Asthma Flashcards
definition of asthma
increase responsiveness of trachea and bronchi to various stimuli causing reversible airway narrowing
4 main asthma triggers
control status
H/o exacerbation
enviornmental triggers
seasonal, genetic, immunologic RF
what are the enviornmental triggers of asthma
exercise smoke cold-induced occupational drug induced--B-blockers, ASA/NSAID
what are the seasonal/genetic/immunologic triggers
URI recurrent sinus infection atopic asthma allergic rhinitis PND
what is the early phase of asthma attack
bronchospasm + mucosal edema after initiating event
followed by wheeze, SOB, cough, edema
within 1-2hrs
what do early phase asthma attacks respond to
MDI
nebulized bronchodilators
what is the late phase asthma attack
mucosal inflammation & increase mucous production
within 4-6hrs
what do late phase asthma attacks respond to
anti-inflammatory (Steroids)
what are asthma related deaths due to?
lack of access lack of AAP underuse of steroid overuse of brochodilator underestimation of severity lack of measure of airway obstruction non-adherence
if you are using a SABA >2 times a week what is indicated
anti-inflammatory therapy
what are the most effective anti-inflammatory agents
ICS
what can be added to ICS if they aren’t enough
LAMA
LABA
what is the final step when all common therapies have been attempted
immunologic and avoidance of triggers
why don’t we use epinephrine & isoproterenol?
cardiac stimulation via B1–tachy/arrythmias common
why don’t we use albuterol, metaproterenol, terbutaline in pill forms?
worse ADR’s w/ skeletal muscle tremor and nervousness
what are the rescue therapies?
SABA
SAMA
steroids
what are the maintenance therapies
ICS LABA LAMA leukotriene mast-cell stab. Immunotherapy
why do we prefer inhalers?
fast onset
small dose
better ADR profile
what are the 4 inhalers?
MDI
Soft Mist
Dry Powder
Neb
what is good about soft mist?
formulation propelled forward
what do you have to do prior to MDI use?
shake
what can be used w/ MDI to help get more drug into lungs?
VHS or spacer
who should use dry powder inhalers?
ppl w/ technique issues of MDI
example of inhaler wrapped in foil?
advair
example of inhaler not in foil?
proair
how should you breathe when using MDI, soft mist inhaler?
slow and deep
how should you breathe when using an DPI?
quick and deep
SABA drugs
albuterol
Levabuterol
what forms does albuterol come in?
DPI and HFA
what form does levabuterol come in?
dpi
MOA of SABA
stimulate adenylyn cyclase–increase cAMP–relax smooth muscel to allow for vasodilation
how fast do SABA’s work?
5 min w/ peak @30m-60min
clinical indications for SABA
relieve broncohspasm
prophylactic for working out
how often can you take albuterol ?
2 puffs q4-6hrs
dosage of neb albuterol
1.25-5mg in 3mL saline q4-8hrs
are nebs more effective?
no
when is a pt taking too much albuterol and then what should we do?
2x/wk
anti-inflammatory tx
ADR of albuterol
tachycardic
palpitations
tremor
what increases ADR’s of albuterol
high doses
what is the rescue therapy (antimusc)
nebulized ipratropium + albuterol
when does rescue therapy need to be initiated?
FEV1 or PEF <50% or no response to albuterol alone
what systemic steroids do we use?
prednisone
Methylprednisolone
dexamethasone
benefits of dexamethasone
longer 1/2 life
high potency
tolerated more by pts
MOA of steroids
inhibit production of inflammatory cytokines and reduce bronchial reactivity
clinical indication of steroids
exacerbation
use w/ SABA +/- ipatropium
ADRs of steroids
insomnia
nervousness
increase appetite
hyperglycemia
what ICS do we use
budesonide
Fluticasone
what is the only ICS neb?
budesonide
what ICS is a prodrug?
Ciclesonide
where is ciclesonide activated?
in the long
clinical indications of ICS
presistent asthma
what dose ICS should we use?
low!
what if low dose ICS + albuterol isn’t enough?
increase to medium dose or add LABA
what should we do before medium/high dose ICS?
try LABA or leukotriene modifier
what is the most potent long-term controller of asthma symptoms?
ICS
pt ed for ICS
rinse mouth after use
take 1-2 weeks before effective
what are budesonide, fluticasone, and ciclesonide substrates of
CYP3A4
what pt population/med is bad to combine with ICS?
