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Integrated Drug Structure, Function, and Therapeutics Winter Term > Asthma Treatment Principles - Dr. Kradjan > Flashcards

Asthma Treatment Principles - Dr. Kradjan Flashcards

1
Q

What are the guidelines for Asthma?

A
  • Expert panel 3: guidelines for the diagnosis and Management of asthma (updated 2013)
  • Global initiative for Asthma 2016
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2
Q

What is the definition of asthma?

A
  • A chronic inflammatory disorder of the airways

- Reversible airflow obstruction (unique part)

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3
Q

What symptoms are common with asthma?

A
  • Wheezing
  • Breathlessness
  • Chest tightness
  • Coughing
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4
Q

What time of day do asthma symptoms most commonly occur?

A

Usually at night or in early morning

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5
Q

What does inflammation in asthma cause?

A

A hyper responsiveness in the bronchials to a variety of triggers.

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6
Q

How many age groups are used to classify asthma? What are they?

A

0-4
5-11
>12 and adults

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7
Q

What are the stages of severity of asthma, and how do you classify someone as having a particular severity of asthma?

A
  • Intermittent (2 or less night awakenings/month, symptoms/inhaler use 2 or less times/week)
  • Mild persistant (more than 2 days of symptoms/week, 3-4 night awakenings/month)
  • Moderate persistant (daily symptoms, night awakenings more than 1/week)
  • Severe persistant (daily symptoms, night awakenings greater than 4/week)
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8
Q

At what stage would you want to get aggressive in treating asthma?

A

In the mild persistent stage, before the symptoms worsen to moderate or severe persistent.

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9
Q

What are some things to consider when treating asthma?

A
  • Season (allergic rhinitis is basically same disease at different part of the body)
  • Daily fluctuations
  • Inhaler compliance and proper technique
  • Exercise-induced asthma (more than 2x/week = persistent asthma)
  • Peak flow monitoring
  • cough variant
  • wheezy bronchitis in children
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10
Q

What are the therapeutic goals of treating asthma?

A
  • Minimal, infrequent episodes
  • maintain normal activity including exercise
  • maintain pulmonary function
  • Prevent episodes (no more than 2 beta agonists/week, no emergency room visits or hospitalizations)
  • Avoid SEs of medications
  • Prevent asthma-related deaths
  • Meet family expectations
  • Educate family about symptoms, triggers, MDI technique, daily use/controller vs as needed/reliever inhalers, peak flow monitoring
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11
Q

Is peak flow monitoring more useful for asthma or COPD?

A

Asthma. It is so you can become proactive in the yellow zone and never reach the red zone, while COPD patients commonly live in the red zone.

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12
Q

What is the approach to managing intermittent asthma?

A 
Environmental control (avoid allergens and other triggers)
PRN bronchodilators (albuterol or ipratropium if albuterol causes shakiness)
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13
Q

What is the approach to managing mild persistent asthma?

A

Environmental control
PRN bronchodilators

Children under 5: budesonide with face mask. Cromolyn nebulizer alternative

Age 5-12: Fluticasone MDI with face mask or holding chamber. Alternative is leukotriene or cromolyn with holding chamber.

Age 12 - adult: Add anti-inflammatory (steroid preferred, leukotriene modifier alternate)

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14
Q

What is the approach to managing moderate persistent asthma?

A

Child under 5: step up to medium-dose budesonide nebulized

Child 5-12: Step up to medium-dose inhaled fluticasone with face mask

  • or continue low dose inhaled steroid and add leukotriene modifier to avoid LABA
  • or add theophylline (watch for drug interactions)
  • Combination of anti-inflammatory plus long-acting bronchodilators
  • Or increase dose of anti-inflammatory
  • Second anti-inflammatory?
    Adult
  • Continue albuterol prn and low dose inhaled steroid
  • Add either long acting beta agonist (75% use this)
    or long-acting anticholinergic or leukotriene modifier
    OR step up to medium dose inhaled steroid alone
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15
Q

What is the approach to managing severe persistent asthma?

A

Adult & child

  • Continue albuterol prn
  • medium dose inhaled steroid plus LABA or LAMA
  • Alternatives include steroid + leukotriene modifier/theophylline, OR steroid plus LABA and leukotriene modifier
  • refer to pulmonologist
  • short course oral steroids
  • Use combos of 3-4 drugs
  • Allergy desensitization
  • Add immunosuppressants (Omalizumab, methotrexate, soluble IL-4 receptor)

child may want to be referred to allergist

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16
Q

What should you do if there is an acute exacerbation of asthma?

