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FINAL - Respiratory symptom assessment readings > ASTHMA TREATMENT > Flashcards

ASTHMA TREATMENT Flashcards

1
Q

What are the general goals of therapy for chronic ambulatory asthma treatment?

A
  • maintaining a good state of symptom control
  • Decreasing the risk of exacerbations
  • reducing airflow limitations
  • Decreasing the risk of asthma-releated mortality
  • Minimizing adverse event related to pharmacotherapy.

Remember, these are general goals. It’s important to determine what the patient’s goals are and what type of therapy they want to pursue. Their asthma will not be dealt with if you do not have buy in from them. Moreover, you must consider their level of health literacy with regards to asthma. Then communicate to them in a way that they understand.

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2
Q

What are potential modifiable risk factors that can be helped with for asthma patients?

A
  • what are their beliefs and concerns about asthma
  • Are they able to usethe inhaler prescribed
  • Can they afford it
  • How likely do you think they are to take it
  • Are there comorbidities affecting asthma control?
    (rhinosinusitis, GERD, Paradoxical vocal fold motion, anxiety and dpression)
  • Identifying as many barriers to treatment as you can help make your patient’s asthma therapy more successful
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3
Q

What are 8 very important non-pharm things that patients can do/ should know about to help manage asthma?

A
  1. Asthma education - Asthma is a chronic inflammatory condition in which airways are hyper-reactive and/or instrinsic factors
  2. Identify triggers - Identify and avoid of environmental triggers specific to the patients
  3. Asthma control for all patients - Asthma can be controlled and all patients with asthma can lead a normal life. Regular symptoms, poor lung function and asthma exacerbation indicate treatment.
  4. Minimal to no exacerbations for all patients: identify risk factors for asthma exacerbations
  5. Reliever vs. Controller: the differences between these
  6. Written asthma action plan: - How and how often to assess asthma control (self-monitoring), instructions to maintain good control emphasizing adherence to contrller meds and making specific environmental changes, signs and symptoms indicating poorly-controlled asthma, with instructions on what to do during loss of control (medication to add or increase, how much and how long; when and how to seek additional help (eg. when to go to the hospital or call the health care provider)
  7. medication safety and side effects: Expected onset of action and potential side effects of meds
  8. Inhaler teaching - Teaching and verification of the inhalation technique specific to the devices prescribed for the patient, and how to tell when an inhaler is empty
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4
Q

What are all potential triggers for asthma that patients should try and avoid

A

Patients should avoid:
- Smoke and vaping, substances with strong odors
- Avoid exertion outdoors when levels of air pollution are high
- Avoid use of nonselective betablockers
- Avoid sulfite-containing foods (Particularly as a preservative and other foods if they are sensitive to them (Beer, wine, dried fruit and open salad bars)
- ASA, NSAIDS should be counseled regarding the risk of sever and even fatal exacerbations (Aspirin exacerbated respiratory disease) from using these drugs. This becomes more common as age and severity of asthma increases.
- Have an action plan - Action plans should outline daily preventative management to maintain control, when and how to adjust reliever therapy (and controller therapy in adults prone to exacerbations) for loss of control and provide clear instructions regarding when to seek urgent medical attention. They have been shown to reduce exacerbations in children and adults.

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5
Q

When are NSAID exacerbated respiratory disease risk highest (which age groups, taking which meds, with what medical conditions?

A
  • Aspirin or NSAID exacerbations are more common in patients who are coricosteroid resistant asthmatics in thei 4th or 5th decades with perennial rhinitis and nasal polyposis
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6
Q

Poor inhaler technique is still as high as ____%

A

70%
AND can be associated with poor asthma control and exacerbations

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7
Q

Why should an MDI ALWAYS be used with an aerochamber??

A

an aerochamber should always be used as it reduces drug-throat deposition and also mitigates actuation-coordination with pMDIs

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8
Q

When might DPI be no a great option for patients?

A

Dry powder inhalers require a minimal inspiratory pressure and therefore may be less useful in certain populations (young children, adults with low FEV1, or during asthma exacerbations).

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9
Q

What type of inhaler and device is preferred for:
1. 1-3 yrs
2. 4-6 yrs
3. >6 years
4. >12 yrs and adults

A
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10
Q

How is asthma severity defined?

A

Asthma severity is defined by the medication needed to maintain asthma control. It therefore only describes where the patient is at and not what therapeutic decision should be made

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11
Q

What are the two general classes of asthma medications?

A

Controllers and relievers

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12
Q

What are examples of reliever medications?

