Asthma Therapeutics Flashcards by Pierre Wadeie

Define self-management in asthma

What the patient does to manage their own chronic disease
- NOT what the health clinician does

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What are the overall asthma goals of therapy? (7)

maintain control of daytime symptoms
maintain control of night-time symptoms
Maintain normal activity and exercise levels
Maintain normal spirometry values
Prevent asthma exacerbations
Provide optimal drug therapy while avoiding use of reliever inhaler
- less than 2x/week
Prevent asthma mortality

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Is it possible for every patient to achieve all the asthma goals?

No, patients who have more severe sx may not achieve all of this

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What are the 5 steps for a patient to become a good self-manager of asthma (i.e developing a partnership with a patient)

Provide asthma education
Setting asthma goals of therapy
Self-monitory of their asthma (green, yellow, red zone) (asthma diary form)
Asthma review
Create an asthma action plan

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What should you review with a patient about their asthma? (3)

Asthma control
Adherence to plan
Inhaler technique

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What are key features of an asthma action plan (6)

Doses and frequencies of daily meds
- when and how to use reliever + controller meds
How to adjust meds at home in response to symptoms
Listing patients PEF levels
Symptoms when they need to seek emergency medical care
Emergency phone #s
A list of triggers

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What is the MOA of the specific allergen immunotherapy? is it efficacious?

Give patients weekly injections of allergens to improve tolerance
MOA
- immune modification of T-lymphocytes away from Th2 inflammation (driver of allergic inflammation

Modest efficacy

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Does flu vaccine protect asthma exacerbation and improve asthma control?

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What are 2 features of a treatment plan for asthma patients

Asthma control
- not just symptom control, but QOL
Risk for exacerbations

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What is considered a well-controlled asthma patient in the following characteristics:
Daytime sx
Nighttime sx
Physical activity
Exacerbations
Absence from school or work
Need for a reliever
FEV1 or PEF
PEF dirunal variation

Daytime sx: 2x/week or less
Nighttime sx: None
Physical activity: Normal
Exacerbations: mild and infrequent (not affecting qol)
Absence from school or work: None
Need for a reliever: 2x/week or less
FEV1 or PEF: 90% of personal best
PEF dirunal variation: less than 10-15%

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Do individuals who have well-controlled asthma/mild asthma still have risk of exacerbation

Yes

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Define an asthma exacerbation

Episode of progressively increasing SOB, cough, wheeze, chest tightness, which is potentially life threatening
- see MD or ER

**Watch out for poor perceivers

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Which values do they monitor in the ER during an exacerbation? (2)
What is the treatment? What shouldn’t you do?

Monitor:
- FEV1 or PEF
- O2 saturation (90%+ adult, 95%+ children)
- cardiac function

Treatment
1. O2 and hydration
2. SABA (pMDI + spacer) continuously for the 1st hour
- if not better? SABA + anticholinergic
3. May use systemic corticosteroids
NO SEDATION

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What are the 3 classes of reliever medications?

SABA
LABA
Anticholinergic inhaler

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What are the 3 SABA inhalers

Salbutamol
Terbutaline
Formoterol

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What are the 2 LABA inhalers (specific criteria) Age?

Formoterol + budesonide: symbicort
- can be used as a reliever + controller
Salmeterol + fluticasone: advair
- CAN’T be used as a reliever (controller)

All 12+

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What is the anticholinergic inhaler? age?

Ipratropium bromide (atrovent)
18+

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Class, Onset, duration, type of therapy (reliever/controller/both)
Salbutamol
Salmeterol
Formoterol

Salbutamol
Class: SABA
Onset: 3-5 min
Duration: 4-6h
Type: Reliever

Salmeterol
Class: LABA
Onset: 30-50 min
Duration: 12hr
Type: Controller

Formoterol
Class: SABA/LABA
Onset: 3-5 min
Duration: 12 hour
Type: Reliever and controller ONLY in combo tho

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What is the MOA of SABA and safety profile?

