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Advanced Pediatric Pharmacology Exam 1 > Asthma > Flashcards

Asthma Flashcards

1
Q

Asthma Characteristics (5)

A
  1. Chronic inflammatory disorder of the airways
  2. Airway hyper-responsiveness
  3. Bronchoconstriction
  4. Airway edema
  5. Mucus plug formation
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2
Q

Asthma epidimiology (2)

A
  1. Most common chronic disease among children in the US

2. Slightly higher incidence in males until adolescence then switches

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3
Q

Asthma etiology (3 genetic, 7 environmental)

A
  1. Genetic
    –35-70% have hereditary association
    –Gender
    –Cytokine response
2. Environmental
–RSV infection in early childhood
–Socioeconomic status
–Family size
–Exposure to second-hand smoke
–Allergen exposure
–Urbanization
–Decreased exposure to common infections
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4
Q

Asthma Triggers (6)

A
  1. Infection: RSV, rhinovirus, influenza, parainfluenza
  2. Allergens: Airborne pollens, dust-mites, dander, roaches
  3. Environment: Cold air, fog, tobacco smoke, ozone, wood smoke
  4. Emotions: Anxiety, stress, laughter
  5. Exercise: Particularly in cold, dry climates
  6. Medications: Aspirin, NSAIDs, sulfites, beta-blockers
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5
Q

Asthma Pathophysiology (7)

A

Airway inflammation:

  1. Acute and/or chronic
  2. Mast cell activation: Histamine, PG, LTs
  3. Eosinophil infiltration: Produce LT, PAF to cause smooth muscle contraction
  4. TH2 lymphocytes – release cytokines and interleukins

Airflow obstruction

  1. Bronchospasm
  2. Edema
  3. Hypersecretion
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6
Q

Consequences of asthma pathophysiology (6)

A
  1. Hyper-responsive airway to physical, chemical, and pharmacologic stimuli
  2. Mucus production
  3. Airway smooth muscle contraction
  4. Inflammation
  5. Nitric oxide less effective
  6. Remodeling of the airway
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7
Q

Asthma Classifications (4)

A

1: Mild intermittent
2: Mild persistent
3: Moderate persistent
4: Severe persistent

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8
Q

Diagnosis of Asthma (9)

A
  1. History of cough, recurrent wheezing, recurrent difficulty breathing, recurrent chest tightness
  2. Symptoms occur or worsen at night or with exercise, viral infection, exposure to allergens and irritants, changes in weather, hard laughing or crying, stress, or other factors
  3. In all patients 5 or older, use spirometry to determine that airway obstruction is at least partially reversible
  4. Considered other causes of obstruction
  5. Decrease in FEV1 of at least 30% following 6 minute of near maximal exercise
    –Only useful in older children (i.e. 5 years old)
  6. Elevated eosinophil count
  7. Elevated IgE concentration in blood
  8. Positive methacholine challenge
    –PC20 FEV1 < 12.5 mg/mL
    -Provocation concentration of methacholine to cause a decrease in FEV1 by 20%
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9
Q

Mild Intermittent Asthma (6)

A
  1. Symptoms < 2 days per week
  2. Asymptomatic and normal PEF (peak expiratory flow) between exacerbations
  3. Exacerbations brief, intensity may vary
  4. Nighttime symptoms < 2 nights per month
  5. FEV1 or PEF > 80% predicted
  6. PEF variability < 20%
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10
Q

Mild Persistent Asthma (5)

A
  1. Symptoms > 2 times per week but < 1 time per day
  2. Exacerbations may affect activity
  3. Nighttime symptoms > 2 nights a month
  4. FEV1 or PEF > 80% predicted
  5. PEF variability 20-30%
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11
Q

Moderate Persistent Asthma (7)

A
  1. Daily symptoms
  2. Daily use of inhaled beta-agonist
  3. Exacerbations affect activity
  4. Exacerbations > 2 times a week
  5. Nighttime symptoms > 1 night per week
  6. FEV1 or PEF > 60%, < 80% predicted
  7. PEF variability > 30%
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12
Q

Severe Persistent Asthma (6)

A
  1. Continual symptoms
  2. Limited physical activity
  3. Frequent exacerbations
  4. Nighttime symptoms frequent
  5. FEV1 or PEF < 60% predicted
  6. PEF variability > 30%
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13
Q