A

GO to the emergency room for treatment

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17
Q

For refilling asthma medications, what are important points to cover?

A
  • Compliance
  • MDI technique
  • Severity of asthma (SNIFF)
  • Exacerbation risk (frequency and severity)
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18
Q

How do you categorize the severity of asthma?

A

SNIFF
(Symptom frequency, nighttime awakenings, interference with normal activities, frequency of short-acting beta agonist use per time frame, and FEV1 in 5+)

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19
Q

What does a score of 19- on the ACT mean?

A

That the patient’s asthma is not as controlled as it could be.

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20
Q

What does a score of 20+ on the ACT mean? What is ACT?

A

ACT is the Asthma Control Test for those 12 and older. 20 or more may mean that the patient’s asthma is under control, but there might be other factors.

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21
Q

What is a warning that the approach for managing intermittent asthma is not working?

A

If the MDI is being used more than 2 times a week or 1 time a week for 3 months, or night awakenings.

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22
Q

What kind of environmental control might help reduce asthma symptoms?

A

The same as allergic rhinitis:

Bedding, carpets, stuffed animals, pets, avoid allergens and triggers.

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23
Q

What options are there for rescue or reliever drugs?

A
  • SABA (short-acting beta adrenergic agonist bronchodilators) - albuterol (MDI, nebulization solution), levalbuterol (R-enantiomer of albuterol)
  • Epinephrine, isoproterenol, isoetharine
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24
Q

What is the reason that someone would choose levalbuterol over albuterol?

A

It is the R-enantiomer of albuterol, which supposedly less inflammatory than the S enantiomer. Albuterol is a racemic mixture.

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25
Q

What drugs are in the rapid-acting anticholinergic bronchodilator class?

A
  • Ipratropium (Atrovent): MDI or nebulization solution

- Ipratropium with albuterol (Combivent Respimat, DuoNeb)

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26
Q

What is the difference in action between albuterol and ipratropium?

A

Albuterol has a faster onset, but is shorter acting. Ipratropium has a slower onset, but is longer acting. It can be used as an alternative if someone doesn’t tolerate albuterol.

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27
Q

What form of ipratropium is used in acute exacerbations of asthma or COPD?

A

Usually the combo with albuterol

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28
Q

What should you avoid if you have a peanut allergy?

A

The ipratropium MDI.

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29
Q

What drug causes side effects of blurred vision and dry mouth?

A

Ipratropium

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30
Q

What drug causes side effects of decreased heart rate and shakiness? What are the dangers with this drug?

A

Albuterol. Fixed dose and continuous therapy can be dangerous.

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31
Q

When an allergen and IgE set off a mast cell degranulation, what happens to calcium flow, cGMP, and cAMP? What enzyme is used?

A

Calcium flow increases
cAMP decreases
cGMP increases
Phospholipase A2 is used

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32
Q

What do these drugs have in common?
Beclomethasone HFA (Qvar)
Budesonide (Pulmicort, Symbicort)
Ciclesonide HFA (Alvesco)
Fluticasone (Flovent) w/ salmeterol (Advair), w/ vilanterol (Breo Ellipta)
Mometasone (Asthmanex), w/ formoterol (Dulera)

A

All inhaled corticosteroid controller drugs: anti-inflammatory. No difference in effectiveness.

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33
Q

What do these drugs have in common?
Leukotriene modifiers:
- Lipooxygenase inhibitor: Zileuton (Zyflo, Zyflo CR)
- Receptor blocker: Zafirlukast (Accolate), montelukast (Singulair)
Mast cell stabilizer
- Cromolyn nebulizer solution

A

They are non-steroid controllers: anti-inflammatory. Montelukast is the most common (90-95% of the category)

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34
Q

What does calcium increase, cAMP decrease, and cGMP increase cause the mast cell to do? What is in the mast cell?

A

They cause the mast cell to rupture, releasing its contents of histamine and mediator-recruiters. The phospholipids in the membrane are also released.

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35
Q

What happens after the mast cell degranulates?

A

The phospholipid membrane breaks down, which allows arachidonic acid to be released. This is broken down into leukotrienes and prostaglandins by lipooxygenase and cyclooxyrgenase, respectively.