A
  • Salbutamol
  • Terbutaline
  • Budesonide/formoterol

Budesonide/formoterol is only approved as a reliever in those ≥ 12 years and should not be used as a reliever unless it is also being used as a controller.

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13
Q

True or false, bud/form can be used as a reliever in any patient?

A

FALSE

Budesonide/formoterol is only approved as a reliever in those ≥ 12 years and should not be used as a reliever unless it is also being used as a controller.

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14
Q

Why do patients not use their controllers?

A

Asthma is an inflammatory condition that is not curable but controllable. Unfortunately, data suggests that patients are more likely to treat symptoms with a short acting β2-agonist (SABA) than use their controller, as their SABA makes them “feel” better. This behaviour has been ingrained in patients with asthma and has led to problems in asthma treatment.6,9

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15
Q

What is frequent use of SABA reliever a risk factor for?

A

Frequent use of a SABA reliever is a risk factor for severe exacerbations and asthma-related death. This is because the underlying pathology of inflammation is not being treated.

The use of more than two inhalers of SABA in a year should prompt revaluation of asthma control. SABAs should not be regularly used “to open the airways” before controller therapy as this has been shown to increase risk of exacerbations.

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16
Q

When and ONLY when should PRN SABAs be used on their own?

A

PRN SABAs on their own should only be used as a treatment option in individuals with well-controlled very mild asthma who are currently on PRN SABA but not at risk of exacerbation.5

This is different from the GINA10 guidelines who do not recommend a PRN SABA as single therapy ever for patients ≥ 12 years of age. This is because SABAs alone, even with mild asthma were shown to be at risk of asthma-related death, asthma related events, and worse outcomes than those on ICS alone from the start.12-14

17
Q

Dispensing ___ or more SABA canisters per year has been linked to increased risk of exacerbations regardless of how severe they were.

A

3

18
Q

Dispensing _____ or more canisters per year has been associated with an increased risk of death due to asthma.

A

12 or more

This is further complicated by the fact that controller therapy is underutilized in approximately 50% of patients with mild asthma, and SABA therapy is over utilized by many.17

19
Q

List the 5 controller corticosteroid inhalers

A

Beclomethasone, budesonide, fluticasone, mometasone, ciclesonide

20
Q

What are the most effective anti-inflammatory available to treat asthma?

A

ICS are the most effective anti-inflammatories available to treat asthma

21
Q

Why are ICS effective in asthma?

A
  • they increase the number of beta-adrenergic receptors
  • They improve the receptor responsiveness to beta2-adrenergic stimulation
  • reduce mucus production and hypersecretion
  • reduce bronchial hyperresponsiveness
  • reduce airway edema and oozing of mucus
22
Q

Describe the dose response curve of ICS?

A

ICSs have a flat dose-response curve with a: two-fold increase in dose having limited additional effect an asthma control; and a four-fold increase perhaps improving control, but putting patients at risk of adverse events.

23
Q

When are symptoms expected to improve when starting inhaled corticosteroids for asthma?
When is max effect expected?

A

mprovement in clinical symptoms occurs within 1-2 weeks of starting daily ICS (can be as early as 12 hours), although it can take months (2-3) to see maximal improvement.2

24
Q

Describe the dose response effect with ICS?

A

There is a dose-response effect that occurs with ICS such that minimal extra effect is achieved with high doses of ICS as compared to low-medium doses of ICS. The lowest effective dose should always be used. As mentioned previously, for patients with poorly-controlled asthma, reasons for poor control should be assessed and corrected before a change in therapy occurs.

25
Q

What should happen to therapy for patients who have a loss of control and were on PRN SABA?

A

Those who have a loss of control and were on PRN SABA should be switched to daily ICS + PRN SABA (all ages) or PRN budesonide/formoterol (≥ 12 years of age).

26
Q

What if a patient lost control on PRN SABA, but it is anticipated that they will have adherence issues, or a trial with regular ICS demonstrated adherence issues, what is another option for these patients?

A

If poor adherence to daily medication is a problem despite evaluating all reasons for this, PRN budesonide/formoterol is recommended over daily ICS + PRN SABA. PRN budesonide/formoterol decreased the risk of severe exacerbations by 60-64% as compared to placebo19,20. When compared to regular low dose ICS, PRN budesonide/formoterol, risk of severe exacerbation was similar19,20 or lower.20,22

27
Q

Is taking an ICS each time a SABA is taken recommended in Canada?