Goals of Asthma Therapy (6)

A
  1. Prevent chronic symptoms
  2. Maintain normal pulmonary function
  3. Maintain normal activity levels
  4. Prevent recurrent exacerbations
  5. Provide optimal pharmacotherapy with minimal side effects
  6. Meet expectations/satisfaction with care
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14
Q

Long Term Control Medications (6)

A
  1. Corticosteroids
  2. Immunomodulators
  3. Leukotriene inhibitors
  4. Long-Acting B-agonists
  5. Mast cell stabilizer (Cromolyn Sodium)
  6. Methylxanthines
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15
Q

Short Term Relief Medications (3)

A
  1. Anticholinergics
  2. Short-acting B-agonists
  3. Systemic corticosteroids
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16
Q

Beta-2 Agonists (2)

A
  1. Most effective bronchodilators and treatment of choice for severe acute asthma
  2. Chronic administration may lead to down-regulation of receptors
    –May be reversed with corticosteroids
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17
Q

Beta-2 Agonists Mechanism of Action (4)

A
  1. Mostly beta-2 selective
  2. Stimulates beta-adrenergic receptors –> production of cyclic AMP –> smooth muscle relaxation –> bronchodilation
  3. Mast cell stabilization
  4. beta1 and alpha1 actions seen with high doses
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18
Q

Short Acting B2 Agonists (5)

A
  1. Albuterol (PO, MDI, Neb); tx of choice
  2. Levalbuterol
  3. Terbutaline (PO, IV, Subq)
  4. Metaproterenol - not used a lot
  5. Pibuterol
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19
Q

Long Acting B2 Agonists (2)

A
  1. Formeterol

2. Salmeterol

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20
Q

Combination of Short and Long Acting B2 Agonists (3)

A
  1. F/Budesonide
  2. S/Fluticasone
  3. F/Mometasone
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21
Q

Albuterol Dosing (2)

A

ProAir, Ventolin HFA

  1. MDI: 90 mcg/puff (max dosing outpatient: 2 puffs q4h)
  2. Neb: 2.5 mg/ampule (max dosing OP = 5 mg q1 – 4h)
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22
Q

Albuterol ADEs (6)

A
  1. HypoK+
  2. Excitability/hyperactivity, shakiness or tremors
  3. Loss of appetite, GI discomfort
  4. Rare: hyperglycemia, bronchospasm
  5. Tachycardia, palpitations
  6. Caution with overuse
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23
Q

Albuterol Onset

A

Inhalation almost immediate

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24
Q

Levalbuterol (Xopenex)