36
Q

What acts on lipooxygenase?

A

Zileuton

37
Q

What acts on cyclooxyrgenase?

A

NSAIDS

38
Q

What blocks receptors for leukotrienes?

A

Zafirlukast and montelukast

39
Q

What increases cAMP?

A

Beta agonists (albuterol) and phosphodiesterase inhibitors

40
Q

What decreases cGMP?

A

Anticholinergics (ipratropium)

41
Q

What blocks phospholipase A2?

A

Corticosteroids (steroids)

42
Q

What is the general dosing for inhaled steroids?

A

No more than 2x a day - won’t make a difference
Always start with a low dose
Most are pretty comparable and interchangeable

43
Q

When comparing adult and child doses of inhaled steroids, what are the main differences?

A

There are smaller max doses for children in beclomethasone and fluticasone.
More nebulizer options, with differences in dosing for those under 5 years old.

44
Q

What are some problems with inhaled steroids in terms of side effects? Which drug avoids this?

A
  • Thrush, hoarseness (dysphonia), cough
  • Less with ciclesonide ( a pro-drug activated in the lungs
  • Growth suppression in children and osteoporosis in women in higher doses only.
45
Q

What helps reduce the risk of oral thrush?

A

Rinsing mouth out after use
Use a spacer so that the drug that is not inhaled into the lung stays in the spacer instead of the mouth. This should also minimize the cough.

46
Q

About how much of the drug is inhaled into the lungs vs. stays in the mouth or spacer?

A

10% gets to lung with good technique, about 90% does not.

47
Q

If you have good MDI technique, is it still important to use a spacer?

A

You would not need one in terms of drug delivery, but it still would be good in terms of preventing thrush.

48
Q

Is he a fan of intermittent steroid use for mild persistent asthma?

A

No, he would rather the patient use inhaled steroids on a continuous basis.

49
Q

What works better for asthma, montelukast or inhaled steroids?

A

Inhaled steroids

50
Q

What interactions do the leukotriene receptor blockers have (montelukast and zafirlukast)?

A

Zafirlukast only has a warfarin interaction documented. They both use 2C9 and 3A4.

51
Q

What test is required with zileuton use?

A

A liver function test.

52
Q

What is used to assess asthma control?

A

Use of MDI, including technique
Symptoms occurrence (Nighttime awakenings, symptoms, frequency of SABA, interference with normal activity, FEV1)
Compliance
Exacerbation risk

53
Q

What do the following medications have in common?
Salmeterol (Serevent)
Formoterol (Foradil)
Indacaterol (Arcapta)
Olodaterol (Striverdi)
Vilanterol (only in combo products for COPD - Breo Ellipta)

A

They are long acting beta agonists. Salmeterol and formoterol are the only ones indicated for use in asthma (the others for COPD) but the others would work as well.

54
Q

What do the following medications have in common?
Salmeterol + Fluticasone = Advair Diskus
Formoterol + mometasone = Dulera
Formoterol + budesonide = Symbicort
Vilanterol + fluticasone = Breo Ellipta (COPD)

A

They are all LABA/steroid combinations. Most people use the combos.

55
Q

What is the triple crossover idea? Who is it for?

A

It is a step-up therapy for children who are already on a low dose steroid, and are still showing symptoms in mild persistent to moderate persistent.
They rotate through three medication regimens every 16 weeks:
- medium dose steroid (fluticasone 250mcg)
- low dose steroid + salmeterol
- low dose steroid + montelukast

56
Q

With the triple crossover design, what was the therapy that was most successful? How were the others?

A

The most successful therapy was the low dose steroid plus salmeterol (45% had best success with this). There was a 98% success rate total, and the others two had 30% success each. None is truly superior, all work pretty well.

57
Q

What are some benefits and issues with LABA’s?

A

They are not rescue inhalers (salmeterol and formoterol compared with albuterol).
Onset of salmeterol is 20 minutes, while formoterol and indacaterol are more comparable to albuterol.

58
Q

What is the duration of action with the LABAs? What combos are they in?

A

Salmeterol and formoterol are 12 hours, while indacaterol is 24 hours. They are in steroid combos, which most people use.

59
Q

What is the cheapest LABA/steroid combo right now?

A

Symbicort (over Advair)

60
Q

What is PFT?

A

Pulmonary function tests

61
Q

What do PFTs measure, and what are the three tests?

