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NRS 271A: optho, pulm, GU, Renal, Heme/onc > Asthma and COPD Meds > Flashcards

Asthma and COPD Meds Flashcards

1
Q

Step 1 therapy for Asthma in Adults

A

sxs < 2x/month

  • Controller:
    • TAke ICS whenever SABA is taken
  • Reliever:
    • SABA
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2
Q

SABA

A

short acting beta agonist

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3
Q

Step 2 therapy for Asthma in Adults

A

sxs 2x/month + but less than 4-5days/week

  • Controller:
    • low dose maintenance ICS
  • Reliever:
    • PRN SABA
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4
Q

ICS

A

inhaled corticosteroid

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5
Q

Step 3 Therapy for Asthma in Adults

A

sxs most days, or waking with asthma once/week +

  • Controller:
    • low dose maintenance ICS-LABA
  • Reliever:
    • PRN SABA
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6
Q

LABA

A

long acting beta 2 agonist

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7
Q

LTRA

A

leukotriene receptor antagonist

i.e. singulair (montelukast)

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8
Q

Step 4 Therapy for Asthma in Adults

A

sxs most days, or waking with asthma once/week+, or low lung function

  • Controller:
    • medium/high dose maintenance ICS-LABA
  • Reliever:
    • PRN SABA
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9
Q

Step 5 Therapy for Asthma in Adults

A
  • Controller:
    • add on LAMA
    • refer for phenotypic assessment
    • +/- anti-IgE, anit-IL5/5R, anti-IL4R
    • consider high dose ICS-LABA
  • Reliever:
    • PRN SABA
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10
Q

Age for pediatric asthma tx

A

6-11 years old

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11
Q

Step 1 therapy for Asthma in Peds

A

sxs <2x/month

  • Controller:
    • low dose ICS whenever SABA is taken; or daily low dose ICS
  • Reliever:
    • PRN SABA
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12
Q

Step 2 Therapy for Asthma in Peds

A

sxs 2x/month+ but less than daily

  • Controller:
    • daily low dose ICS
    • other:
      • daily LTRA, or low dose ICS taken whenever SABA taken
  • Reliever:
    • PRN SABA
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13
Q

Step 3 Therapy for Asthma in Peds

A

sxs most days, or waking with asthma 1x/week+

  • Controller:
    • low dose maintenance ICS-LABA or medium dose ICS
    • Other:
      • low dose ICS + LTRA
  • Reliever:
    • PRN SABA
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14
Q

Step 4 Therapy for Asthma in Peds

A

sxs most days or waking with asthma 1x/week + AND low lung function

  • Controller:
    • medium dose ICS-LABA and refer for expert advice
    • other:
      • high dose ICS-LABA, or add on tiotropium or add on LTRA
  • Reliever:
    • PRN SABA
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15
Q

Step 5 Therapy of Asthma for Peds

A
  • Controller:
    • Refer for phenotypic assessment + add-on therapy. e.g. anti-IgE
    • other:
      • add-on anti-IL5, or add on low dose OCS but consider side-effects
  • Reliever:
    • PRN SABA
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16
Q

SABAs

A

Short acting beta-2 agonists

  • albuterol
  • levalbuterol
  • metaproterenol
  • Terbutaline
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17
Q

Albuterol (Proventil-HFA; Proair-HFA)

A

SABA: MDI and neb

  • dosing: 2puffs Q4-6hours (90mcg/puff)
  • stimulates beta-2 receptors = bronchial muscle relaxation
  • SEs: HypoK especially during continuous neb
    • beta-2 stimulation causes cellular uptake of K+ = decreased srum K+
    • also tachycardia (because not very selective and will stimulate beta-1 receptors)
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18
Q

Levalbuterol (Xopenex-HFA)

A

SABA: MDI and neb

  • steroisomer of albuterol, but higher affinity for beta-2 so less sysstemic sympathetic effects = b/c less binding to beta-1
  • SEs: HypoK
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19
Q

Metaproterenol (Alupent)

A

SABA: PO

  • SEs: palpitations
    • tachycardia
    • hypoK
    • tremor
    • HA, nausea, nervousness
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20
Q

Terbutaline

A

SABA: PO or pareneteral (SQ injection)

  • often used for acute attack (0.25mg SubQ)
  • SEs:
    • SABA
    • tocolytic
    • not approved for children <6yo
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21
Q

