Asthma, COPD, smoking cessation Flashcards
Drugs that can cause PAH
cocaine
SSRI use during pregnancy (increase the risk of persistent PPHN)
weight loss drugs
methamphetamines/amphetamines
diagnosis
right heart catheterization is required to confirm PAH
Responder
-if MAP falls by at least 10 mmHg
-initially treated with CCB such as nifedipine, diltiazem, and amlodipine
non-responder
-prostacyclin analogs and receptor agonists
-endothelin receptor antagonists
-PDE-5 inhibitors
-soluble guanylate cyclase (sGC) stimulator
Prostacyclin analogs and receptor agonists
epoprostenol (Flolan, Velteri)
-continuous IV infusion
-vasodilation reactions (hypotension, flushing)
-risk of sepsis and blood stream infections from chronic infusions
-potent vasodilator; avoid interruption and sudden large dose reductions
-protect from light
Endothelian receptor antagonists
-bosenten, ambrisentan
-REMS: teratogenic and must have a negative pregnancy test before initiation and monthly thereafter
-hepatotoxicity with bosentan
PDE-5 inhibitors (PAH)
-Sildenafil (Revatio), Tadalafil (Adcirca)
-contraindication: use with nitrates and riociguat
-hearing loss, vision loss, hypotension, priapism
soluble guanylate cyclase stimulator
-riociguat (adempas)
-REMS: teratogenic and must have a negative pregnancy test before initiation and monthly thereafter
-contraindications: use with PDE-5 inhibitors
-hypotension
drugs that can cause pulmonary fibrosis
amiodarone/dronedarone
bleomycin
busulfan
carmustine
lomustine
FEV1
how much air can be forcefully exhaled in one second
FVC
after taking a deep breath, the maximum volume of air that is exhaled
FEV1/FVC
the percentage of air capacity that can be forcefully echaled in one second
asthma relievers
low-dose ICS + formoterol
inhaled SABA
systemic steroids
inhaled epi
inhaled SAMA
asthma controllers
ICS (first line for all patients)
LABAs (only to be used in combo)
oral leukotriene receptor antagonists (LTRAs)
theophylline (serum conc monitoring)
LAMAs
mAbs
Asthma: step 1: symptoms < 2x/month
PRN ICS + formoterol or SABA + low dose ICS
Asthma: step 2: symptoms or need for SABA > 2x/month
Rescue: PRN ICS + formoterol OR SABA w/ controller
Controller: low dose ICS
Asthma: step 3: symptoms on most days or waking at night > 1x/week
1: low dose ICS-formoterol (as rescue and controller)
2. SABA + low-dose ICS-LABA
Asthma: step 4: symptoms daily, waking at night > 1x a week, or initial presentation is with an exacerbation
- low dose ICS-formoterol + medium dose ICS-formoterol
- SABA + medium dose ICS-LABA`
Asthma: step 5
- low dose ICS-formoterol + high-dose ICS-formoterol
- SABA + high dose ICS-LABA
Asthma: SABA
albuterol (ProAir HFA)
-MDI/DPI
-nebs
-PO
-nervousness, tremor, tachycardia, palpitations, cough, hyperglycemia, decrease K
Asthma: ICS Inhalers
Salmeterol (serevent diskus), beclomethasone (QVAR Redihaler)
Budesonie (Pulmicort)
Budesonide + formoterol (symbicort)
Fluticasone (Flovent HFA/Diskus, Annuity)
Fluticasone + salmoterol (Advair Diskus)
Fluticasone + vilanterol (Breo Ellipta)
Mometasone + formoterol (Dulera)
Asthma: ICS
-increased risk of asthma-related events
-increased risk of hospitalizations in pediatric and adolescent patients
-dysphonia, oral candidiasis, cough
-rinse mouth
Controller inhalers: ICS
Asthma: Beclomethasone, Budesonide, Fluticasone
COPD: no single agent is FDA approved
Controller inhalers: LABA
Asthma and COPD: Salmeterol (Serevent Diskus)
Controller inhalers: LAMA
Asthma and COPD: tiotropium (sprivia respimat)
Controller inhalers: ICS/LABA
Asthma and COPD: symbicort, advair diskus, and breo ellipta
Asthma only: mometasone/formoterol (Dulera)
Controller inhalers: LAMA/LABA
Asthma: no FDA approval combination
COPD: anoro, stiolto, bevsi
Controller inhalers: LAMA/LABA/ICS
asthma and COPD: trelegy ellipta (umeclidinium/vilanterol/fluticasone)
MDIs
-HFAs, respimat, or no suffix
-aerolized liquid
-slow deep inhalation while pressing the canister
