Asthma and COPD Medications

Question 1

Two categories of asthma meds and differences

Answer 1

Drugs used to treat asthma are classified as controllers (maintenance), or relievers (rescue). Controllers are taken on a daily basis, chronically, to keep asthma symptoms under control, primarily by reducing inflammation. Rescue or reliever meds are used as needed to quickly reverse bronchoconstriction or preventatively for exercise-induced bronchospasm.

Question 2

Which asthma medications are generally classified as “controller” medications?

Answer 2

Long-acting medications and antiiflammatory medications

Question 3

Which asthma/COPD medications are classified as “rescue” medications?

Answer 3

Short-acting medications (beta-agonist bronchodilators and anticholinergics) and systemic steroids

Question 4

How do the goals of treatment differ in asthma vs COPD?

Answer 4

Asthma treatment seeks to primarily to normalize lung function and decrease the inflammation that causes attacks. COPD treatment cannot restore lung function as irreversible loss has occurred, so seeks to decrease symptoms.

Question 5

Glucocorticoids MOA

Answer 5

Block the cleavage of arachidonic acid from the plasma membrane which results in lower T cell activation and cytokine production

Question 6

Cromolyn sodium MOA

Answer 6

Stabilize mast cell membranes by blocking calcium influx, so no degranulation

Question 7

Leukotriene inhibitors examples

Answer 7

Montileukast and zafirleukast

Question 8

Leukotriene inhibitors MOA

Answer 8

Block the D4 leukotriene receptor, blocks major stimulus oh type 1 hypersensitivities. Downstream effects are lower Ca and increased cAMP, both leading to bronchial muscle relaxation

Question 9

What are SABAs and MOA

Answer 9

Short Acting Inhaled Beta 2 Agonists

Question 10

Side effects of SABAs

Answer 10

Tremor, lightheadedness, palpitations, hypokalemia, tachycardia, hyperglycemia.

When given in high doses or systemically, can cause arrythmias or cardiac muscle ischemia, and troponins (cardiac muscle proteins released in cardiac damage) are monitored while on high dose ihlaed or systemic continuous therapy in higher-risk patients.

Question 11

When to increase from a SABA to a new medication

Answer 11

If using SABA greater than two days per week

Question 12

Examples of SABAs

Answer 12

Albuterol, Levalbuterol (Levalbuterol is the L-isomer of albuterol and is indicated ONLY for patients who have a documented ventricular arrhythmia with standard albuterol.)

Terbutaline is an IV beta-2 agonist that is given to relax smooth muscle in severe asthma but can also be given in premature labor to relax uterine contractions.

Question 13

When are LABAs indicated

Answer 13

LABA should only be used in asthma patients as an adjunctive therapy in patients who are currently receiving but are not adequately controlled on an inhaled corticosteroid). Once asthma control is achieved and maintained for 3 months, assess the patient at regular intervals and step down therapy (discontinue LABA) if possible without loss of asthma control.

Question 14

Contraindications for LABAs

Answer 14

active coronary artery disease.

Question 15

LABA example

Answer 15

Salmeterol

Question 16

Anticholinergic MOA

Answer 16

They block the action of acetylcholine and decrease cGMP at parasympathetic sites in the bronchial smooth muscle causing bronchodilation and decreased mucus production.

Question 17

SAAB example

Answer 17

Short Acting Anticholinergic Bronchodilators (SAABs)

Ipratropium bromide: This is one of the most common meds you will see used for symptom control in COPD.

Question 18

Long acting anticholinergic example

Answer 18

Tiotropium

Question 19

Theopylline MOA

Answer 19

Mechanism: theophylline blocks phosphodiesterase causing increase cAMP which promotes release of epinephrine from adrenal medulla cells as well as bronchial smooth muscle relaxation. This results in bronchodilation, diuresis, CNS and cardiac stimulation and gastric acid secretion.

Question 20

Theophyline contraindications

Answer 20

Warnings: caution in patients with cardiovascular disease, hyperthyroidism, peptic ulcer disease and seizure disorder since use may exacerbate these conditions.

Question 21

Theophyline side effects

Answer 21

Side effects: same as caffeine: nausea, loose stools, headache, tachycardia, insomnia, tremor, and nervousness.