A

They assess air outflow.
Peak flow
FEV1
FVC

62
Q

What is the maximum rate of of airflow out of the lungs during a forced exhalation? What is the usual measured rate?

A

Peak flow. Usually >500 L/min in an adult

63
Q

What is the total volume of air expired during a forced exhalation? What is the usual measured amount?

A

FVC (forced vital capacity). 4.5-5L in adults

64
Q

What is the maximum volume of air expired in the first second of a forced exhalation? What is the usual volume?

A

FEV1 (Forced expiratory volume in one second). Usually 80% of FVC. 4.0-4.5 L in adults.

65
Q

What does the peak flow meter measure?

A

It measures the peak flow rate, or the fastest airflow during forced exhalation.

66
Q

What percentage are you looking for in bronchodilation improvement to consider a change?

A

You are looking for 15-20% improvement in absolute change. This can be in FEV1, or in PFR.
You need to consider that if the baseline is low, 20% change can occur very easily. Therefore, the change has to be at least either 0.2L FEV or >20 L/min PFR as well as 20% change.
Also, if the change is not above 15-20% but the patient feels better, it is still clinically significant.

67
Q

Do you have to blow the air out slowly or quickly for FVC?

A

Quickly. Otherwise, you just get vital capacity.

68
Q

What PFT is more reliable for obstruction in the airway?

A

FEV1 over PEFR

69
Q

What variables are used to estimate PEFR and FEV1?

A

Gender, height, and age. However a person may be within 1-2 standard deviations from the normal even without COPD or asthma.

70
Q

When taking a measurement from a PFT, how many times do you perform the test? What value is reported?

A

Perform the test three times, and take the highest value rather than the average when you report it.

71
Q

How do you take a postbronchodilator measurement?

A

Administer a PFT. You wait until 10-20 minutes after the bronchodilator has been administered, and then perform it again. If the postbronchodilator test is consistently above the baseline, then the asthma is poorly controlled. The baseline goals will have to be adjusted upwards. If there is no reversibility, then the person may have non-reversible airway disease, such as COPD, chronic bronchitis, or emphysema.

72
Q

What is reversibility?

A

It is the capacity of the bronchioles to dilate.

73
Q

PFT: How do you measure percent of predicted?

A

Observed/predicted x 100

74
Q

PFT: How do you measure percent of personal best?

A

observed/personal best x 100

75
Q

PFT: How do you measure percent of change?

A

(post-albuterol value - pre-albuterol value)/pre-albuterol value

76
Q

When looking for trends over time, is it best to use pre- or post-bronchodilator scores?

A

Pre-bronchodilator scores will be better for trends over time, especially if taken during exacerbations.

77
Q

What does PC stand for in terms of airways?

A

Provocative concentration: A concentration that causes asthma to be 20% worse. Want these to be higher.

78
Q

What is the gold standard for PFT?

A

Spirometry, which measures FEV1. Peak flow is not the gold standard.

79
Q

What was the goal of the SMART study?

A

To measure the respiratory-related deaths or emergencies of people of salmeterol.

80
Q

What were the findings of the SMART study?

A

That black subjects were at a higher risk for ED and hospital visits.

81
Q 
What do the following medications have in common?
Tiotropium (Spiriva)
Aclidinium (Tudorza)
Umeclidinium (Icruse Ellipta)
Glycopyrrolate (Seebri)
A

They are all LAMA, or Long acting muscarinic antagonists. The only one indicated for asthma is Spiriva.

82
Q

What do the following medications have in common?
Oldaterol + tiotropium = Stioloto
Vilanterol + umeclidinium = Anoro
Indacaterol + glycogyrrolate = Utibron

A

All are combo LABA/LAMA combinations that are indicated for COPD.

83
Q

What are the options available for children in terms of beta agonists?

A

Albuterol tabs and syrup, as well as nebulizer solution and MDIs.
Metaproterenol syrup and tabs
Terbutaline tabs

84
Q

What are some issues with theophylline?

A

Variability in dosing for age, heart failure, liver disease, smoking, interactions

85
Q

What happens when you end up in the ER with an asthma exacerbation?

A
  • Frequent inhaled high-dose beta agonists
  • Systemic cortisosteroids. More than one dose!! (oral or parenteral)
  • Consider ipratropium
  • Avoid theophylline

Integrated Drug Structure, Function, and Therapeutics Winter Term (18 decks)

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