Asthma Drugs Flashcards
As needed
Reduces exacerbation risk compared SABA alone
Max dose of fast acting LABA component: 72 mcg
ICS + Formeterol
As needed
Quickly reverses bronchodilation
SABA
IV or PO used for exacerbation or asthma that is difficult to control
Systemic steroids
Reliever available OTC but not part of GINA guidelines
Inhaled epinephrine
Can be used in combination with SABA to control exacerbation
SAMA
Preferred anti-inflammatory and first line agent for all asthma patients
ICS
Preferred add-on to ICS but avoid as monotherapy
LABA
Can be used as add-on if LABA cannot be used
Can be added to an ICS-LABA
Preferred in children
Oral Leukotriene Receptor Antagonist
As add-on to ICS-LABA if history of excerbation
LAMA
For specific asthma type
Monoclonal antibodies
Not preferred agent due to increased ADR, DI and need for level monitoring
Theophylline
Monoclonal for severe allergic asthma
Omalizumab
For severe eosinophollic asthma
Mepolizumab
Reslizumab
Benralizumab
Dupilumab
Step 1 treatment
Prn ICS-Formoterol
Or
Prn SABA+ low-dose ICS
Step 2 treatment
Prn ICS-Formoterol
Or
SABA (reliever) and Low dose ICS (controller)
Step 3 treatment
Low dose ICS-Formoterol (R and C)
Or
SABA (R) and low dose ICS-LABA (C)
Step 4 treatment
Low dose ICS-Formoterol (R) and medium dose ICS-Formoterol (C)
Or
SABA (R) and medium dose ICS-LABA (C)
Step 5 treatment
Referral
Low dose ICS-Formoterol (R) and high dose ICS-Formoterol (C)
Or
SABA (R) and high dose ICS-LABA (C)
Maintain current regemen
Or
Step down if at least 3 months of control
Well-controlled
Step up 1 step
Partly controlled
Step up 1-2 steps +/- short course oral steroids
Uncontrolled
Proair (HFA, Respiclick, Digihaler)
Proventil HFA
Ventolin HFA
Albuterol
1-2 puffs every 4-6 hr prn
Albuterol
Available PO but not recommended
Albuterol
Albuterol dose/inhalation
90 mcg
R-isomer of albuterol
Levoalbuterol
Shake SABA HFA products
Yes
Xopenex (Concentrate, HFA)
Xopenex
Levoalbuterol
SABA not used due to non-selectivity for beta receptors
Inhaled epinephrine
Asthmaneferin
Inhaled epinephrine
Warning:
CVD
Glaucoma
Hyperthyroidism
Hyperglycemia
Seizures
Beta agonist
Serevent diskus (DPI)
Salmeterol
Increased risk of asthma related death and hospitalization
Slameterol
( use with ICS)
QVAR Redihaler (MDI)
Beclomethasone
Pulmicort (Flexhalers, Respule) DPI
Budesonide
Symbicort
Budesonide + Formoterol
Flovent (HFA, Diskus)
Arnuity Ellipta (DPI)
ArmonAir Digihaler (DPI)
Fluticasone
Advair (Diskus, HFA)
Airduo (Respiclick, Digihaler)
Wixela Inhub
Fluticasone + Salmeterol
Breo Ellipta
Fluticasone + Vilanterol
Asmanex
Mometasone
Dulera
Mometasone + Formoterol
Alvesco
Ciclesonide
Contraindicated in Status asthmaticus and acute asthma episodes
ICS
Immunosuppression
Growth retardation
Increase Fracture risk
Adrenal insufficiency
Oral thrush
Dystonia
ICS
ICS does not require shaking
QVAR and Alvesco
Only ICS nebulizer
Budesonide
Use jet nebulizer
Records and stores its own data
Armonair and Airduo digihalers
LAMA indicated for asthma use
Tiotropium
Spirivia respimat
Tiotropium
LAMA-LABA-ICS for asthma use
Trelegy ellipta
Trelegy ellipta
Umeclidinuim/Vilanterol/Flutocasone
Inhibits LTD4
Montelukast
Singulair
Montelukast
Inhibit LTD4 and LTE4
Zafirlukast
Accolate
Zafirlukast
5-lipooxygenase inhibitor. Inhibits leukotriene formation
Zileuton
Zyflo
Zileuton
Tablet, Chew, Packet
Montelukast
Approved for allergic rhinitis and EIB
Montelukast
Use 2hrs before exercise
Montelukast
> 14yrs: 10mg daily
6-14yrs: 5 mg daily
1-5yrs: 4mg daily
Montelukast
20mg BID
5-11yrs: 10mg BID
Zafirlukast
1hr before or 2hr after a meal
Zafirlukast
Not recommended for < 12yrs
Zileuton
Warning: Neuropsychiatric disorders
Montelukast
Hepatotoxicity
Zafirlukast
Zileuton
Granules can be mixed with soft food and used within 15 mins of opened
Montelukast
Dispense in original container
Zafirlukast
2C8/9 and 3A4 substrate
2C8/9 inhibitors
Gemfibrozil increases level
Lumefactor decreases level
Montelukast
2C9 substrate
2C8/9 inhibitors
Increase theophylline level
Erythromycin and theophylline increase level
Zafirlukast
1A2, 2C9, 3A4 substrate
1A2 inhibitors
Increase theophylline, propranolol and warfarin levels
Zileuton
Phosphodiesterase inhibitors= increased cAMP = release of epinephrine from adrenal medulla
Theophylline
Elixophyllin, Theo-24
Theophylline
Caffeine and 3-methylxanthine are active metabolites
Theophylline
Toxicity: persistent vomiting, arrhythmias, seizures
Theophylline
Therapeutic level: 5-15 mcg/ml
