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pulmonology > asthma meds > Flashcards

asthma meds Flashcards

1
Q

what is the step up therapy approach?

A
  • start tx at step appropriate to asthma severity at time of eval: if not achieved gradually step up therapy until successful
  • gradually increase and add options
  • consider alt. explanations for poor asthma control
  • consider asthma specialist consult
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2
Q

What is the step down therapy approach?

A
  • tx exacerbation sxs aggressively
  • gradual reduction of long term control meds to lowest level possible to achieve max control
  • continue to attempt reduction of daily oral steroid use
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3
Q

What do quick relief meds do?

A
  • inhibit smooth muscle contraction

- these are Short acting b2 agonists

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4
Q

What do the long term control meds do? examples?

A
  • prevent and/or reverse inflammation (Most effective approach):
    anticholinergics, corticosteroids, mast cell stabilizing agents, leukotriene modifiers, methylanxthines
  • inhibit smooth muscle contraction: LABA
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5
Q

What are the different admin. techniques?

A
  • MDI: metered dose inhaler, releases specific amt of aerosolized particles, use a spacer
  • nebulizer: liquid medicine used in a machine, provides nebulized particles with moist continuous airflow. Ideal for peds or those unable to use MDI
  • inhaled powder: rotacaps, disc-haler, mechanical crushing of tablet or capsule releases powder for inhalation
  • systemic admin: oral or parenteral routes (SQ, IM, IV), generally assoc with more side effects
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6
Q

What are the sympathomimetics bronchodilators or B2 agonists?

A
  • produce airway dilation
  • stimulation of Beta-adrenergic receptors
  • activation of G proteins with resultant formation of cyclic AMP
  • decrease release of mediators
  • improve mucociliary transport
  • short acting: effective for acute attack (rescue) and prevention of exercise induced bronchospasm
  • long acting: effective for prevention and maintenance therapy
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7
Q

What is the most widely used B agonist?

A
  • albuterol (proventil, ventolin)
  • beta-2 selective
  • rescue med
  • active by all routes: inhalation increases bronchial selectivity, more rapid onset, oral and IV admin (offers no advantages over inhaled)
  • quick onset, lasts 4-6 hrs
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8
Q

What are the other short acting B 2 agonists?

A
  • Terbutaline (Brethine): also used to prevent uterine contractions
  • Bitolterol (Tornalate)
  • Pirbuterol (Maxair)
  • these are all similar to albuterol
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9
Q

What is usualy dosing for B2 agonists?

A
  • MDI: 2-4 puffs q 4-6 h and prn
  • increasing use more than 1 canister (200 puffs) per month signals lack of adequate asthma control
  • more frequent use associated with more adverse effects
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10
Q

What are the adverse effects of B-2 agonists?

A
  • tachycardia
  • tremor
  • hypokalemia
  • HA
  • hyperglycemia
  • increased lactic acid
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11
Q

What are the LABAs?

A
  • salmeterol (Serevent) inhaled
  • Formoterol (Foradil) inhaled: oral - sustained release albuterol, not rescue drugs for breakthrough sxs, admin of extra doses can cause cumulative SEs
  • these have slower onset, long lasting (9-12 hours), widely used for maintenance, not recommended for tx of acute episodes: slow onset of action (approx 30 min)
  • Newer LABAs:
    Levalbuterol (Xopenex): long acting, may have more beta-2 selectivity than albuterol
    Fenoterol (Berotec): available in Canada, soon in US, similar to albuterol or terbutaline
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12
Q

What are the anticholinergics used? what effects do they have?

A
  • ipratropium bromide (Atrovent): may enhance bronchodilation achieved by beta agonists, main use is in combo with Beta agonist
  • slow to act: 60-90 minutes, minimal side effects: beneficial with pts with heart disease
  • modest potency, doesn’t block Exercise induced, and doesnt modify rxn to antigen
  • Tiotropium (Spiriva): same profile as ipratropium, but longer acting (24 hours)
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13
Q

What is the methylxanthine bronchodilator? Use?

A
  • theophylline
  • medium potency bronchodilator
  • undefined MOA
  • therapeutic plasma concentrations 10-15 mcg/mL (narrow window, hard to achieve and maintain)
  • some recommend even 8-12 mcg/ml
  • dose required to achieve desired plasma level varies widely from pt to pt
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14
Q

What factors decrease theophylline clearance? increase clearance?

A
  • neonates
  • elderly
  • acute and chronic hepatic dysfxn
  • cardiac decompensation, cor pulmonale
  • febrile illnesses
  • concurrent use of macrolide abx, quinolone, allopurinol, propranolol
  • Clearance is increased in children and concurrent use of cigarettes, marijuana, phenobarbital, and phenytoin
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15
Q

Maintenance therapy of theophylline?

A
  • long acting theophylline compounds (Slo-bid) - usually give 1 or 2 a day or once daily
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16
Q

Most common SEs of Theophylline?

A
  • insomnia, nervousness, N/V, anorexia, HA, and tachycardia

- plasma levels greater than 30 g/mL - risk of seizures and cardiac arrhythmias

17
Q

Theophylline dosing?

A
  • start with 16 mg/kg/day or 400 mg/day in divided doses
  • adjust dose based on clinical response, SEs and serum levels
  • single dose admin in evening reduces nocturnal sxs
  • if serum level is more than 30 mcg/ml than skip 2 doses and reduce dose by 50%
18
Q

How should you monitor theophylline?

A
  • if pt is stable: measure serum levels q 6-12 months

- if pt is showing toxicity or breakthrough sxs adjust dose and recheck serum levels in 3 days

19
Q

What is the IV methylxanthine called? -

A
  • aminophylline (IV theophylline)
20
Q

How do corticosteroids work?