MOA
Activate B2 receptors on mast cells to reduce mast cell degranulation and prevent release of inflammatory mediators
- relax bronchiole smooth muscle
- Dec. vascular leakage
- Improve mucous transport out of airways

Safety
- low usage: safe
- high usage: lose selectivity of B2, targets B1 (heart) + B2 –> tremor, palpitations, tachycardia

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What is the indication (3) of anticholinergic (ipratropium bromide)? Efficacy?

Indication (add-on)
- Pt with asthma exacerbations in hospital
- If has both asthma and COPD
- Intolerant of SABA side effects

Efficacy
- less potent, less effective, slower onset than SABA’s
- poorly absorbed

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What is the MOA and safety (side effects) of anticholinergics?

MOA
Inhibits ACh binding to muscarinic receptors in airways
- relax bronchiole smooth muscle
- Dec. vascular leakage
- Improve mucous transport out of airways

Safety
- dry mouth, bitter test
- urinary retention
- ocular effects (eye pain, blurred vision, redness)

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What is the MOA of ICS?

MOA
- Prevents formation of PG’s, leukotrienes, chemical modulators, transcription factors that produce inflammatory cytokines
- Alters synthesis of mRNA when interacted with glucocorticoid receptor

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ICS Onset: initial improvement, max improvement
Symptoms
FEV1
BHR (hyper-responsiveness)

Symptoms
- Initial: 1-2 weeks
- Max: 4-8 weeks

FEV1
- Initial: 1-2 weeks
- Max: 3-6 weeks

BHR (hyper-responsiveness)
- Initial: 2-3 weeks
- Max: 1year+

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What are some local (3) and systemic effects of ICS (5)?
What are solutions to the local effects

Local effects
- Thrush (candidiasis): Rinse mouth
- Dysphonia (hoarse voice): d/c ICS
- Upper Airway irritation + reflex cough: Switch to DPI

Systemic effects
- Osteoporosis
- Catarcats (opaque lens)
- Glaucoma
- HPA (hypothalamus-pituitary-adrenal) axis suppression
- Decreased growth velocity
- Increased glucose

What dosage form help prevent thrush? What makes it more difficult to prevent thrush?

Help prevent: - Aerochamber More difficult - DPI

What is upper airway irritation & reflex cough caused by?

Surfactants in the pMDI - switch to DPI

When should you use OP prophylaxis? Which is more important? (asthma control or risk of OP)

ORAL steroids 3 months+ Asthma control outweighs risk of OP

Explain what happens in a stress response during HPA suppression? - What happens if long-term ICS is suddenly stopped?

Suppresses adrenal gland --> cortisol production BY THE BODY is stopped --> uses exogenous ICS dose IF LONG-TERM SUDDENLY STOPEPD - body unable to make its own cortisol + unable to use exogenous ICS = FATAL (surgery, shock, sepsis)

What happens in the decreased growth velocity in children? How long?

Slows down in the first 6mo-1year but does not affect overall predicted height

When are oral corticosteroids used?

When patient's asthma is still uncontrolled with SABA and ICS, LTRA and still daily limitations - Additive to current inhaler to gain asthma control

What are oral prednisone dosing for adults and children

Adult - 25-50 mg daily f7-10 days Children - 1-2 mg/kg per day max 50 mg f3-5 days

When to use Leukotriene receptor antagonists LTRAs? Efficacy? Who can respond well to this?

2nd line FOR ALL AGES Efficacy - less effective than low-dose ICS - never use in place of a SABA (small effect for bronchodilation) Good for: aspirin-sensitivity asthma patients

What are side effects of montelukast? in children and adult

Well-tolerated Children: Nightmares Adults: suicidality

What is the indication for ICS + LABA combo? (when is it used)

Adults: used if inadequate control at LOW dose ICS children (6+): used if inadequate control at MEDIUM dose ICS **NO LABA for under 6 years old

Which LABA is combo has less risk in asthma-related deaths? Formoterol/Salmeterol

Formoterol

Which ICS + LABA combo is approved for BOTH controller and reliever? which combo is only controller? Age for each?

6+ Controller - fluticasone/salmeterol - Mometosone/formoterol 12+ Controller + reliever - Budesonide/formoterol

When is theophylline used? Side effects?

VERY RARE (hail Mary) - only with severe asthma when B2-agonist and ICS have failed Has severe side effects

Can biologics replace controller/reliever therapy?

