

Diskus (Dry powder inhaler): how to use

A
  • Hold Diskus in palm of hand (sandwich)
  • Push thumb grip until it clicks into place
  • Slide lever away from you
  • Place it in your mouth between your teeth and close you mouth around it.
  • Start to breathe in deeply and rapidly.
  • Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
  • Always check the number in the dose counter window to see how many doses are left
74
Q

Twisthaler (Dry powder inhaler): how to use

A
  • Twist white cap counter clockwise
  • Exhale away from Twisthaler
  • Hold horizontally
  • Place it in your mouth between your teeth and close you mouth around it.
  • Start to breathe in deeply and rapidly.
  • Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
  • Replace cap and twist clockwise.
  • Make sure it clicks to completely close it.
  • Rinse mouth and gargle
75
Q

Spacers: benefit

A
  • Enhanced drug delivery, highly recommended with ICS for pediatrics
  • Canister holds drug in place. Can inhale at own pace – good for pedi who may not have high lung capacity
76
Q

Asthma: Step-Up Pharmacotherapy for Well Controlled

A

Well controlled

  • Frequent follow up (1 – 6 month intervals)
77
Q

Asthma: Step-Up Pharmacotherapy for Not well controlled

A

Step up 1 step and re-evaluate (2 – 6 weeks)

78
Q

Asthma: Step-Up Pharmacotherapy for Poorly controlled

A

Step up 1 or 2 steps and re-evaluate
Consider short course of oral corticosteroids

79
Q

How does pregnancy affect asthma?

A
  • Worsens in one-third of pregnant females
80
Q

Asthma and pregnancy: preferred rescue agent

A

Albuterol: Preferred rescue agent

81
Q

Asthma and pregnancy: preferred maintenance agent

A

Budesonide: Preferred maintenance agent

82
Q

Asthma and pregnancy: agents to avoid

A

Long-acting beta agonists
Omalizumab
Zileuton

Pharm N895 (13 decks)

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