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243 FINAL > Asthma IV: Pharmacotherapy > Flashcards

Asthma IV: Pharmacotherapy Flashcards

1
Q

asthma goals of pharmacotherapy (1 main, 3 small)

A

maintain asthma control with the minimum amount of medication (lowest effective dose) necessary and
result in the least amount of side effects.
• Prevent or minimize asthma symptoms
• Restore lung function to best resultspossible
• Minimize risk of asthma-related death

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2
Q

Short-Acting β2-Agonists (SABAs)

Type / Class of Medication
AE (3)

A
  • Bronchodilators
  • Used as relievers
  • Tremors or shakiness
  • Nervousness
  • Tachycardia / palpitations
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3
Q

Short-Acting β2-Agonists (SABAs)

Purpose / MOA

A

• Relaxes the muscles around the bronchi to relieve
bronchoconstriction.
• Work within ~20 minutes, last ~4-6 hrs
• Provides temporary relief of symptoms, including cough, chest tightness, dyspnea, and wheeze.

  • prophylactically for physical activity, cold air
  • 10 min before exposure of known triggers (sign of poorly controlled asthma)
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4
Q

Short-Acting β2-Agonists (SABAs)

additional notes
what is it intended for?
overuse associated with?

A

SABA-only treatment is no longer recommended, even in well controlled asthma
• Intended for PRN use only; regular use is not recommended and is an indication of poorly- controlled asthma

Regular use (overuse) is associated with
• Increased tolerance
• Airway sensitivity
• Morbidity / mortality

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5
Q

Short-Acting β2-Agonists (SABAs)

drugs
name 4

A

Ventolin® salbutamol - MDI, diskus, nebules, tabs (discont’d)
Airomir® salbutamol - MDI
Bricanyl® terbutaline - turbuhaler
orciprenaline - syrup (less common)

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6
Q

Inhaled Corticosteroids (ICSs)

Type / Class of Medication
AE (5)

A
  • Anti-inflammatories
  • Used as controllers
  • Mild fungal infections of the mouth / throat
  • “Thrush” or “oral candidiasis”
  • Voice changes / hoarseness that are reversible
  • Sore throat / sore mouth
  • Possible adrenal crisis (rare!)
  • With high doses, systemic side effects:
  • Osteoporosis, cataracts, skin thinning, growth reduction in children (~1 cm by adult age)
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7
Q

Inhaled Corticosteroids (ICSs)

Purpose / MOA

A
  • Treats airway inflammation
  • Treats mucus production
  • ICS are first-line controller therapy for all ages
  • ICS therapy takes up to 8 weeks before full clinical effect, although usually some benefit after 1 week
  • Helps prevent/minimize symptoms
  • Minimizes need for reliever therapy
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8
Q

Inhaled Corticosteroids (ICSs)
additional notes
which has less side fx

A
  • Ciclesonide is a prodrug that is biologically inert until activated by esterases in the lung to the active medication; it may have fewer topical side effects (thrush)
  • Requires daily use to control symptoms (reduce severe exac by 44%)
  • The risks associated with uncontrolled asthma are greater than risks associated with possible side effects
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9
Q 
Inhaled Corticosteroids (ICSs)
drugs
A

Alvesco® Ciclesonide - MDI
Arnuity® fluticasone Furoate - Ellipta
- Note: More potent and longer action than propionate

Flovent® fluticasone propionate - MDI, diskus
QVAR® Beclomethasone dipropionate - MDI
Pulmicort® Budesonide - turbulaher, nebules
- preferred in preg

Asmanex® mometasone - twisthalers

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10
Q

Long-Acting β2-Agonists (LABAs)

Type / Class of Medication
AE (4)

A
  • Bronchodilators
  • Used as controllers
  • Never on their own!!
  • Tremors
  • Tachycardia
  • Irritability
  • Insomnia
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11
Q

Long-Acting β2-Agonists (LABAs)

Purpose / MOA

A

• Longer duration of action than SABAs
• Indicated for patients whose asthma is not well-controlled on an ICS alone or…
• Indicated in ICS/LABA combination for those who
present with severe disease
• In either case, may reduce number of exacerbations

