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Pharmacotherapy > Asthma > Flashcards

Asthma Flashcards

1
Q

What is the key prevention to asthma related deaths according to expert advocates

A

Patient education

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2
Q

Asthma Risk Factor: household

A
  • Asthma history in the family
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3
Q

Asthma Risk Factor: birth and nursing

A

_ Caesarian Section

_ Formula feeding

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4
Q

Asthma risk factor: farm living

A

_ Sheep farming

_ pressed or loose hay

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5
Q

Asthma risk factor: Urban living

A

_ Altered dietary practices

_ Community associated infection

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6
Q

Asthma risk factor: microbiological exposure

A

_ Dysbiotic microbiota
_ Respiratory viral infection
_ Bacterial pathogens
_ Lower burden helmith infection

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7
Q

Asthma risk factor: lower socioeconomic status

A

_ Increased smoking rates

_ Higher stress

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8
Q

Asthma Risk factors: other environmental factors

A

_ Smoking
_ Obesity
_ Use of antibiotics

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9
Q

What are the major characteristics of asthma

A
  • airflow obstruction: Bronchospasm, edema, mucous hypersecretion
  • bronchial hyper-responsiveness
  • airway inflammation
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10
Q

Pathophysiology of Asthma

A
  • Basement membrane is inflamed and have mucus plug

- Inflammatory cells induce submucosal edema or inflammation

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11
Q
  • Bronchoconstriction
  • occurs in minutes
  • mast cells
A

Immediate acute response

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12
Q

_ Submicosal edema, hyper-responsiveness

_ occurs in hours

_ inflammatory cells activation

A

Late acute response

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13
Q
  • epithelial cell damage, mucus hypersecretion, hyper-responsiveness
  • occurs within days
  • eosinophils and lymphocytes
A

Chronic asthma

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14
Q

Forced vital capacity

A

Volume of air that can be forcibly blown out after full inspiration

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15
Q

Forced expiratory volume one

A

Forced expiratory volume in one second

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16
Q

How is FEV1 represented

A

Percentage of the predicted

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17
Q

Spirometry

A

Measures FVC and FEV1

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18
Q

Peak expiatory flow

A

Measures maximum flow of an expelled in one forceful breath out in L/min

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19
Q

Used in conjunction with asthma action plan

Measures highest of 3 readings

A

Peak expiatory flow

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20
Q

What is the control-based asthma management cycle

A

Assess
Adjust
Review response

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21
Q

How is asthma symptoms graded

A

Intermittent to chronic

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22
Q

True/False: Asthma is always wheezing and wheezing is always asthma

A

False

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23
Q

How is asthma diagnosed

A

Patient history

Airway obstruction reversibility following SABA

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24
Q

What are the long-term management goals for asthma

A

Reduce impairment and risk:

Prevent chronic symptoms
Require infrequent SABA use
Maintain normal lung function and activity

Prevent exercebation
Minimize need for emergency care
Minimize ADR of therapy

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25
Q

Steps to asthmas diagnosis

A

Detailed history and examination for asthma

Perform spirometry and reversibility test

Confirm diagnosis

Treat for asthma

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26
Q

What is the normal FEV1/FVC ratio in healthy adults and children

A

Adults > 0.75-0.80

Children > 0.85

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27
Q

What is the bronchodilator reversibility and what is it used for

A

FEV1 increasing by > 200ml and > 12% of the baseline value after a bronchodilators

Used for asthma diagnosis

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28
Q

What FEV1/FVC ratio value used for asthma diagnosis

A

< 70%

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29
Q

What is another indication for asthma looking at the FEV1

A

FEV1 increasing by > 200ml and > 12% of the baseline value after 4 weeks anti inflammatory treatment

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30
Q

How is asthma symptom severity assessment classified?

A

Well controlled

Partly controlled

Uncontrolled

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31
Q

When is symptoms considered controlled?

Daytime Sx > 2x/week

Nighttime asthma waking

SABA needed > 2x/week

Any activity limitation due to asthma

A

No to any of the above

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32
Q

When is symptoms considered partly controlled?

Daytime Sx > 2x/week

Nighttime asthma waking

SABA needed > 2x/week

Any activity limitation due to asthma

A

Yes to 1 or 2 of the above

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33
Q

When is symptoms considered uncontrolled?