LABAs

A

long acting beta-2 agonists

  • salmeterol DPI (Serevent Diskus)
  • Formoterol DPI (Foradil)
  • Arformoterol (Brovana)
    • not for kids
  • Indacaterol (Arcapta)
    • not for kids
  • Olodaterol (striverdi Respimat)
  • (Some Fish Are Inherently Odorous)
22
Q

Salmeterol DPI (Serevent Diskus)

A

LABA

do not use as monotherapy

  • partial agonist
23
Q

Formoterol DPI (Foradil)

A

LABA

  • helpful for nighttime sxs
  • full agonist
  • onset = to that of albutero but DO NOT USE FOR ACUTE BRONCHOSPASM
  • SEs: paradoxical bronchospasm
24
Q

Arformoterol (Brovana)

A

LABA: neb

  • used for COPD only!!
  • 2x more potent than formoterol
  • SEs:
    • ​paradoxical bronchospasm
    • palpitation/tachy/tremor
    • lightheadedness/nervousness/HA/nausea
    • NOT APPROVED FOR CHILDREN
25
Q

Indacaterol (Arcapta)

A

LABA: DPI

  • for COPD
  • SEs:
    • paradoxical bronchospasms
    • palpitations/tachy/tremor
    • nervousness/lightheadedness/HA/nausea
    • NOT APPROVED IN CHILDREN
26
Q

Olodaterol (Striverdi Respimat)

A

LABA: inhaler

  • Long half life!! t1/2 = 45hours
  • 2C9 substrate = increased side SEs
    • plus Same SEs as other LABAs
27
Q

Inhaled Corticosteroids (ICS)

A

MOA: inhibit inflammatory cells (mast cell, eosinophils, neutrophils) and cytokines (histamine, leukotriens)

**Flat dose response curve = double the dose adds limited additional effect **

BID Dosing is better (need more in smokers)

  • Beclomethasone HFA (QVAR)
  • Budesonide DPI (Pulmicort)
  • Ciclesonide (Alvesco)
  • Fluticasone HFA (Flovent)
  • Fluticasone DPI (Flovent Diskus)
  • Flunisolide (Aerobid)
  • Mometasone DPI (Asmanex)
  • SEs:
    • oral candidiasis
    • cough
    • Dysphonia
    • Adrenal Suppression (at high dose)
28
Q

Omalizumab (Xolair)

A

monoclono- anti-IgE antibody

  • stops release of inflammatory mediatorys
    • used for moderate to severe asthma
  • significantly reduces ICS use
  • SQ injection
  • SEs:
    • injection site rxn, bruising, redness, pain, stinging, itching etc
    • anaphylaxis (rare)
      • monitor 2 hours after injection for 3 months then 30 min thereafter
29
Q

Combined ICS/LABA

A
  • Fluticasone/Salmeterol (Advair) DPI
  • Fluticasone/Vilanterol (Breo Ellipta)
    • +3A4 inhibitors (both advair and breo) = increased LABAs = QT prolongation
  • Budesonide/Formoterol HFA (Symbicort)
  • Mometasone/Formoterol (Dulera)
  • SEs: Thrush
    • dysphonia
    • pharyngitis
    • HA
    • nausea
    • tremor
30
Q

GOLD 1-4

A

for COPD

  • Gold 1: FEV1 >80%
    • mild
  • Gold 2: FEV1 50-79%
    • moderate
  • Gold 3: FEV1 30-49%
    • severe
  • Gold 4: FEV1 <30%
    • very severe
31
Q

ABCD categorization of COPD

32
Q

Stage A COPD Tx

A
  • First Line:
    • SABA prn or SAMA prn (bronchodilators)
  • Second Line:
    • LAMA or LABA or SABA + SAMA
33
Q

Stage B COPD Tx

A
  • First line:
    • LAMA or LABA (long acting bronchodilators)
  • Second Line:
    • LAMA + LABA
34
Q

Stage C COPD Tx

A
  • First line:
    • ICS + LABA or LAMA
  • Second Line:
    • LAMA + LABA
      • LAMA + PDE4i
      • LABA + PDE4i
35
Q

Stage D COPD Tx

A
  • First Line:
    • ICS + LABA and/or LAMA
  • Second Line:
    • ICS + LABA and LAMA
    • ICS + LABA and PDE4i
    • LAMA + LABA
    • LAMA + PDE4i
36
Q

Phosphodiesterase (PDE)-4 inhibitors

A

inhibit breakdown of cAMP = reduction of inflammation

Roflumilast (Dalirespt)

