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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
Indacaterol (Arcapta)
LABA: DPI * for COPD * _SEs_: * **paradoxical bronchospasms** * palpitations/tachy/tremor * nervousness/lightheadedness/HA/nausea * **NOT APPROVED IN CHILDREN**
26
Olodaterol (Striverdi Respimat)
LABA: inhaler * **Long half life!!** t1/2 = 45hours * *2C9 substrate =* increased side SEs * plus Same SEs as other LABAs
27
Inhaled Corticosteroids (ICS)
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
Omalizumab (Xolair)
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
Combined ICS/LABA
* 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
GOLD 1-4
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
ABCD categorization of COPD
32
Stage A COPD Tx
* First Line: * SABA prn or SAMA prn (bronchodilators) * Second Line: * LAMA or LABA or SABA + SAMA
33
Stage B COPD Tx
* First line: * LAMA or LABA (long acting bronchodilators) * Second Line: * LAMA + LABA
34
Stage C COPD Tx
* First line: * ICS + LABA or **LAMA** * Second Line: * LAMA + LABA * LAMA + PDE4i * LABA + PDE4i
35
Stage D COPD Tx
* First Line: * ICS + LABA and/or LAMA * Second Line: * ICS + LABA and LAMA * ICS + LABA and PDE4i * LAMA + LABA * LAMA + PDE4i
36
Phosphodiesterase (PDE)-4 inhibitors
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
Most common bacterial organisms associated with mild exacerbation of COPD and More Severe COPD
* Mild: * strep pneumo, H.flu, Moraxella * Severe: * E.coli, Klebsiella, enterobacter, pseudomonas
38
Pseudomonas risk factors
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
Mepolizumab (Nucala)
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
Reslizumab (Cinqair)
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
Methylxanthines
**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
LAMAs
long acting muscarinic antagonists * Tiotroprium * alcidinium * glycopyrrolate * Umeclidinium
43
SABA + Anticholinergic
* Albuterol/Ipratroprium (Combivent Respimat) * Duoneb * _SEs_: paradoxical bronchospasm * palpitations/tremor/tachy * **CONTRAINDICATION: soy or peanut allergy** * NOT for Children
44
Leukotriene Inhibitors
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
Omalizumab (Xolair)
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
Abx for COPD exacerbation outpt (⅓ cardinal sxs)
Mild, no abx needed cardinal sxs: increased dyspnea, sputum volume, or purulence
47
Abx for COPD exacerbation outpt (⅔) no risk factors
macrolide 2nd and 3rd gen ceph doxy Septra (TMP/Sulfamethoxazole)
48
Abx for COPD exacerbation outpt (⅔ cardinal signs) with risk factors
respiratory FQs (moxi/levo/gemi) Amoxicillin/Clavulanate (Augmentin)
49
Abx for COPD exacerbations in hospital (⅔ of cardinal) with risk factors for pseudomonas
FQ (levo PO or IV) Cephalosporins (Cefepime IV or Ceftazidime IV) Zosyn IV (piperacillin + tazobactam)
50
Abx for COPD exacerbations in hospital (⅔ cardinal) with no pseudomonas risk
FQ (levo or Moxi) Cephalosporins (ceftriaxone or cefotaxime)
51
Complicated COPD
FEV1\<50% age \>65 \>/= 3 exacerbations/year cardiac disease

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

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