Asthma, Allergic Rhinitis, Anaphylaxis

Question 1

Asthma

Answer 1

Hyperresponsive airways (inflammatory condition)
-wheezing
-tight chest
-cough
-dyspnea
(Worse early morning) 

• constriction of smooth muscles
• chronic inflammation leading to narrowed airways
• overproduction of mucus

Question 2

Controllers in asthma

Answer 2

Anti-inflammatory and/or sustained bronchodilator action

• Inhaled, oral and IV corticosteroids
• Leukotriene receptor antagonists
• Cromolyns

Question 3

Beclomethasone

Answer 3

Inhaled corticosteroid
-controller

SE: dysphonia, oral candidiasis

Question 4

Oral corticosteroid indications

Answer 4

• poorly controlled asthma at high doses of ICS and controller medication
• rescue medication (to regain control of Sx)

Question 5

Leukotrine receptor antagonists

Answer 5

-Controller in asthma (oral agent)
-blocks receptor for cysteinyl leukotrines
(Leukotrines released from activated mast cells and eosinophils causing oedema, smooth muscle contraction and enhanced mucus secretion)

• prevent early and late bronchoconstrictor responses (allergens, aspirin sensitive asthma, exercise induced asthma)
• prevention of chronic asthma

Question 6

Sodium chromoglycate

Answer 6

• controller in asthma

- prevents histamine release form mast cells

Question 7

Long acting B2 agonists

Answer 7

-controllers: bronchodilators, but weak/unproven anti-inflammatory effect

Question 8

Relievers

Answer 8

SABA

Ipratropium bromide - anticholinergic

Question 9

Short acting B agonists mechanism

Answer 9

• stabilize mast cells (inhibit mediator release)
• enhance mucociliary clearance
• stimulate B2 receptors of airway smooth muscle

-may be used as sole therapy in mild intermittent asthma and exercise induced asthma

Question 10

Salmeterol

Answer 10

Long acting B2 agonist

-sustained bronchodilator action but weak/unproven anti-inflammatory effect

Question 11

Formoterol

Answer 11

Long acting B2 agonist

-sustained bronchodilator action but weak/unproven anti-inflammatory effect

Question 12

Corticosteroid side effects

Answer 12

Inhaled: dysphonia, oropharyngeal candidiasis

Systemic with oral

Question 13

Budenoside

Answer 13

Inhaled corticosteroid

-controller for asthma

Question 14

Ciclesonide

Answer 14

Inhaled corticosteroid

-controller in asthma

Question 15

Fluticasone

Answer 15

Inhaled corticosteroid (long acting!!)
-controller in asthma

-T1/2 = 14h (others ICS only 3h)

Question 16

Methylxanthines

Answer 16

Aka. Phosphodiesterase inhibitors
-Sustained release theophylline

-narrow therapeutic index NB

Question 17

Salbutamol

Answer 17

Short acting B2 agonist

-reliever in asthma

Question 18

Fenoterol

Answer 18

Short acting B2 agonist

-reliever in asthma

Question 19

Terbutaline

Answer 19

Short acting beta 2 agonist

-reliever in asthma

Question 20

B agonist side effects

Answer 20

• tachycardia
• irritability
• headaches
• tremor
• metabolic effects and hypokalemia in large systemic doses

Question 21

Long acting B2 agonist indications

Answer 21

-bd use with low dose ICS (NEVER MONOTHERAPY)

• control Sx
• reduce frequency of exacerbations

-useful for nocturnal Sx and exercise induced asthma

Question 22

Ipratropium bromide

Answer 22

Anticholinergic
-reliever in asthma

-used in pts who cannot tolerate B2 agonist SE (esp elderly)

• potent inhibitor of vagus-mediated bronchoconstriction
• not a preferred reliever, more useful in COPD

Question 23

Anticholinergic SE

Answer 23

• dry mouth
• nausea
• constipation
• tiotropium - may cause urinary retention in prostatism
• arrhythmias

Question 24

Theophylline

Answer 24

Phosphodiesterase inhibitor aka methylxanthine

-reliever in asthma

Question 25

Aminophylline

Answer 25

Phosphodiesterase inhibitor (aka methylxanthines)
-reliever in asthma

Question 26

Phosphodiesterase inhibitors mechanism

Answer 26

• inhibit enzymes that degrades cAMP -> increased cAMP lvls -> bronchodilation
• narrow therapeutic index

Question 27

GINA step 1

Answer 27

Controller: Consider low dose ICS

Reliever: SABA as needed

Question 28

GINA step 2

Answer 28

Controller: low dose ICS

Other controller options: Leukotriene receptor antagonist or low dose theophylline

Reliever: SABA

Question 29

GINA Step 3

Answer 29

Controller: Low dose ICS + LABA

Other controller options:
-med/high dose ICS
OR
-low dose ICS + leukotriene receptor antagonist / theophylline

Reliever:
-SABA as needed
OR
-low dose ICS/formoterol

Question 30

GINA Step 4

Answer 30

Controller: med/high dose ICS + LABA

Other controller option:
-Triotropium bromide, High dose ICS + leukotriene receptor antagonist (or theophylline)

Reliever:
-SABA as needed
OR
-low dose ICS/formoterol

Question 31

GINA step 5

Answer 31

Controller: refer for add-on Rx eg anti-IgE

Other controller options:
- add tiotropium bromide and low dose oral corticosteroids

Reliever:
-SABA as needed
OR
-low dose ICS/formoterol

Question 32

Asthma Rx plan

Answer 32

All pts: 2 puffs SABA as needed

All pts: ICS as baseline Rx

If not well controlled: add LABA (preferred over raising the ICS dose, never use LABA alone)

Alternative: double ICS dose, or add LTRA (montelukast) or PDI (theophylline)

Oral steroids and IgE therapy only to be used as maintenance with extreme caution

Question 33

1st Gen antihistamine SE

Answer 33

Dry mouth
Urinary retention
Tachycardia
Sedation
Weight gain
Constipation

Question 34

Antihistamine mechanism

Answer 34

Competitive antagonist at H1 receptor site

Question 35

Chlorpheniramine

Answer 35

1st gen antihistamine

Question 36

Fexofenadine

Answer 36

2nd gen antihistamine

Question 37

Levocetirizine

Answer 37

2nd gen antihistamine

Question 38

Promethazine

Answer 38

1st gen antihistamine