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Pharm exam 2 > Asthma > Flashcards

Asthma Flashcards

1
Q

What is asthma?

A
  • Chronic inflammatory disorder of the airways
  • Characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation
  • Airflow limitation is generally reversible, but may eventually lead to airway remodeling
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2
Q

What is the most prevalent chronic disease of childhood?

A

Asthma

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3
Q

Genetic risk factors

A

-Atopy or family history of atopic disease
-Parental history of asthma
60-80% of susceptibility

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4
Q

Environmental risk factor

A
  • Socioeconomic status
  • Family size
  • Second hand tobacco exposure
  • Allergen exposure
  • Occupational exposure
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5
Q

Inflammation leads to….

A

-Airway hyper responsiveness
-Airway obstruction
both lead to clinical symptoms.

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6
Q

Anatomy of an Asthma attack

A
  • Smooth muscle spasm- tightening of the airway, swelling and inflammation
  • Occur due to fluid build up, infiltration by immune cells, excess mucous secretions.
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7
Q

Symptoms

A
  • Cough
  • Recurrent wheezing
  • SOB or chest tightness
  • Nocturnal cough
  • Exercise-induced cough or wheezing
  • Onset of symptoms after exposure to airborne allergens or other stimuli
  • History of respiratory tract infections
  • Associated conditions
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8
Q

Signs

A
  • Evidence of bronchial obstruction
    • Wheezing
    • Prolonged expiration
  • Airway obstruction at least partially reversible
  • Evidence of atopy on physical exam (nose, eyes, and skin)
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9
Q

diagnosis

A
  • Patient medical & family hx
  • Physical exam of upper rest. tract & skin
  • Confirmatory spirometry required for diagnosis & grading of asthma severity
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10
Q

What is spirometry?

A

Objective test to assess severity of lung dx and response to tx.

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11
Q

What does spirometry measure?

A
  • Forced Expired Volume in One Second (FEV1)
  • Forced Vital Capacity (FVC)
  • FEV1/FVC ratio gives a clinically useful index of airflow limitation
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12
Q

What result is diagnostic for exercise- induced asthma?

A

FEV1 of greater 15%

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13
Q

What result is diagnostic for asthma?

A

Reversible airflow obstruction with 12% increase in FEV1 after bronchodilator.

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14
Q

What is FEV1?

A

volume of air pt can breath out after having full lungs

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15
Q

What is FVC?

A

Volume of air in lungs that is exhaled fully when lungs are full.

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16
Q

What are the treatment goals?

A

Reduce impairment and reduce risk

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17
Q

Reduce impairment:

A
  • Prevent chronic symptoms
  • Require infrequent use of rescue medications
  • Maintain near normal lung function
  • Maintain near normal activity levels
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18
Q

Reduce Risk:

A
  • Prevent exacerbations
  • Minimize need for emergency care and hospitalization
  • Prevent loss of lung function
  • Minimize adverse effects of therapy
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19
Q

Severity categories

A

To initiate therapy:

  • Intermittent
  • Persistent (mild, moderate, severe)
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20
Q

Control:

A

To monitor and adjust therapy (follow-up visits)

  • Controlled
  • Partially controlled
  • Uncontrolled
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21
Q

Initial visit steps

A
  • Diagnose asthma
  • Assess asthma severity
  • Initiate medication and demonstrate us
  • Develop written asthma action plan
  • Schedule follow-up appointment
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22
Q

Asthma triggers

A
  • Smoking (most common)
  • Indoor allergens
  • Outdoor allergens
  • Exercise
  • Cold air
  • Pollutants
  • Mediations
  • Sulfites
  • Resp. tract infections
  • Medical comorbidities
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23
Q

Follow-up visit steps

A
  • Assess & monitor asthma control
  • Review medication techniques & adherence; assess side effects; review environmental control
  • Maintain, step up, or step down medication
  • Review asthma action plan, revise as needed
  • Schedule next follow-up visit.
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24
Q

Modifying therapy: well controlled

A
  • Maintain current step

- Consider step down if well controlled for 3 months

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25
Q

Modifying therapy: not well controlled

A

-Step up at least 1 step

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26
Q

Modifying therapy: very poorly controlled

A

-Step up 1-2 steps and consider short course of oral steroids.

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27
Q

Rescue medications (as needed)

A
  • Short-acting Beta 2 agonists (SABAs)

- Systemic corticosteroids (for acute exacerbation).

28
Q

Controller medications (daily)

A
  • Inhaled corticosteroids (ICS)
  • Long-acting beta2 agonists (LABA)
  • Leukotriene receptor antagonists (LTRAs)
  • Mast cell stabilizers
  • Methylxanthines.
29
Q

Short-acting beta2 agonists (SABA): mechanism

A

Relax airway smooth muscle (bronchodilator)

30
Q

Short-Acting β2-Agonists (SABA) adverse effects

A

-tacycardia, tremor, palpitation, dizziness, headache

31
Q

Inhaled Corticosteroids (ICS) MOA

A

-Cornerstone of asthma therapy
-Mechanism:
Decrease inflammation and hyperresponsiveness

32
Q

Inhaled Corticosteroids (ICS) indication

A
  • Reduce symptoms, improve qualify of life, and improve lung function
  • Reduce frequency and severity of exacerbations
  • Reduce asthma mortality
33
Q

Inhaled Corticosteroids (ICS) adverse efects

A

-Cough, dysphonia
-Oral thrush
Ensure patients RINSE MOUTH AFTER EACH USE
- Systemic adverse effects are minimal