  • for prevention of COPD
  • SEs:
    • diarrhea, decreased appetite, weight loss, abdominal pain
    • headache, insomnia
    • anxiety and depression
  • DDI: CYP 1A2 and 3A4
    • inducers: butalbital, phenytoin, rifampin, carbamazepine (avoid use)
    • inhibitors: amiodarone, clarithromycin, cimetidine, ketoconazole (use with caution)
37
Q

Most common bacterial organisms associated with mild exacerbation of COPD and More Severe COPD

A
  • Mild:
    • strep pneumo, H.flu, Moraxella
  • Severe:
    • E.coli, Klebsiella, enterobacter, pseudomonas
38
Q

Pseudomonas risk factors

A
  1. 4 or more courses of abx over the past year
  2. recent hospitalization (2+ days in past 90)
  3. isolation of pseudomonas during a previous hospital visit
  4. severe underlying COPD
    1. FEV1<50
39
Q

Mepolizumab (Nucala)

A

monoclondal antibody that targets IL-5

  • IL-5 stimulates matural and release of eosinophils in bone more = inflammation
  • Indication: maintenance tx of severe asthma age >/=12 yo
  • SEs:
    • anaphylaxis, angioedema, bronchospasm, hypotension, urticaria, rash
    • herpes zoster has occurred: IZ if appropriate prior to starting therapy
40
Q

Reslizumab (Cinqair)

A

monoclonal antibody against IL-5

  • indications: add on maintenance tx with severe asthma for >/= 18 yo and an eosinophilic phenotype
  • IV infusion only
  • SEs:
    • anaphylaxis, malignancy
    • CPK electation = adverse muscle related rxns
    • oropharyngeal pain
41
Q

Methylxanthines

A

theophylline

inhibit phosphodiesterase = bronchodilation

  • less effective than ICS
  • narrow therapeutic index 5-15mcg/mL
  • metabolized by CYP 1A2 and 3A4
    • DDI: inducers: carbamazeine, phenytin, rifampin, ST. John Wort
      • inhibitors: clarithromycin, telithromycin, ketoconazole, itraconazole, voriconazoe, grape fruit juice
    • SEs:cardiac arrhythmias, seizures
42
Q

LAMAs

A

long acting muscarinic antagonists

  • Tiotroprium
  • alcidinium
  • glycopyrrolate
  • Umeclidinium
43
Q

SABA + Anticholinergic

A
  • Albuterol/Ipratroprium (Combivent Respimat)
  • Duoneb
  • SEs: paradoxical bronchospasm
    • palpitations/tremor/tachy
    • CONTRAINDICATION: soy or peanut allergy
    • NOT for Children
44
Q

Leukotriene Inhibitors

A

only for asthma (LTRA)

  • montelukast (Singulair)
  • Zileuton (Zyflo)
    • SEs: hepatotoxicity
    • DDIs:
      • inducers: rifampin, carbamazepine, St. John’s wort
      • inhibitors: fluconazole, amiodarone, fluvoxamine, metronidazole, voriconazole
45
Q

Omalizumab (Xolair)

A

immunomodulator (anti-IgE antibody)

  • inhibits biding of IgE onto mast cells and basophils = stops release of inflammatory mediators

mainly used in COPD, but also for moderate-severe asthma

  • SQ injects Q2-4 weeks in clinic, must be observed 2 hours after injection x 3months, then 30 min thereafter.
    • significantly reduces use of ICS
46
Q

Abx for COPD exacerbation outpt (⅓ cardinal sxs)

A

Mild, no abx needed

cardinal sxs: increased dyspnea, sputum volume, or purulence

47
Q

Abx for COPD exacerbation outpt (⅔) no risk factors

A

macrolide

2nd and 3rd gen ceph

doxy

Septra (TMP/Sulfamethoxazole)

48
Q

Abx for COPD exacerbation outpt (⅔ cardinal signs) with risk factors

A

respiratory FQs (moxi/levo/gemi)

Amoxicillin/Clavulanate (Augmentin)

49
Q

Abx for COPD exacerbations in hospital (⅔ of cardinal) with risk factors for pseudomonas

A

FQ (levo PO or IV)

Cephalosporins (Cefepime IV or Ceftazidime IV)

Zosyn IV (piperacillin + tazobactam)

50
Q

Abx for COPD exacerbations in hospital (⅔ cardinal) with no pseudomonas risk

A

FQ (levo or Moxi)

Cephalosporins (ceftriaxone or cefotaxime)

51
Q

Complicated COPD

A

FEV1<50%

age >65

>/= 3 exacerbations/year

cardiac disease

NRS 271A: optho, pulm, GU, Renal, Heme/onc (10 decks)

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