A

Taking an ICS each time a SABA is taken (PRN ICS- PRN SABA) is recommended in GINA but is not approved for use in Canada. In Canada, this is only recommended as a harm reduction measure in patients ≥18 years of age at higher risk for exacerbations who can’t use regular ICS + PRN SABA or PRN budesonide/formoterol. Probably because at this point you would be using two inhalers. I believe in Europe or the US there is a fixed combo of budesonide and salbutamol available.

28
Q

What are the options for patients who are well controlled on PRN SABA or no medication at lower risk of exacerbation?

A

Patients who are well controlled on a PRN SABA or no medication with a lower risk for exacerbations can continue PRN SABA or be switched to either daily ICS+PRN SABA (all ages) or PRN budesonide/formoterol (≥12years of age) to obtain better asthma control or reduce their risk for exacerbations. In all patients, leukotriene receptor antagonists (LTRA) are used as second line therapy to daily ICS.

29
Q

In those patients not controlled on low ICS therapy what is the next step?

A

-Children < 11 should be increased to a medium dose of ICS.

        -Children ≥ 12 and adults should be started on an ICS/LABA combo.
30
Q

In those patients not controlled on medium dose ICS therapy:
1-5
6-11 years

A

-Children < 6 should be referred to an asthma specialist.

-Children 6-11 should be started on a second controller medication, either a LABA (preferably in the same inhaler as the ICS) or a LTRA.

31
Q

In those patients not controlled on a ICS and a second controller (LABA, LTRA or tiotropium)

A
  • Children ≥ 12 and adults not controlled or are prone to exacerbations while on an ICS/LABA combo can be switched to budesonide/formoterol maintenance and prn.

-Those patients who are on a moderate dose of ICS and another controller and not achieving control are now considered severe.

32
Q

What are the low, medium and high doses for the following inhalers in each age group of 1-5 years, 6-11 years, 12 years and older
1. Beclomethasone (Qvar)
2. Budesonide (pulmicort)
3. Ciclesonide (Alvesco)
4. Fluticason furoate (arnuity)
5. Fluticasone propionate
6. Mometasone furoate

A
33
Q

Should Long-Acting Beta-2 agonists be used alone?

A

Long-Acting Beta2-Agonists (Formoterol, Salmeterol)

Never used alone in any age group. They MUST BE IN combinations with steroids.

34
Q

Which of the LAMAs is approved in Asthma?

A

Long Acting Anti-Muscarinic Agents (LAMAs)

New agents used in asthma. Tiotropium Respimat is the only one approved in asthma.

35
Q

What is the black box warning about LTRA?

A

Leukotriene Receptor Antagonists (Montelukast)

There is a black box warning has been issued for LTRAs due to neuropsychiatric side effects, most commonly irritability, aggressiveness, anxiety and sleep disturbance including suicidal thoughts or actions.4 This has been seen in up to 16% of pediatric asthma patients started on montelukast and usually occurs within 2 weeks of starting the drug.

36
Q

How often should patients with non-severe asthma be reviewed and how is therpay adjusted?
1. Regular patients
2. Pregnancy
3. after an exacerbation

A

Patients should be assessed 2-3 months after starting treatment and every 3-12 months after that. In pregnancy more often and after an exacerbation they should be seen within a week. Lung function may need to be assessed 3-6 months after controller treatment and then maybe once or twice per year based on the patient and their asthma severity.11

37
Q

When would step up therapy occur? What should be considered when thinking about stepping up therapy?

A

If a current level of medication is not providing sufficient asthma control, consider stepping up therapy after 2-3 months. Always consider inhaler technique, poor adherence, modifiable risk factors and co-morbid conditions.

38
Q

Once an asthmatic has attained good asthma control, when can they consider step down?

How is step down done typically and how often?

What monitoring needs to be done?

Do we ever completely stop ICS in adults or adolescents?

A

Similarly, once an asthmatic has attained good asthma control for at least 3 months, step-down therapy can be considered.

This should be done in 2–3-month intervals and can include reducing ICS by 25–50%, reducing another agent or removing another controller.

Stepping down allows the patient to be controlled at the lowest dose possible. An appropriate time should be chosen: no respiratory infection, not travelling, not pregnant.

Make sure the patient is engaged in stepping down, and make sure the instructions are clear to the patient. Monitor with symptoms and/or PEF, and schedule follow-up. Make sure they have an action plan.

You should not see someone on a LABA alone. Do not completely stop ICS in adults or adolescents

39
Q

MEMORIZE THE ASTHMA MANAGEMENT CONTINUUM

A

FINAL - Respiratory symptom assessment readings (9 decks)

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