34
Q

ICS inhalers: metered-dose inhalers

A
  • Beclomethasone (Qvar HFA)
  • Fluticasone propionate (Flovent HFA)
  • Mometasone (asmanex HFA)
35
Q

ICS Inhalers: Dry-Powder inhalers

A
  • Fluticasone proporzionate (Flovent Diskus)
  • Fluticasone furoate (arnuity ellipse)
  • Mometasone (Asmanex TwistHaler)
36
Q

Long-Acting β2-Agonists (LABA) MOA

A

-Relax airway smooth muscle with longer duration of action

37
Q

Long-Acting β2-Agonists (LABA) Indication

A
  • NOT for acute exacerbations or mono therapy
  • Black box warning: increase risk of asthma-related deaths
  • Add-on therapy to ICS; prescribe in combo
38
Q

Long-Acting β2-Agonists (LABA) Adverse effects

A

Tachycardia, skeletal muscle tremor, hypokalemia.

39
Q

Salmeterol & Fometerol

A

Long-Acting β2-Agonists (LABA)

40
Q

Leukotriene Receptor Antagonists MOA

A

Interfere with pathway of leukotriene mediators. which are released from mast cells, eosinophils, and basophils.

  • Added therapy for mild to moderate
  • No relief from corticosteroids alone
41
Q

Leukotriene Receptor Antagonists Indication

A
  • Alternative to inhaled steroids in mild persistent

- Can be adjunctive to ICS but not preferred in children > 12 and adults compared to addition of LABA

42
Q

Leukotriene Receptor Antagonists Adverse effects

A

-Headache, GI upset, hepatotoxicity

43
Q

Montelukast, Zafirlukast, Zileuton

A

Leukotriene Receptor Antagonists

44
Q

First line therapy for all

A

Rescue inhaler and short acting corticosteroid.

45
Q

Last line agent

A

Mast Cell Stabilizers, only available as nebulizer

46
Q

Mast Cell Stabilizers: MOA

A

Stabilize mast cells and interfere with chloride channel function
Weak anti-inflammatory effects

47
Q

Mast Cell Stabilizers: Indication

A
  • Alternative, but not preferred
  • Can be used for exercise-induced bronchospasm
  • May need 4-6 week trial to determine max benefit
  • Used 3-4 times daily
48
Q

Mast Cell Stabilizers: adverse effects

A
  • Unpleasant taste
  • Cough
  • Dry throat
  • Headache
  • N/V
49
Q

Methylxanthines MOA

A

Relaxation of smooth muscle, modest anti-inflammatory properties

50
Q

Methylxanthines: Indication

A

May be beneficial as add-on therapy to ICSs but less effective than LABA

51
Q

Methylxanthines: Adverse effects

A
  • N/V
  • Loose stools
  • Tachycardia
  • Cardiac arrhythmias
  • Seizures
  • Headache
52
Q

Methylxanthines: Caution

A
  • Mutliple drug interactions

- Monitoring required! Narrow therapeutic range, 5-15 mcg/ml.

53
Q

Peak flow 80-100%

A

Doing well

  • Breathing is good
  • Able to do all usual things
54
Q

Peak flow 50-80%

A

Caution

  • Has breathing problems
  • Can do some, but not all, activities
55
Q

Peak flow <50%

A

Medical alert

  • Breathing is hard and fast
  • Cannot do usual activities
56
Q

Follow up care

A
  • Every 2-6 wks while gaining control
  • Every 1-6 months to monitor control
  • Every 3 months if step down therapy is anticipated.
57
Q

What is an asthma exacerbation?

A
  • Exacerbation – acute episode of progressively worsening SOB, cough, wheezing, or chest tightness
  • Characterized by decrease in expiratory airflow
58
Q

Asthma exacerbation goal

A

Relieve airflow obstruction and hypoxemia and prevent future relapses.

59
Q

Oral corticosteroids

A
  • Primary use as a rescue medication for acute asthma exacerbations.
  • Short oral burst for 3-10 days, taper may or may not be needed.
60
Q

Prednisone, prednisolone, methylprednisolone

A

Oral corticosteroids.

61
Q

Acute use oral corticosteroid adverse effects

A
  • Fluid retention
  • Mood changes
  • Sleep disturbances
  • Appetite increase
  • Hypokalemia (additive with other drugs)
  • Hyperglycemia
  • Hypertension
62
Q

Chronic use oral corticosteroid adverse effect

A
  • Cushingoid changes
  • Growth suppression in children
  • Cataracts
  • Osteopenia, osteoporosis
  • HPA axis suppression
63
Q

Pediatric considerations

A
  • Use spacers ± mask for infants and smaller children
  • Provide duplicate rescue inhaler prescription for school
  • ICS use may slow growth rate, but no decrease in adult height
  • Risk vs. benefit; utilize lowest dose possible
64
Q

Elderly considerations

A

-consider dexterity and ability to use devices

65
Q

Pregnancy considerations

A
  • SABAs, LABAs, cromolyn and ICSs are safe in pregnancy

- Inhaled corticosteroids are preferred long-term control medication

66
Q

Asthma Clinical Pearls

A

-Steroids are the cornerstone of therapy
-As low of a dose of ICS is needed to maintain control of symptoms
-Assess PRN SABA use
Ensure every patient has a SABA for PRN use
-Patient education and environmental control
-Do not use LABAs alone

Pharm exam 2 (6 decks)

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