Question 22

Signs of theophylline toxicity

Answer 22

Signs of toxicity - persisted and repetitive vomiting, ventricular tachycardia, seizures.

Question 23

Magnesium MOA and admin

Answer 23

Magnesium Sulfate IV

It functions as a calcium channel blocker due to competitive inhibition for divalent cationic binding sites in smooth muscle, cardiac muscle, and membranes of electrical conduction systems throughout the body

Question 24

Magnesium side effects

Answer 24

. Side effects of this therapy are related to its effects on smooth muscle as well as membrane depolarization: nausea, vomiting, hypotension (we bolus patients with normal saline prior to giving magnesium to prevent this), and as patients get into the toxic range, decreased deep tendon reflexes and the rapid development of pulmonary edema.

Question 25

Inhaled corticosteroids examples

Answer 25

beclomethasone, budesonide, fluticasone

Question 26

First line treatment for asthma

Answer 26

Inhaled corticosteroids

Question 27

Inhaled corticosteroids contraindications

Answer 27

primary treatment of status asthmaticus or acute episodes of asthma or COPD. Inhaled corticosteroids are not for the relief of acute bronchospasm and oral steroids should be used if patients are in an asthma exacerbation.

Question 28

Side effects of inhaled corticosteroids

Answer 28

dysphonia (voice changes), oral candidiasis, hyperglycemia, increased risk of fractures and pneumonia (with high doses and long term)

Question 29

Patients on high dose inhaled steroids are at increased risk for severe outcomes with which viral infection?

Answer 29

Varicella, all should be vaccinated

Question 30

MOA of zileuton

Answer 30

Zileuton is 5-lipoxygenase inhibitor which inhibits leukotriene formation in the first place

Question 31

Uses for leukotriene modifiers

Answer 31

All agents help decrease airway edema, constriction and inflammation caused by leukotrienes. Based on their mechanism of action, they are also useful for co-suppression of allergic rhinitis!

Question 32

Side effects/warnings for leukotriene inhibitors

Answer 32

Warnings: psychiatric events, monitor for signs of aggressive behavior, hostility, agitation depression and suicidal thinking. Depression and suicide are a black box warning for this group of drugs and all patients should be warned at the time of prescribing.

Systemic eosinophilia, sometimes presenting the clinical features of vasculitis, can also occur.

Question 33

What monitoring must be done for zileuton

Answer 33

monitoring of LFTs every month for first three months, every 2-3 months for the rest of the first year of therapy.

Question 34

Cromolym sodium MOA

Answer 34

This drug is a nonsteroidal compound that stabilizes the plasma membranes of mast cells and eosinophils, preventing the degranulation and release of histamine, leukotrienes and other substances that cause airway inflammation.

Question 35

Cromolym sodium administration

Answer 35

The oral bioavailability is only 1%, but when administered by inhalation is major effect is exerted on the respiratory tract and very little is absorbed into the circulation

Question 36

Cromolym toxicities

Answer 36

Does not interact with other drugs and has a very low toxicities profile

Question 37

MOA of omalizumab

Answer 37

Omalizumab is an IgG monoclonal antibody that inhibits IgE binding to the IgE receptor on mast cells and basophils

Question 38

Major side effect with omalizumab

Answer 38

Anaphylaxis has occurred after the first dose but also has occurred beyond one year after beginning treatment. This means it is one of the few drugs you can anaphylax to THE FIRST TIME YOU TAKE IT

Question 39

Mepolizumab MOA

Answer 39

By blocking IL-5, This monoclonal antibody blocks major stimuli for the maturation, proliferation, recruitment, and activation of eosinophils.

Question 40

Roflumilast MOA

Answer 40

Roflumilast and its active metabolite are selective inhibitors of type four phosphodiesterase (PDE4) in lung tissue, thereby increasing intracellular levels of cAMP

Used only in COPD

Question 41

Indications of uncontrolled asthma

Answer 41

using albuterol > twice a week, any nighttime cough, daytime coughing spells more than twice a week, FEV1 <80% predicted

Question 42

All COPD patients should:

Answer 42

be counseled about quitting smoking at every visit and offered medication to assist with stopping smoking,

should be vaccinated annually in October against influenza,

should also be given the 23-valent pneumococcal polysaccharide vaccine against Strep pneumoniae at the time of diagnosis, regardless of season.