A

(R) enantiomer of albuterol; theoretically less tachycardia and adverse effects

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25
Levalbuterol Dosing
1. MDI: 45 mcg/puff (8 puffs q20 min up to 4 hrs) | 2. Neb: 0.075 – 0.15 mg/kg/dose (comes in 0.31, 0.63, & 1.25 mg)
26
Levalbuterol ADEs (6)
1. Hypokalemia 2. Excitability/hyperactivity, shakiness 3. Loss of appetite, GI discomfort 4. Rare: hyperglycemia, bronchospasm 5. Tachycardia 6. Caution with overuse
27
Long Acting Beta Agonist Info (6)
1. NOT FOR ACUTE SYMPTOMS 2. Long-term prevention of symptoms 3. MDI is FDA approved > 12 years of age - Clinically used in younger children 4. Preventative agent for EIA 5. 2 puffs 30-60 minutes prior to exercise 6. Effective for nocturnal symptoms
28
Methylxanthines/Theophylline (2 and Mechanism of Action)
1. Mild to moderate bronchodilator 2. Mechanism of Action –Increases cyclic AMP via phosphodiesterase inhibition --> Increase catecholamine stimulation - Enhances mucocilliary clearance - Increases diaphragmatic contractility 3. EPR3: May be considered as adjunctive therapy in combination with ICS (level B evidence)
29
Theophylline Dosing (3)
1. Loading and maintenance dose recommendations (available IV & PO) 2. Monitoring –Therapeutic level of 5-20 mg/L 3. Dose titration: Increase dose every 3 days until target dose achieved –Further dosage adjustments based on patient symptoms and serum concentrations
30
Theophylline ADME
A –Good PO absorption D –Poor distribution to fat (hydrophillic molecule) –Vd increased in neonates M –Metabolized to caffeine via CYP enzymes –DDI: macrolides, propranolol, cimetidine, rifampin E –Highly variable –Dependent on age, liver fxn, & cardiac fxn –Up to 30 hrs in neonates & as low as 3.4 hrs in children
31
Methylxanthine ADEs
1. Tachycardia 2. Increased urination 3. Irritability 4. Restlessness
32
Methylxanthine Toxicity (3)
1. Headache 2. Tachycardia 3. N/V
33
Anticholinergics (3)
1. Indication = Useful for relief of acute bronchospasms (Evidence B) 2. Long-term benefits in daily therapy not established 3. Long-standing use for asthma, no FDA-approved indication for asthma
34
Anticholinergics Mechanism of Action
Anticholinergic --> inhibits vagal mediated reflexes (inhibits seromucous gland secretions) –Prevent increases in CAMP
35
Anticholinergic Available Options (3)
1. Ipratropium (treatment of choice) - Available as MDI and Neb - Q6 – 8h 2. Tiotropium 3. Also used in neonates for bronchopulmonary dysplasia
36
Anticholinergic ADEs (8)
Hot as a hare 1. Hyperthermia Blind as a bat 2. Dilated pupils Dry as a bone 3. Dry skin Red as a beet 4. Vasodilation Mad as a hatter 5. Hallucinations/agitation Bowel and bladder lose their tone and the heart goes on alone 6. Ileus 7. Urinary retention 8. Tachycardia
37
Corticosteroid Indications (2 inhaled, 2 systemic)
Inhaled: 1. Long-term prevention of symptoms 2. Dosage varies based on severity of disease Systemic (oral) 1. Use in short-bursts (3-10 days) for exacerbations 2. Long-term prevention of symptoms in severe asthma
38
Corticosteroid Mechanism of Action (3)
1. Reverses down-regulation of beta-receptors 2. Inhibits migration of inflammatory cells 3. Inhibits cytokine and histamine production
39
Inhaled Corticosteroid Options (5)
1. Beclomethasone (Beclovent) 2. Budesonide* (Pulmicort) 3. Flunisolide (AeroBid) 4. Fluticasone* (Flovent) 5. Triamcinolone (Azmacort)
40
Inhaled Corticosteroid Info
The dose-response curve for ICS treatment begins to flatten for many measures of efficacy at low to medium doses, although some data suggest that higher doses may reduce the risk of exacerbations. Most benefit is achieved with relatively low doses, whereas the risk of adverse effects increases with dose
41
Methylprednisolone (Solu-Medrol) (route, antiinflam effects, half life, dose)
Route of Admin: IV, IM, PO Relative anti-inflammatory effects: 5 Plasma Half life: ~7.5 Equivalent Dose: 4
42
Prednisolone (Ora-Pred, Prelone) (route, antiinflam effects, half life, dose)
Route of Admin: PO Relative anti-inflammatory effects: 4 Plasma Half life: ~2-4 Equivalent Dose: 5
43
Prednisone (route, antiinflam effects, half life, dose)
Route of Admin: PO Relative anti-inflammatory effects: 4 Plasma Half life: ~2-3 Equivalent Dose: 5
44
Dexamethasone (Decadron) (route, antiinflam effects, half life, dose)