HIV meds–COBI
HIV patients on ICS can develop what condition
cushings b/c too much steroid d/t inability to metabolize it
ADR of budesonide, fluticasone, and ciclesonide
dysphonia OP candidiasis skeletal effects--stunts growth increase risk osteoporosis occular issues skin issues
how can budesonide, fluticasone, and ciclesonide effect the eyes?
increase IOP–glaucoma
increase cataract formation
what do budesonide, fluticasone, and ciclesonide do to the skin?
increase risk of bruising/purpura
what are the LABAs
salmeterol
Formoterol (NEB)
what is the only SOLO laba inhaler?
salmeterol
MOA of LABA’s
lipid soluble–dissolves in smooth muscle cell membrane to slowly release
what type of agonist is formoterol
full agonist
what type of agonist is salmeterol
partial
what is the BB warning for salmeterol
increase risk of severe asthma attack & death if used solo
should you ever use salmeterol alone?
no! medical negligence
what is salmeterol a substrate of?
3A4
if CYP3A4 inhibitor is present and you use salmeterol, what are the effects?
tachycardia
palpitations
what is the LAMA
tiotropium
MOA of LAMA
long-acting antimuscarinic
what is a SAMA
ipatropium
when should we use tiotropium
add on to high dose ICS + LAba
minimum age for LAMA
12
ADR of lama?
dry mouth
pharyngeal irritation
how do leukotrienes exacerbate asthma
chemotaxis of inflammatory cells
produce mucous and edema in the airway
bronchoconstriction
what do leukotrienes result from
5-lipoxygenase on arachidonic acid
what is the 5-lipo inhibitor
zileuton
do we use zileuton?
no
2 drugs that are cysteinyl leukotriene receptor antagonist
Zafirlukast
Montelukast
what is the only leukotriene modifer we use
montelukast (tablet)
ADR of montelukast
hA
neuropsych effects
what patient population is montelukast best for?
those w/ allergies
what does montelukast NOT do to help asthma
no effect on smooth muscle tone
when should montelukast be taken? exacerbation or prophylatically
prophylactically
MOA of theophylline
bronchodilator
blocks PDE
what is theophylline a substrate of
1A2
what drugs inihibit 1A2
ciprofloxacin
amiodarone
OCP
cimitidine
what pt RF decrease ability to clear theophylline
<1yr
>60yr
concurrent dz
drug interactions
what theophylline conc causes increase pulm fcn
10mcg/mL
what theophylline conc causes anorexia, N/V, abdominal pain, anxiety, HA
> 15-20mcg/mL
what theophylline conc causes seizures and arrythmias
> 40mcg/mL
what anti-IgE antibody do we use
Omalizumab (SQ)
MOA of omalizumab
IgG binds to free IgE in circulation and blocks its attachment to surface of mast and basophils
clinical use of omalizumab
pts >6 w/ mod-severe asthma w/ allergic components
serious ADR of omalizumab
anaphylaxis
how do we give the 1st 3 injections of omalizumab
monitored!
what med should pts w/ eosinophilic phenotype get?
IL-5 antibodies
IL-5 antibody drugs
mepolizumab
reslizumab
benralizumab
MOA of mepolizumab and Reslizumab
bind to IL-5 and decrease survival of eosinophils/basophils to decrease airway inflammation
MOA of benralizumab
bind to IL-5 causing apoptosis of eosinophils/basophils to decrease airway inflammation
IL-4 antagonist
Dupliumab (SQ)
MOA of duplimuab
bind to IL-4 receptor to inhibit signaling of cytokines to decrease inflammation drivers
what pts should get dupliumab
mod-severe asthma + eosinophilic phenotype
what are contract indicated when on dupliumab
live vaccines
what ADR has been reported with dupliumab
eosinophila–E-GPA (pneumonia, vasculitis)
what NSAID should asthma pts use
celecoxib
do we go low & slow dosing for asthma?
NO
once we control pts asthma symptoms how long do we stay at that level
3 months
how many months should each step down be until we reach a lowest dose?
3 months
Risks of asthma in pregnancy
preeclampsia preterm birth LBW or IGUGR congeital malformation perinatal death
drugs in pregnancy for asthma
SABA (C)
LABA (C)
ICS (B)
how frequently should pregnant pts w/ poor asthma control be seen ?
1-2wks