A
  • not bronchodilators
  • reduce inflammation
  • use with acute illness: severe airway obstruction is not resolving or is worsening
  • use with chronic disease: failure of a previously optimal regimen with frequent recurrences of sxs of increasing severity
  • inhaled steroids: reduce airway reactivity, start aerosolized steroids in any pt who isn’t controlled by bronchodilators, if sxs aren’t eliminated by std dose, than increase 2 fold or more
  • alternative to oral glucocorticoids
  • greatly facilitate withdrawal of oral steroids
21
Q

What are the SEs of corticosteroids?

A
  • Thrush
  • dysphonia
  • larger doses: adrenal suppression, cataract formation, decreased growth in children, interference with bone metabolism, and purpura
  • it takes 2-4 weeks to produce a beneficial effect (may need to start short course of oral glucocorticoids simultaneously with inhaled drug
22
Q

Corticosteroid class: in order from highest potency to lowest?

A
  • fluticasone (flovent)
  • Budesonide (Pulmicort)
  • beclomethasone (Vanceril, Beclvent, QVAR)
  • Triamcinolone (Azmacort)
  • Flunisolide (aerobid, Aerobid-M)
23
Q

What are the pros about Budesonide (Pulmicort respules) which is a newer agent?

A
  • administered by turbuhaler, DPI, or nebulizer
  • first nebulized corticosteroid
  • studied in children aged 6 mo to 8 yrs
  • greater number of sx free days
  • decreased need for B agonists
  • reduced hospitalization rates
24
Q

What PO steroids are used in acute settings?

A
  • methylprednisolone - IV (attack)
  • Prednisone 60 mh po can be subsituted
  • rapid tapering of glucocorticoids frequently results in recurrent obstruction
  • reducing dose by 1/2 every 3-5 days following an acute episode
25
Q

Use of PO steroids for chronic tx?

A
  • alt. day schedule
    to minimize side effects
  • continuous corticosteroid admin. interrupts growth
  • long acting preps (dexamethasone) shouldnt be used: prolonged suppression of pituitary adrenal axis
26
Q

What are the newer combo agents?

A
  • advair diskus: fluticasone+salmeterol
    dry powder for inhalation
  • combivent MDI: ipratropium + albuterol, Duoneb for neb
27
Q

What are the mast cell stabilizers? What do they do?When are they the most effective?

A
  • antiinflammatory
  • cromolyn (Intal), Nedocromil (Tilade)
  • don’t influence airway tone
  • inhibit degranulation of mast cells
  • Prevent release of chemical mediators of anaphylaxis
  • most effective for seasonal disease: 4-6 weeks before beneficial effects
  • dose: 2 puffs qid
  • prophylactically 15-20 min pre contact with precipitant
28
Q

leukotriene inhibitors function and examples?

A
  • anti-inflammatory
  • montelukast (singulair): 5 mg qd (chewable tablet)
  • zafirlukast (accolate)
  • zileuton (leutrol, zyflo)
  • MOA: suppress action of cysteinyl leukotriene (proinflammatory mediators involved in asthma pathogenesis)
29
Q

Use of leukotriene inhibitors?

SEs?

A
  • improvement in FEV1, asthma exacerbations
  • improvement in frequency of prn b-agonist use
  • safe in children ages 6-14
  • adverse SEs minimal
  • effective in combo with corticosteroid or B-agonist
  • alt to inhaled corticosteroid
  • add on therapy when response to inhaled corticosteroids is suboptimal
  • help reduce higher doses of inhaled corticosteroids
  • not for reversal of acute attack (onset 1 hr)
  • SEs:
    LFT abnormalities, HA
30
Q

What is omalizumab used for?

A
  • newer approach to tx of asthma
  • inhibits the binding of IgE to mast cells
  • Doesn’t promote mast cell degranulation to already bound IgE
  • lowers plasma IgE to undetectable levels
  • clinical trials have shown repeated IV or SQ injection to lessen asthma severity and reduce the corticosteroid requirement in pts with moderate to sever asthma
31
Q

Tx for step 1 intermittent?

A
  • tx: quick relief: prn SABA if you use more than 2x a week might need to start long term control therapy
32
Q

Tx for step 2 mild persistent?

A
  • quick relief: prn SABA
  • 1 daily long term control med:
    inhaled cortico (low) or -cromolyn or nedrocromil
  • 2nd line choices: leukotriene modifier or theophylline
33
Q

Step 3: moderate persistent tx?

A
  • tx: quick relief - SABA
  • long term control:
    inhaled corticosteroid (Medium) or low dose + LABA (salmeterol) or sustained release Theophylline
  • if needed (medium- high dose) inhaled corticosteroid + LABA or sustained release theophylline
34
Q

Step 4: severe persistent tx?

A

Tx: quick relief - prn SABA

- long term control: high dose inhaled cortico + LABA or sustained theophylline or LABA + oral corticosteroids

35
Q

Tx for allergic asthmatic?

A
  • elimination of causative agent:
    ASA even in small quantities
  • other NSAIDs: ibuprofen, naproxen
  • Tartraxine (coloring agent)
  • sulfiting agets (preservatives)
  • desensitization or immunotherapy not proven highly effective
  • change of occupation or relocation of dwelling: significant role
  • eliminating aerosol sprays such as deodorants, hair sprays, and insecticides from the household
36
Q

Since asthmatics are at High risk for other diseases what is impt for them to have?

A
  • immunizations:

yearly influenza vaccination and pneumococcal vaccine

pulmonology (20 decks)

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