Asthma Therapy Flashcards
First line for mild intermittent asthma
Albuterol inhaler alone. If attacks are infrequent, there is no need for inhaled glucocorticoids
First line for mild persistent asthma
Albuterol inhaler plus corticosteroid inhaler
In well-controlled asthma, a SABA should not be needed more than __ per week.
In well-controlled asthma, a SABA should not be needed more than two days per week.
Epinephrine hydrofluoroalkane
Available over-the-counter in an inhaled form as a SABA in place of albuterol or levalbuterol
Used for intermittent asthma only. Costs less than perscription inhalers.
If asthma is worsening, these patients should be switched to albuterol or levalbuterol for rescue and started on a maintenance therapy
Ipratropium bromide for intermittent asthma
Can be used off-label for intermittent asthma when patients cannot tolerate SABAs
Preferred Treatment Guide by asthma severity
Ciclesonide and beclomethasone dipropionate vs other inhaled corticosteroids
Ciclesonide and beclomethasone dipropionate are prodrugs that are activated only in the lungs, and so they have less on-target side effects in the oropharynx.
However, they still predispose to the development of thrush at a rate of about 5%.
LABAs for asthma maintenance therapy
Always in addition to, NEVER instead of, an inhaled corticosteroid
Salmeterol and Formoterol are the preferred agents
First line for moderate persistent asthma
Daily AND PRN low-to-medium dose inhaled corticosteroid and formoterol
Why is LABA monotherapy contraindicated?
LABA monotherapy increases the risk of asthma-related death
“Three drug inhaler”
Contains the ICS fluticasone furoate, the LAMA umeclidinium, and the LABA vilanterol (Trelegy Ellipta)
Approved for both COPD and persistent asthma. Shows benefits in lung function compared to ICS + LABA therapy alone, but no deacrease in frequency of asthma exacerbations.
Where do montelukast and zafirlukast fit in asthma therapy?
They can be an alternative to low-dose ICS for those in whom this is contraindicated, but are less effective.
They can also be added on to therapy in individuals who are already on ICS and LABA.
Zileuton
5-LOX inhibitor
Many side effects compared to leukotriene receptor antagonists. Reserved as an add-on for severe asthma therapy.
Black box label for leukotriene receptor antagonists
For neuropsychiatric symptoms
Increased risk of completed suicide
Theophylline in asthma
It is occasionally used in patients whose asthma is not controlled with an ICS and a LABA alone, however montelukast has generally taken this role
It has largely been replaced by safer alternatives due to its risk of arrhythmias.
Oral corticosteroids in asthma
Used in severe asthma exacerbations, and may even be required as maintenance therapy in those with very severe persistent asthma
In whom is omalizumab indicated?
Those with:
- Moderate to severe persistent asthma not well controlled on an ICS
- Documented allergens, such as mold, pollen, or pet dander
Ironically, omalizumab carries a black box warning for ___
Ironically, omalizumab carries a black box warning for anaphylaxis
This is unrelated to on-target IgE activity and appears to be a true allergic reaction to the structure itself.
Mepolizumab and Resolizumab
Anti-IL-5 monoclonal antibodies
An add-on treatment for severe eosinophilic asthma. Quite effective in these patients, reducing rates of asthma attacks by ~50-60%.
Treating eosinophilic asthma
- Characterized as elevated blood eosinophils (>3%) or elevated sputum eosinophils
- Does not respond well to inhaled ICS
- Rather, responds to oral corticosteroids and anti-IL-5 therapy
Dupilumab
Anti-IL-4 subunit (effectively anti-IL-4 and anti-IL-13)
Add-on maintenance treatment of moderate to severe asthma with an eosinophilic phenotype or oral corticosteroid-dependent asthma
Can decrease the rate of attacks by 50-70% in oral corticosteroid dependent asthma
Adverse reactions to dupilumab
Eosinophilic pneumonias and EGPA-like (Churg-Strauss-like) vasculitis have been reported, but causal link has not been established