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12
Q

Long-Acting β2-Agonists (LABAs)

Additional notes

A
  • Not to be used as monotherapy

* May increase risk of asthma related death

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13
Q

Long-Acting β2-Agonists (LABAs)

drugs

A

Oxeze® *formoterol - turbuhaler
Note: Rapid onset, can be used as a reliever (prn) with ICS
Serevent® salmeterol - diskus

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14
Q

Combination ICS / LABAs

Type / Class of Medication
AE (4)

A
  • Combination bronchodilator and anti-inflammatory
  • Used as controller medications
  • Tremors
  • Palpitations
  • Mild fungal infections in the mouth and throat
  • Voice changes / hoarseness
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15
Q

Combination ICS / LABAs

Purpose / MOA

A

• Treats airway inflammation and relaxes muscles around the bronchi
• As mentioned, LABAs should only be used as add-on therapy (in combination) with ICS- controller
therapy
• formoterol can be used as an immediate reliever.

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16
Q

Combination ICS / LABAs

Additional notes

A

• In terms of systemic side effects, they can be similar to those of oral steroids, but less severe
▫ At high doses, over a long period of time, SE include bone weakening, cataracts, glaucoma, and skin thinning
 Generally, this would occur at >1000-1500mcg/day doses of beclomethasone or equivalent

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17
Q

Combination ICS / LABAs

drugs (4)

A

Advair® fluticasone propionate / salmeterol - MDI, disk
Symbicort® budesonide / formoterol - turbuhaler
The only combination product officially indicated for reliever use in patients >12

Breo® Vilanterol + Fluticasone furoate - Ellipta
Zenhale Formoterol + Mometasone - MDI

18
Q

Combination ICS / LABAs

what is the SMART Strategy

A

single maintenance and reliever therapy

  1. Let’s say a patient is on a medium dose of controller medication for maintenance of their asthma
    • i.e. Symbicort 200/6mcg ii puffs bid
  2. During this winter’s cold snap, they began to experience poor control of their asthma symptoms
    • The patient’s prescriber recommended they increase their Symbicort® use as follows:
    • Add 1 additional puff prn to a maximum of 8 total inhalations perday
19
Q

Long-Acting Muscarinic Antagonists
(LAMAs)

Type / Class of Medication
AE (5)

A
  • Bronchodilator
  • Controller medication
• Dry mouth
   - Rinse mouth to decr. dry mouth AE.
• Tremors
• Tachycardia / palpitations
• Urinary retention
• Increased intraocular pressure orblurred vision if in contact with the eye
20
Q

Long-Acting Muscarinic Antagonists
(LAMAs)

additional notes
what is it not intended for

A

Not intended for use as a reliever medication for acute bronchospasm

21
Q

Long-Acting Muscarinic Antagonists
(LAMAs)

drug (1)

A

Spiriva® tiotropium bromide - capsules for handihaler, respimat

22
Q

Short-Acting Muscarinic Antagonists (SAMAs)

Type / Class of Medication
AE (2)

A
  • Bronchodilator
  • Used as relievers if only option
  • Dry mouth
  • Glaucoma possible if in direct contact with the eye
23
Q

Short-Acting Muscarinic Antagonists (SAMAs)

Purpose / MOA

A
  • May be used as add-on therapy to β2- agonists for acute exacerbations
  • Compared to β2-agonists, SAMAs have a delayed onset of action but longer duration of action
  • Useful for patients who do not tolerate SABA side effects
  • unusually susceptible to tremor or tachycardia from beta2-agonist
24
Q

Short-Acting Muscarinic Antagonists (SAMAs)

Additional Notes

A
  • SAMAs are used more frequently for COPD
  • less commonly used for true “reliever” because of their delayed onset of action
  • useful in beta-blocker–induced bronchospasm
25
Q

Short-Acting Muscarinic Antagonists (SAMAs)

drug (1)

A

Atrovent® ipratropium - MDI

26
Q

Leukotriene Receptor Antagonists (LRTAs)

Type / Class of Medication
AE (3)

A
  • Leukotriene receptor antagonists
  • Used as a controller medication

Generally well tolerated
• Headache
• Abdominal pain
• Depression / nightmares

27
Q

Leukotriene Receptor Antagonists (LRTAs)