Drawn with peak at steady state or after 3 days if oral dosing
Theophylline
Requires loading dose at 5mg/kg of IBW
Theophylline
Aminophylline x 0.8
Aminophylline to Theophylline dose conversion
Theophylline/0.8
Theophylline to Aminophylline conversion
Major 1A2 and Minor 2E1 and 3A4 substrate
Theophylline
1A2 inhibitors will increase level
Cimetidine
Cipro
Fluvixamine
Propranolol
Zileuton
Theophylline
Drugs will increase theophylline level
Zafirlukast
Allopurinol
Alcohol
Estrogen
Methotrexate
Verapamil
Condition/Food will increase theophylline levels
CHF
Liver disease
High carb
Low protein
Condition/Food will decrease theophylline levels
Cystic fibrosis
Hyperthyroidism
Low carb
High protein
Inhibits muscarinic cholinergic receptors = reduction in vagal tone = bronchodilation
Anticholinergic
LAMA approved in asthmatic patients 6yrs or older with exacerbation history despite ICS-LABA
Tiotropium
Inhibits IgE binding to receptors of mast cell and basophil
Omalizumab
Xolair
Omalizumab
SC injections q2-4 weeks
Omalizumab
Approved for 6 yrs and older with severe asthma defined as a positive skin test of perennial aeroallergen or inadequate sx control at step 5
Omalizumab
First 3 doses administered under healthcare supervision
Self administration if no anaphylaxis after 3 doses and can properly treat anaphylaxis reactions with right injection techniques
Omalizumab
Warning includes: increase risk of CV and CNS ADR and malignancy
Omalizumab
Monitor baseline IgE level, s/sx of anaphylaxis
Omalizumab
Anaphylaxis reaction like with first dose or 1 year after initiation
Omalizumab
Cytokine responsible for eosinophilic activation in asthma patients
Interleukin
Interleukin 5 inhibitors
Mepolizumab
Reslizumab
Benralizumab
Nucala
Mepolizumab
Cinqair
Reslizumab
Fasenra
Fasenra pen
Benralizumab
Interleukin 3&4 inhibitors
Dupilumab
Dupixent
Dupilumab
Indicated for management of severe asthma with an eosinophillic phenotype
Mepolizumab
Reslizumab
Benralizumab
Dupilumab
6yrs and older
Once monthly SC injection
Mepolizumab
Adults
Once monthly IV injection
Warning: anaphylaxis
Reslizumab
12yrs and older
Once monthly SC for three doses then once every 2 montht
Benralizumab
12yrs and older
SC injection every other week
Dupilumab
Tezspire
Tezepelumab
(For asthma)
Take 5-15 mins before exercise
Duration 2-3h or 12hrs
SABA or ICS-Formoterol
Alternative to SABA in EIB
Take 30mins before
Salmeterol
2hrs before exercise
Duration 24hrs
Montelukast
Should be continued during pregnancy and preferred controller
ICS
Should last 30 days with a total of 60 inhalation
Advair diskus
Asmanex
Should last 30 days with a total of 120 inhalation
QVAR Redihaler
Should last 12 months with total of 200 inhalation
Albuterol MDI
Should last 3-4 months with total of 60 inhalation
Ventolin HFA
Time between each inhalation
60 seconds
Sequence of administration if more than one inhaler
Bronchodilator before ICS
(SABA —> LABA/LAMA —> ICS)
Wait 60 seconds before the next inhalation
Albuterol nebulizer concentration needs dilution in NS prior to use
0.5%
0.083% is ready to use no dilution necessary
Types of nebulizers
Jet
Ultrasound
Mesh
Do not use with spacers
DPI
MDI can be used with spacers
How often a spacer should be cleaned
Weekly
Personal best of a peak expiratory flow rate is measured with what device
Spirometry
Peak expiratory flow rate takes in account what factors
Age
Gender
Height
PEFR is muscle dependent
Developed for patient to manage asthma at home and minimize the risk of hospitalization due excerbation
Asthma action plan
When is peak flow best measured
In the morning with awakenings before inhaler administration
How is the peak flow meter cleaned
With warm water and soap only
At least weekly
What is green zone on peak flow meter
Within 80-100% of personal best
Indicates good control
Continue maintenance therapy as indicated
What is indicated by yellow zone on peak flow meter
Within 50-80% of personal best
Worsening lung function
Increase dose or add-on therapy
What is indicted by the red zone on a peak flow meter
< 50% of personal best
Medical emergency
Use rescue +/- steroids or ED admissions
When is steroids indicated in yellow zone
If sx persists and do not return to green zone after 1hr of rescue use
When should a patient seek medical emergency if in red zone
Still in red zone 15 minutes after rescue and oral steroids
Should not be cleaned by putting into water
Symbicort
Dulera
Budesonide ampules should be used within what timeframe of opening the aluminum package
2 weeks