Daytime Sx > 2x/week

Nighttime asthma waking

SABA needed > 2x/week

Any activity limitation due to asthma

A

Yes to 3 or 4 of the above

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34
Q

GINA guideline for asthma control therapy:

symptoms less than twice a month

A

Preferred controller and reliever:

ICS-Formoterol prn

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35
Q

GINA guideline for asthma control therapy:

symptoms twice a month or more but less than daily

A

Preferred controller:

Low dose ICS daily
Or
Low dose ICS-formoterol prn

Preferred reliever:

Low dose ICS-formoterol prn

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36
Q

GINA guideline for asthma control therapy:

Symptoms most days
Waking with asthma once a week or more

A

Preferred controller:

Low dose ICS-LABA

Preferred reliever:

Low dose ICS-Formoterol

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37
Q

GINA guideline for asthma control therapy:

Symptoms most days
Waking with asthma once a week or more
Low lung function ( PEF < 80%)

A

Preferred controller:

Medium dose ICS-LABA

Preferred reliever:

Low dose ICS-Formoterol prn

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38
Q

When can oral corticosteroids be added to asthma therapy

A

When patient has severe uncontrolled asthma

PEF < 60%

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39
Q

What is the characteristics of metered dose

A

Contain medication + propellant

Delivers 5-50% of actuated dose

Must be shaken

Slow, deep inspiratory flow

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40
Q

What is the characteristics of dry powder inhalers?

A

Its breath actuated

Does not require hand-breath coordination to operate

Inspiratory flow is deep and forceful

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41
Q

Which group of patients should use spacers

A

Patient using metered dosing inhalers

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42
Q

What is the benefit of spacers

A

Decreases oropharyngeal deposition

Can help decrease side effect: hoarseness and thrush

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43
Q

How should spacers be cared for

A

Wash weekly with dilute detergent

Single rinse

Drip dry

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44
Q

Albuterol and Levalbuterol

A

SABA reliever

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45
Q

Symbicort ( budesonide + formoterol )

A

ICS + formoterol reliever

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46
Q

Dulera (mometasone + formoterol)

A

ICS + formoterol reliever

47
Q

Prednisone or prednisolone

A

Oral corticosteroids reliever

48
Q

Commonly used controller

A

ICS

ICS + LABA

Leukotriene modifiers

49
Q

Symbicort

Dulera

Advair ( fluticasone + salmeterol)

A

Commonly used ICS+LABA controllers

50
Q

Montelukast, zileuton, zafirlukast

A

Commonly used leukotriene modifiers controllers

51
Q

Cromolyn and nedcromil

A

Infrequently used mast stabilizers controller

52
Q

Theophylline, aminophylline

A

Infrequently used methylxanthines controllers

53
Q

Anti-IgE, Anti-IL5, Anti-IL4R

A

Infrequently used biologics controller

54
Q

First line of therapy for acute exacerbation

A

SABA

55
Q

How is SABA dosed

A

As needed

56
Q

ADR of SABA and LABA

A

Tachycardia

Tremor

Headache

Hypokalemia

Hyperglycemia

57
Q

R isomer of Albuterol with less side effect

A

Levalbuterol

58
Q

Bronchodilators

A

SABA

59
Q

SABA advantage

A

Most effective for reversal of acute exacerbation

Inhaled less systemic ADR

Tolerance to side effect can develop

60
Q

SABA disadvantage

A

No anti-inflammatory effect

Ineffective against nocturnal Asthma

Continuous use can lead to hyper-responsiveness in patients with severe cases

Tolerance can develop

Continuous overuse can confuse with preventative

61
Q

Traditional therapy for patients with newly diagnosed or mild Asthma

A

Albuterol

62
Q

Oral should not be used for Asthma

A

Albuterol

63
Q

How is Albuterol dosed

A

2.5 mg = 1 nebulizer dose = 4 puffs MDI

64
Q

How long should one Albuterol MID last?

A

One month

65
Q

First line for maintenance therapy

A

ICS

66
Q

What is the emerging place in therapy:

prevention of exercise induced Bronchospasm

relief of acute exacerbation

A

Low dose ICS+ formoterol

67
Q

How is ICS+ formoterol dosed

A

Twice daily

68
Q

ICS ADR

A

Oral candidiasis

Dysphonia

Cough

Osteoporosis

Skin thinning

Increased bruising

Hypothalamic pituitary axis suppression

69
Q

LABA

A

Salmetorol or formoterol

70
Q

Maintenance therapy in combo with ICS

A

LABA

71
Q

Emerging therapy for:

Preventing exercise induced Bronchospasm

Relief of acute exacerbation

A

Formoterol

72
Q

How are LABA dose

A

Twice daily

73
Q

What is the black box warning for using LABA alone

A

Slight increased death risk

74
Q

What are recommendations for using salmeterol

A

Do not use as only long term medication

Maximize ICS prior to addition of salmeterol

Moderate and severe persistent Asthma

75
Q

80mcg/4.5mcg two puffs twice daily

A

Low dose Symbicort

76
Q

100mcg/50mcg one puff twice daily

A

Low dose Advair diskus

77
Q

45mcg/21mcg two puffs twice daily

A

Low dose Advair HFA

78
Q

55mcg/14mcg

Or

113mcg/14mcg

One puff twice daily

A

Low dose Airduo Respiclick

79
Q

100mcg/5mcg two puffs twice daily

A

Low dose Dulera

80
Q

160 mcg/4.5 mcg 2 puffs BID

A

Medium dose Symbicort

81
Q

250 mcg/50 mcg 1 puff BID

A

Medium dose Advair Diskus

82
Q

115 mcg/21 mcg 2 puffs BID

A

Medium dose Advair HFA

83
Q

113mcg/14mcg one puff twice daily

A

Medium dose AirDuo RespiClick

84
Q

200mcg/5mcg two puffs twice daily

A

Medium dose Dulera

85
Q

What are the as needed low close ICS+formoterol?

A

Symbicort ( 80 mcg / 4.5 mcg 2 puffs PRN)

Symbicort ( 160 mcg / 4.5 mcg 1 puff PRN)

Dulera ( 100 mcg / 5 mcg 1 puff PRN)

86
Q

Oral alternative for mild and moderate persistent Asthma

Used for prevention of exercised induced bronchoconstriction

Allergen induced asthma / allergic rhinitis

Used as add on therapy

A

Leukotriene modifiers

87
Q

Monitor liver enzymes

A

Zileuton

88
Q

Take in the morning and doesn’t affect sleep at night.

mood, sleep or behavioral changes

A

Leukotrienes modifiers

89
Q

Short term use as “burst” therapy for exacerbation

Not routinely used as long term therapy

A

OCS

90
Q

What is OCS dosing

A

1-2 mg / kg / day with a max of 60 mg / day

Use lowest dose possible

91
Q

OCS ADR

A

Osteoporosis

Thin skin

Infection

Hyperglycemia

Fluid retention

Mood

92
Q

With each patient visit what should be reviewed

A

Medication

Technique

Adherence

93
Q

What are the 4 c’s to remember at every Patient visit

A

Choose

Check

Correct

Confirm

94
Q

What is considered severe or late symptoms

A

PEF or FEV1 <60% of best

Or

No improvement in symptoms after 48hours

95
Q

How should late or severe symptoms be managed?

A

Continue reliever

Continue controller

Add prednisolone 40-50mg/day

Contact doctor

96
Q

How long till follow up appointment for acute exacerbation

A

1-2weeks

97
Q

How long till follow up appointment while gaining control

A

2-6weeks

98
Q

How long till follow up appointment to monitor control

A

1–6months

99
Q

If anticipating step down how long till follow up with patient

A

Every 3 months

100
Q

What is a sustained step up in asthma therapy

A

Assessing asthma therapy for adjustment if symptoms or exacerbation persist despite 2-3 months controller treatment

101
Q

What is duration of short term step up

A

1-2 weeks usually during a viral infection or allergen exposures

102
Q

Which patient group require day to day adjustment

A

Patients using as needed low dose ICS+formoterol

for mild asthma (Step 1)

Or

As maintenance and reliever therapy (Step 2)

103
Q

When is step down therapy considered

A

Patient achieves good control for 3 months

104
Q

How should ICS based formulation be stepped down

A

Reduce ICS dose by 25-50% at 2-3months interval

105
Q

What are add on treatment in severe asthma cases for patient with good adherence and inhaler technique but still uncontrolled

A

Leukotriene receptor antagonist

Tiotropium

Low dose macrolides

Biologics agents

106
Q

What should you consider then considering using OCS for severe asthma cases

A

Avoid maintenance OCS if other options are available because of serious side effects

107
Q

What is the only adjunctive therapy in mild asthma

A

Mast cells stabilizers

3-4 times daily

108
Q

What group of people are more likely to have inflammatory phenotype

A

Those with persistent symptoms or exacerbation despite high dose ICS, good adherence and inhaler technique

109
Q

How do you step down for patient on high or moderate dose ICS-LABA as maintenance

A

Reduce ICS dose by 50%

110
Q

How do you step down patient on medium dose ICS-formoterol as maintenance and reliever

A

Switch to low dose for maintenance and continue as needed low dose reliever

111
Q

How do you step down patient on low dose ICS-LABA or ICS-formoterol as maintenance

A

Reduce to once daily instead of twice daily

112
Q

How do you step down patient on low dose ICS alone

A

Consider once daily dose ICS

Or

Switch as needed low dose ICS-Formoterol

Consider adding LTRA

113
Q

How do you step down low dose ICS OR LTRA

A

Switch to as needed low dose ICS-formoterol

Pharmacotherapy (12 decks)

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