Additional notes

A

May be used in individuals who cannot / will not
use ICSs
• Second-line
• Add-on, especially in those with comorbid
rhinitis

May provide protection against bronchoconstriction when taken before exercise or allergen / cold air exposure

risk of neuropsychiatric events, suicdality (montelukast)

28
Q

Leukotriene Receptor Antagonists (LRTAs)

drug (1)

A

monteleukast Singulair® - granules or chew tabs

29
Q

Oral Corticosteroids

Type / Class of Medication
AE (short term, long term)

A
  • Anti-inflammatory
  • Used as controllers
Short-term
• Insomnia
• GI upset
• Mood swings / psychosis
• High BP / BG
• Fluid retention
Long-term
• Ulcers
• Impaired immune response
• Acne, diabetes, hypertension
• Increased fat production
30
Q

Oral Corticosteroids

Additional notes

A
  • Short-course therapy does not need to be tapered
  • Canadian guidelines suggest prednisone 25-50mg qd x 7-14 days
  • Minimizing the need for this treatment by optimizing other pharmacotherapy options is the goal
31
Q

Oral Corticosteroids

drugs

A

prednisone - tabs, syrups
methylprednisolone - tabs
Dexamethasone - tabs
- reduces emesis vs prednisone

32
Q

Immunotherapy

AE (3)
costly

A
  • Dizziness
  • Leg pain or fractures
  • Injection site reactions: Pain, redness, irritation
  • Not studied in children or pregnant / breastfeeding women
  • Must be supervised by an asthma or respiratory specialist
33
Q

Immunotherapy

drugs in Canada

A

• Omalizumab (Xolair®) a biologic.
• Used in allergic asthma. If IgE 30-700 IU/mL.
• Omalizumab is for patients aged 6 years and older with moderate to severe persistent Allergic Asthma who are uncontrolled on inhaled corticosteroids
(ICS).
• 150 – 375mg by subcutaneous injection every 2 to 4 weeks (dose based on patient factors)

34
Q

Biologics

AE (5)
Additional notes
• These products have not been studied in unique populations
Mepolizumab, reslizumab, or benralizumab if
eosinophillic asthma e.g. eosinophils >300-400
cell/uL.

A
  • Anaphylaxis
  • Injection site reactions
  • Headache, sore throat
  • Fever and/or infections
  • Back or abdominal pains
  • May be used as add-on maintenance therapy for patients with severe eosinophilic asthma
  • When patients are uncontrolled on medium- to high-dose ICS and LABA
  • Patients with parasitic infections should be treated for that condition first
35
Q

Biologics

Benralizumab
MOA
brand, formulation

A

Fasenra® - SC injection

anti IL-5
Eosinophils involved in the inflammatory process. This medication selectively binds to IL-5 receptors on eosinophils and basophils and induces apoptosis

36
Q

Biologics

Mepolizumab
MOA
brand, formulation

A

Nucala® - SC injection

IL-5 inhibitors

This IgG1 antibody binds with high affinity to IL-5 and prevents it from binding to eosinophils, decreasing survivability of eosinophils

37
Q

Biologics

Reslizumab
MOA
brand, formulation

A

Cinqair® - IV infusion

IL-5 inhibitors

Similar to mepolizumab, IgG4 antibodies bind to IL-5 and decrease survivability of eosinophils

38
Q

Biologics

Reslizumab
MOA
brand, formulation

A

Dupixent® - SC injection

anti-IL-4 & 13 inhibitor

39
Q

spacers
read for more

flu shots read slide

A

All children – kids aged under 4–5 years will need a mask attached

40
Q

Other - Theophylline, azithromycin

when is it used?
AE for azithromycin

A
  • Narrow therapeutic range, frequent adverse effects, & drug interactions limit use
  • 4th line due to systemic toxicity & only mild bronchodilator activity; useful as ‘add on’ agent in some requiring high-dose corticosteroids

azithromycin may decrease ex in > 18 yrs
500mg x 3 time a wk
Risk of incr. QT, resistance, & ototoxicty

243 FINAL (24 decks)

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