-a spacer can be used
-all products require shaking prior to use
-priming required before first use and if has not been used in a long time
DPIs
-diskus, ellipta, pressair, handihaler
-fine powder
-quick, forceful inhalation
-spacer cannot be used
-do not shake
-no need for priming unless it is flexhaler
LTRA: Montelukast
-dosed in the evening
-boxed warning for neuropsychiatric events
-granules can be mixed with food, breast milk/formula
Theophylline
-loading dose based on IBW
-the therapeutic range is 5-15 mcg/mL (measuring peak levels at steady state, after 3 days of oral dosing)
-converting aminophylline to theophylline * 0.8; to convert theophylline to aminophylline, divide by 0.8
-has saturable kinetics (first order > zero order)
Omalizumab (Xolair)
-inhibits IgE binding
-for moderate-severe persistent allergic asthma in patients > 6
-initiated in a healthcare setting under medical supervision
-administered every 2-4 weeks
interleukin receptor antagonists
-mepolizumab, reslizumab, and benralizumab (IL-5 receptor antagonists)
-Dupixent (IL-4 and IL-3 receptor antagonist)
exercised induced bronchospasm
SABA or low-dose ICS+formoterol taken 5-15 min before exercises
COPD GOLD
GOLD 1: mild; FEV1 > 80%
GOLD 2: moderate; 50% < FEV1 < 80%
GOLD 3: severe; 30% < FEV1 < 50%
GOLD 4: very severe; FEV1 < 30%
COPD: Group A
CAT < 10
mMRC 0-1
0-1 exacerbations leading to hospitalization
COPD: Group B
CAT > 10
mMRC > 2
0-1 exacerbations leading to hospitalization
COPD: Group C
CAT < 10
mMRC 0-1
> 2 or > 1 exacerbation leading to hospitalization
COPD: Group D
CAT > 10
mMRC > 2> 2 or > 1 exacerbation leading to hospitalization
COPD Group A treatment
-bronchodilator: SABA PRN or SAMA PRN
-LABA or LAMA
COPD Group B treatment
LAMA or LABA
COPD Group C treatment
LAMA
COPD Group D treatment
LAMA or LAMA + LABA (if highly symptomatic) or LABA + ICS (if eosinophils > 300 cells)
COPD: SAMA inhalers
-ipratropium bromide (atrovent) +/- albuterol (combivent respimat)
COPD: LAMA
-tiotropium (spirivia handihaler/respimat)
COPD: LABA
-salmeterol (serevent diskus) +/- fluticasone (advair diskus)
-formoterol +/- budesonide (symbicort)
-vilanterol + fluticasone (breo)
COPD: PD4 inhibitor
Roflumilast (Daliresp)
-CI: moderate-severe liver impairment
-diarrhea and weight loss
pack year smoking hx
= cigarette packs/day x number of years smoked
Nicotine patch (NicoDerm CQ)
initial dose based on the # of cigarettes smoked/day
Nicotine gum (Nicorette) and Nicotine lozenges (nicorette mini)
initial dose based on timing of the first cigarette smoked upon waking
NRT
-avoid in immediate post MI, arrhythmias, severe angina and pregnancy
-insomina, headache dizziness
-patch: vivid dreams
-combination with patch + gum/lozenge is most effective
-gum/lozenge: can delay/reduce weight gain, do not eat/drink 15 min before or during use
nicotine patch initial dosing: > 10 cigarettes/day
21 mg x 6 weeks then 14 mg x2 weeks then 7 mg x2 weeks
nicotine patch initial dosing: < 10 cigarettes/day
14 g x6 weeks then 7 mg x2 weeks
nicotine gum/lozenge initial dosing: first cigarette < 30 min upon waking
4 mg Q1-2H x6 weeks then 4 mg Q2-4H x3 weeks then 4 mg Q4-8H x3 weeks
nicotine gum/lozenge initial dosing: first cigarette > 30 min upon waking
2 mg Q1-2H x6 weeks then 2 mg Q2-4H x3 weeks then 2 mg Q4-8H x3 weeks
Bupropion SR (Zyban)
-start 1 week before the quit date
-boxed warning: suicidal thinking and behavior in children, adolescents, and young adults
-CI: seizure disorder, anorexia/bulimia, use of MAOi, linezolid or IV methylene blue
Varenicline (Chantix)
-start 1 week before the quit date
-serious neuropsychiatric events
-nausea, insomnia, abnormal dreams, HA
smoking cessation patient and they are worried about weight gain
gum, lozenge and bupropion
smoking cessation and they have depression
buproprion
smoking cessation and they suffer from seziures
do not use bupropion and varenicline
Patch and vivid dreams
can remove patch at bedtime (16 hours)
