Asthma Maintenance Therapy

Question 1

“Older” ICS that are more commonly used

Answer 1

• Budesonide (comes in a nebulized suspension*)

- Fluticasone

Question 2

“Older” ICS that are less commonly used

Answer 2

• Beclomethasone

- Mometasone

Question 3

Newer ICS

Answer 3

Ciclesonide

• “ones” and “-ides”
• Prodrug that is activated in the lung so it causes less ADRs
• Smaller particle size to allow more to reach the lung

Question 4

ICS mechanism of action

Answer 4

• same as systemic steroids

- topical deposition minimizes systemic ADRs

Question 5

ICS indications

Answer 5

• 1st line agent for persistent asthma
• Give lowest dose that maintains asthma control –>may need to change seasonally

-most benefits acheived at LOW doses

Question 6

What should you do if a low dose ICS is not enough for adults?

Answer 6

• Increase to a medium dose or add a LABA

- Definitely add a LABA +/- leukotriene modifier before going to high dose ICS

Question 7

ICS pearls

Answer 7

-Most potent long-term controller of asthma symptoms

Question 8

ICS pt education

Answer 8

• Use a spacer
• Rinse your mouth after use and spit it out
• Takes 1-2 wks for full effect

Question 9

ICS CYP3A4 substrates

Answer 9

• Budesonide
• Fluticasone
• Ciclesonide

-minimal clinical implications

Question 10

ICS local ADRs

Answer 10

• dysphonia

- OP candidiasis (thrush)

Question 11

ICS systemic effects

Answer 11

• Increased intraocular pressure –> open angle glaucoma (monitor for in patients with FH of glaucoma)
• Increased risk for skin bruising or purpura

Question 12

LABA in Brigitte Schaefer’s Pronunciation

Answer 12

• Salmeterol

- Formeterol

Question 13

LABA MOA

Answer 13

• Long duration of action (>12 hrs), highly lipid soluble

- Formeterol is a full ag, salmeterol is a partial ag

Question 14

LABA indications

Answer 14

Add-on therapy for persistent asthma

Question 15

LABA Black box warning

Answer 15

Monotherapy is medical negligence, increases risk of severe asthma attacks and death

Question 16

Salmeterol Cyp interactions

Answer 16

• Sub of 3A4

- Strong inhibitors can cause ADRs (tachy, paplitations) esp in heart disease

Question 17

LABA ADRs

Answer 17

• Same as SABAs

- Tachy, palpitations, tremor possible

Question 18

LAMA

Answer 18

Tiotropium

Question 19

LAMA MOA

Answer 19

Long-acting muscarinic antagonist

Question 20

LAMA Indications

Answer 20

Use as an add-on to high dose ICS plus LABA if asthma still not controlled

Question 21

LAMA Interactions and ADRs

Answer 21

• Other anticholinergics -> increase ADRs

- Dry mouth most common, pharyngeal irritation

Question 22

Leukotriene Modifiers MOA

Answer 22

action of 5-liopoxygenase on arachidonic acid

Question 23

Leukotriene 5-lipoxygenase inhibitor

Answer 23

Zileuton (DO NOT USE, hepatotoxicity)

Question 24

Leukotirene Cysteinyl LTRA

Answer 24

• Montelukastorres

- Zafirlukast (DO NOT USE, hepatotoxicity)

Question 25

ADRs of Montelukastorres

Answer 25

- HA | - Rare neuropsych effects, monitor with pts and family

Question 26

Cromoglycates and include MOA

Answer 26

- Cromolyn | - Alter Cl channels and prevent mast cell degranulation

Question 27

Cromoglycates Indications

Answer 27

- Prophylactic only | - No effect on airway smooth muscle tone, ineffective in reversing bronchospasm

Question 28

Methylxanthines and include MOA

Answer 28

- Theophylline - Non specific inhibition of PDE - Bronchodilator at high serum conc, but anti-inflammatory effect at lower serum conc.

Question 29

Methylxanthines interactions

Answer 29

1A2 and 3A4, main 1A2 inhibitors = ciprofloxacin, amiodarone, OCPs, cimetidine

Question 30

RF for decrease theophylline clearance

Answer 30

- <1yo or >60yo | - Concurrent dz (CHF, fever >102, hypothyroid, liver dz)

Question 31

Methylxanthines ADRs

Answer 31

- 10mcg = increase pulm fxn, no ADRs - 15 to 20mcg = anorexia, NV, abd discomfort, HA, nervousness - >40mcg = decrease K, increase HR, neuromuscular irritability (seizures, arrhythmia, death)

Question 32

Anti-IgE Antibody

Answer 32

Omalizumab

Question 33

Anti-IgE MOA

Answer 33

Monoclonal Ab, binds to free IgE in circulation and blocks attachment to mast cells and basophils

Question 34

Anti-IgE Interactions

Answer 34

Approved for pts 6 yo and older with mod-severe persistent asthma with inadequate control by ICS

Question 35

Anti-IgE ADRs

Answer 35

- Injection site rxns | - Immediate and delayed anaphylaxis rare

Question 36

IL-5 Antibody

Answer 36

- Mepoluzimab - Reslizumab - Benralizumab

Question 37

IL-5 Antibody MOA

Answer 37

- Mepo and Resli: decreased survival of eosino/baso -> decrease airway inflammation - Benra = prevents IL-5 binding, apoptosis of eosi/baso through cell-mediated cytotoxicity- -> decrease airway inflammation

Question 38

IL-5 Antibody Indications

Answer 38

12yo and older who have eosinophilic phenotype

Question 39

IL-4 Antagonists

Answer 39

- Dupilumab | - Same indications as IL-5

Question 40

T/F: go low and slow wit drug titration

Answer 40

False, hit it early and hard

Question 41

Asthma and pregnancy

Answer 41

- SABAs: cat C - LABAs: cat C - ICS: cat B - Follow up monthly who those who have controller therapy during pregnancy