Asthma & COPD

Question 1

B2 Adrenergic Agonists

based on action at B2, why do you give for asthma?

Answer 1

Causes bronchodilation

Question 2

B2 Agonist Adverse Effects

Answer 2

Tachycardia
Hypokalemia
Hyperglycemia
Tremor
Tolerance
V/Q mismatch in COPD
Systemic = more side effects

Question 3

Short Acting B2 Agonists

Answer 3

Albuterol, Levalbuterol

Rapid onset
Rescue & routine use!
PO or inhaled (MDI or nebulizer)

Question 4

Long Acting B2 Agonists

Answer 4

Salmeterol, Indacaterol, Formoterol

NOT FOR RESCUE!
Black box warning: DON’t USE ALONE!
Use in combo w/inhaled corticosteroids for long term control & prevention of symptoms in moderate or severe persistent asthma

Question 5

Anticholinergics (Antimuscarinics)

Answer 5

MOA: inhibit muscarininc cholinergic receptors & reduce vagal tone of airway (inhibit constriction)
Substrates of CYP2D6 & 3A4
AE: Ipratropium & tiotropium
Dry mouth, dry eyes, urinary hesitancy, constipation, increased intraocular pressure (sympathetics)

Question 6

Ipratropium

short acting muscarinic antagonist - SAMA

Answer 6

Inhaled (alone or w/albuterol)

RESCUE medication in COPD or asthma when pts don’t tolerate SABAs

Question 7

Tiotropium

long acting muscarininc antagonist - LAMA

Answer 7

NOT a rescue!

Routine COPD or asthma treatment if B2 not tolerated

Question 8

Aclidinium (LAMA)

Answer 8

Long-term treatment of bronchospasm in COPD

Question 9

Theophylline

Answer 9

MOA: inhibits PDE and causes bronchodilation
Metabolized by CYP450 - smoking induces CYP450!!!
Very toxic! Not preferred in asthma. (zero order kinetics-time dependent elimination)
AE: nervousness, tremor, insomnia, GI distress, tachycardia, toxicity (N/V, seizures, hypotension, arrhythmia, death!)

Question 10

Cromolyn (mast cell stabilizer)

Answer 10

NOT a rescue!
Not bronchodilator but can prevent bronchoconstriction caused by challenge w/ antigen to which pt is allergic
Not absorbed (only local effects)
AE: cough and airway irritation
Preventive treatment prior to exercise

Question 11

Inhaled Corticosteroids

Answer 11

Budesonide, Fluticasone

NOT rescue!
Long term control
Substrate of CYP3A4

AE: local - oral candidiasis, dysphonia, cough (rinse & spit afterward to avoid)
systemic (Cushingoid) - growth retardation, osteomalacia, cardiac hypertrophy, poor wound healing, HPA supression, hyperglycemia

Question 12

To limit ICS toxicity

Answer 12

Lowest dose
Use spacer
Rinse & spit
Monitor growth
Consider osteoporosis risk

Question 13

Antibodies

Answer 13

Omalizumab - anti IgE for asthma

Prevents binding of IgE to high affinity receptors on basophils & mast cells

Question 14

Leukotriene Antagonists

Answer 14

Montelukast

NOT rescue!!
Prevent nocturnal symptoms of asthma
AE: psychiatric disturbances, headache, eosinophilia, vasculitis

Question 15

Magnesium Sulfate

Answer 15

IV admin for life-threatening exacerbation of asthma (rescue)

Question 16

Roflumilast

Answer 16

PDE4 inhibitor
For severe COPD w/ frequent exacerbations
AE: psychiatric events, weight loss, reduced appetite

Question 17

Alpha 1 antitrypsin

Answer 17

Only used for replacement in pts w/ congenital deficiency and evidence of emphysema