No - Add on therapy

Omalizumab MOA Efficacy Safety? (side effects, when is not recommended)

MOA - IgE antibody blocker (prevents allergens from attaching to IgE) Efficacy - reduces allergic exacerbations, ER visits Safety - not recommended in any history of cancer - Uticaria, rash, pruritis, flushing

Benralizumba MOA (class) Who is it for?

Class: Interleukin-5 Antagonist - Add on maintenance for adults with severe EOSINOPHILIC asthma phenotype

What is considered a frequent use of SABA canisters per year that can lead to ED? that can lead to death?

3+ canisters = ED 12+ canisters = death

What are ADE of frequent use of SABA? (6)

- B-receptor downregulation - Decreased bronchoprotection - Rebound hyperresponsiveness - Decreased bronchodilator response - increased allergic response - increased eosinophilic airway

What are high risks for a patient to experience an exacerbation?

1) Any history of exacerbation requiring - steroids - ED, hopsitilization 2) Poorly-controlled asthma, 2+rescue inhaler/week 3) Overuse of SABA 3+ canisters/year 4) Current smoker

What is first line for a patient with poorly controlled asthma? (2) - All ages - 12+

All ages start ICS + PRN SABA 12+ can start Symbicort PRN if poor adherence

What to do if a patient take ICS + PRN SABA or Symbicort?

Consider PRN ICS-SABA

What to do for children (6-11) when they have loss of control at LOW dose of ICS. Provide further steps if still have loss of control (3 steps)

1. Increase low dose to medium dose ICS 2. Add LABA combo (advair diskus, zenhale) OR Add LTRA to medium dose ICS 3. Referral

What to do for adults (12+) when they have loss of control at LOW dose of ICS. Provide further steps if still have loss of control (4 steps)

1. Add LABA in combo (symbicort, advair, zenhale) 2. Increase ICS dose in combo product 3. Add LTRA or tiotropium (anticholinergic, usually in COPD) 4. Refer patient to a respirologist (oral prednisone, biologics)

What if adult patients, after losing control on low dose ICS, are not able to afford symbicort, or no intolerance for LABA, or do not want to add on another med (3)

1. Increase to medium dose ICS 2. Adding LTRA to low dose ICS 3. Later try add on a LABA

What to do for children (1-6) when they have loss of control at LOW dose of ICS. Provide further steps if still have loss of control (2 steps)

1. Increase to medium dose ICS 2. Referral to pediatric specialist

Define what very mild asthma treatment entails?

Well-controlled on SABA PRN

Define what mild asthma treatment entails? (2)

Well controlled on: Low dose ICS (or LTRA) and SABA prn OR Symbicort PRN

Define what moderate asthma treatment entails? (3)

Low dose ICS + second controller and PRN SABA OR Med. dose ICS +/- second controller and PRN SABA OR Low-moderate dose symbicort + PRN symbicort

Define what severe asthma treatment entails? (2)

High ICS dose + 2nd controller OR Systemic steroids for 50% of the year OR is uncontrolled despite this therapy

What to do if a patient finds themselves in a yellow zone?

Recommend a temporary 4-fold increase in

What is the yellow zone criteria? What do you do if you find yourself there, what age?

Yellow zone Reliever use: 4+ times/week Daytime symtpoms: 4+ days/week Nighttime symptoms: 1+ week OVER 16+ AGE ONLY: 4-fold increase in ICS dose for 7-14 days ** need to assess by clinician first

What is the red zone criteria? Physical activity Reliever use Daytime sx Nighttime sx

Physical activity: difficulty talking Reliever use: doesn't work as usual OR last less than 2 hours Daytime sx: All the time Nighttime sx: Every night

What happens when pregnant women experience asthma changes?

They will return to pre-pregnancy asthma state within 3 months after giving

What is the treatment for asthma patients who are pregnant

1. SABAs 2. Budesonide is recommended ICS (pulmicort) 3. If poorly controlled LABA --> symbicort

How does asthma affect fetus?

Asthma reduces O2 in maternal blood --> reduces O2 in fetal blood - impair fetal growth/survival