Route of Admin: IV, IM, PO *10 mg/ml can be given PO Relative anti-inflammatory effects: 25-30 Plasma Half life: ~4 Equivalent Dose: 0.75
45
ADEs of Inhaled Corticosteroids (2)
1. throat irritation | 2. thrush
46
ADEs of Short-term systemic Corticosteroids (4)
1. Weight gain 2. Fluid retention 3. HTN 4. Hyperglycemia
47
ADEs of long-term systemic corticosteroids (4)
1. Adrenal suppression 2. Diabetes 3. Growth suppression 4. Osteoporosis
48
Oral Corticosteroid Clinical Pearls (3)
1. Duration of action with dexamethasone is much longer than half-life 2. Effects with all steroids can be prolonged 3. Prolonged use = increased risk in adverse side effects
49
Montekulast Mechanism of Action
(Singulair) and Zafirlukast (Accolate) inhibits the cysteinyl leukotriene CysLT1 receptor preventing the cysteinyl LT from binding
50
Zileuton (Zyflo) Mechanism of Action (2)
1. Direct 5-lipoxygenase-activating protein (FLAP) inhibitor | 2. Prevents conversion of arachidonic acid to leukotriene
51
Leukotriene Modifiers and M.O.A.
Mediates allergies, bronchoconstriction, and mucous production; ONLY AVAILABLE ORALLY 1. Montelukast 2. Zileuton
52
Leukotriene Modifier Indications (3)
1. Long-term prevention of symptoms in persistent asthma | 2. Relief of symptoms of seasonal allergic rhinitis (Montelukast ONLY)
53
Leukotriene Modifier ADEs
1. Headache 2. Abdominal pain 3. Dyspepsia (indegestion) 4. Increase infection risk
54
Mast Cell Stabilizer Mechanism of Actions (3)
1. Inhibits degranulation of mast cells 2. Inhibits mediator release from leukocytes 3. No bronchodilator activity
55
Mast Cell Stabilizers (2)
1. Cromolyn (Intal): PO, inhaled | 2. Nedocromil (Tilade): inhaled
56
Mast Cell Stabilizer Indications (2)
1. Long-term prevention of symptoms - FDA approved > 2 years of age (cromolyn) - FDA approved > 12 years of age (nedocromil) 2. Preventative agents for EIA (cromolyn) - 2 puffs MDI 10-15 minutes prior to exercise - Administer no more than 60 minutes before exercise
57
Mast Cell Stabilizer ADEs (4)
1. Dry mouth 2. Pharyngitis 3. Cough 4. Unpleasant taste
58
Immunotherapy (3)
1. Allergy-desensitization shots 2. Skin testing performed to determine allergen triggers 3. Based on results, series of therapeutic injections containing small doses of allergens administered to ‘desensitize’ the patient
59
Monoclonal Antibodies (3)
1. Omalizumab (Xolair) 2. IgG monoclonal antibody --> inhibits IgE binding 3. Decreases IgE --> limits activation and release of allergic response mediators
60
Monoclonal Antibody Dosing (2)
Based on IgE serum levels IgE levels remain elevated up to a year after therapy
61
Monoclonal Antibody Caution
ANAPHYLAXIS
62
Quick Relief medications (2)
1. SABA via neb or face mask or spacer 2. Alternative therapy –Oral beta2-agonist –Bronchodilator
63
Step-Wise Approach 1 (2)
1. Controller meds: No daily medication needed | 2. With Severe exacerbations: Systemic corticosteroids should be considered
64
Step-Wise Approach 2 (4)
1. Controller meds: Low-dose inhaled corticosteroids 2. Alternative treatments –Cromolyn or Nedocromil –Leukotriene modifier –Sustained released theophylline
65
Step-Wise Approach 3 (3)
Controller meds 1. Low-medium inhaled corticosteroid AND LABA Alternative treatment 2. Medium dose inhaled corticosteroid alone 3. Low-medium dose inhaled corticosteroid AND leukotriene OR theophylline
66
Step-Wise Approach 4 (3)
1. For Patients with severe recurring exacerbations Controller meds 2. Medium dose inhaled corticosteroids AND LABA Alternative 3. Medium dose inhaled corticosteroid AND leukotriene antagonist OR theophylline
67
Step-Wise Approach 4 (3)
Controller meds 1. High-dose inhaled corticosteroids AND LABA And if needed 2. Systemic corticosteroids long-term 3. Make repeated attempts to reduce systemic steroids and switch to high-dose inhaled corticosteroids
68
Patient Education for Asthma Meds (4)
1. Avoid triggers 2. Warning signs 3. Use spacer for younger aged children 4. Use in conjunction with metered dose inhaler
69
MDI Inhalers (6)
1. Inspect spacer for particulate matter 2. Remove caps and connect MDI to spacer 3. Shake unit 3-4 times vigorously 4. Breathe out of mouth, place spacer to mouth, inhale as pressing the canister 5. Hold breath 10 seconds before exhaling 6. Wait 1 minute between breaths

Advanced Pediatric Pharmacology Exam 1 (8 decks)

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