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ACAAI Review 3rd Edition > Ch. 7 Pharmacology & Therapeutics > Flashcards

Ch. 7 Pharmacology & Therapeutics Flashcards

1
Q

How long does cat allergen remain in the home after cat removal?

A

4-6 months

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2
Q

Indications for AIT?

A

allergic rhinitis/conjunctivitis, allergic asthma, atopic dermatitis with aeroallergen sensitization, venom hypersensitivity

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3
Q

With regard to asthma, AIT improves what?

A

bronchial hyper responsiveness only, there is NO effect on pulmonary functions tests

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4
Q

With regard to AR, AIT improves what?

A

symptom scores, quality of life, and medication reduction

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5
Q

What happens to allergen-specific IgE in the first few months of AIT?

A

allergen-specific IgE increases (decreases later).

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6
Q

What immunologic changes are expected with completion of AIT?

A

Increase: IgG4, IgA in respiratory secretions, Tregs, CD8+ T cells, Th1 cytokines (IFNgamma, IL-12), Th1/Th2 ratio, IFNg/IL-4 ratio

Decrease: allergen-specific IgE (initially increases), early-late response to allergen, FcERII (CD23 - low affinity receptor), basophil hyperactivity, recruitment of eos/baso/mast cells, allergen-specific lymphocyte proliferation

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7
Q

What are the standardized extracts?

A

cat, dust mite, grass (northern grasses and Bermuda), ragweed

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8
Q

What color vial is 1:10,000 vol/vol (1:1,000,000 w/v)

A

silver

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9
Q

What color vial is 1:1000 vol/vol (1:100,000 w/v)

A

green

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10
Q

What color vial is 1:100 vol/vol (1:10,000 w/v)

A

blue

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11
Q

What color vial is 1:10 vol/vol (1:1000 w/v)

A

yellow

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12
Q

What color vial is 1:1 vol/vol (1:100 w/v)

A

red (maintenance)

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13
Q

Name the 7 northern grasses

A

timothy, orchard, kentucky blue, perennial rye, sweet vernal, red top, meadow fescue

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14
Q

Which two southern grasses cross-react?

A

bahia and johnson

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15
Q

What does glycerin in allergen extracts do?

A

inhibitor of proteolytic activity that can be irritating/painful (NOT associated with local reactions)

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16
Q

What does phenol in allergen extracts do?

A

antibacterial

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17
Q

Which allergen extracts contains proteolytic enzymes that degrade pollen?

A

mold and cockroach

Note: can mix mold and cockroach together

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18
Q

T or F, can you mix dust mite (in >10% glycerin) with cockroach and mold?

A

T

Note: Can also mix dust mite with pollen, dog/cat

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19
Q

Which venoms can be mixed together?

A

Mixed vespid (yellow jacket, white hornet, yellow hornet)

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20
Q

What is the maintenance dose for a single venom?

A

100ug

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21
Q

What is the maintenance dose for mixed vespid

A

300ug

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22
Q

What is the effective BAU for cat allergen?

A

1000-4000 BAU

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23
Q

What is the effective dose for dog allergen Can f 1?

A

15ug Can F 1

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24
Q

What is the effective AU for dust mites (Der f1, Der p1)?

A

500-2000 AU

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25
Q

What is the effective BAU for Bermuda?

A

300-1500 BAU

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26
Q

What is the effective BAU for grass

A

1000-4000 BAU

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27
Q

What is the effective dose of Amb a1 and AU?

A

6-12 ug Amb a 1; 1000-4000 AU

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28
Q

In general, what is the range of the effective maintenance dose for most inhalant allergens?

A

5-20 ug per 0.5mL maintenance dose

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29
Q

What are the 5 grasses in the SLIT tablet and when do you start?

A

timothy, orchard, kentucky blue, perennial rye, sweet vernal; 16 weeks before grass season
(age 10-65)

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30
Q

What is the grass pollen in the single SLIT tablet and when do you start?

A

timothy grass; start 12 weeks before grass season

age 5-65

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31
Q

What allergen is in the ragweed tablet and when do you start?

A

Amb a 1; 12 weeks before ragweed season

age 18-65

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32
Q

Which anti-histamines need dose adjustment if there is hepatic impairment, i.e. exclusively cleared by the liver?

A

1st generation: diphenhydramine, doxepin, hydroxyzine

2nd generation: loratadine

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33
Q

Which anti-histamines need dose adjustment for renal impairment, i.e. exclusively cleared by the kidney?

A

fexofenadine

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34
Q

Which anti-histamines are both cleared by the kidney and liver and need adjustment for renal and hepatic impairment?

A

cetirizine, desloratadine, levocetirizine

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35
Q

Which anti-histamines are pregnancy class B?

A

1st gen: chlorpheniramine, diphehydramine
2nd gen: cetirizine, levocetirizine, loratadine
topical: emedastine

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36
Q

Adverse effect of dry mouth and urinary retention are due to H1 antihistamine effects on which receptor?

A

muscarinic / cholinergic receptors

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37
Q

Cyproheptadine can cause increased appetite due to its effect on which receptor?

A

serotonin receptor

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38
Q

What is the mechanism of action of albuterol?

A

binds to B2 receptor (GPCR), activates adenylate cyclase, increases cAMP, activating PKA, leading to phosphorylation and muscle relaxation (bronchodilation)

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39
Q

What accounts for salmeterols longer/slower onset of action compared to formoterol?

A

greater lipophilicity

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40
Q

Increasing the bulk of the B agonist side chain results in what pharmacologic property?

A

increased selectivity for B2 receptor, prolonged duration of action, and protects from catceholamine-O-methyltransferase (COMT) degradation

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41
Q

Increasing the size of the terminal amino group of B agonists results in?

A

protection from degradation by monamine oxidase

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42
Q

What genetic polymorphism has been shown to result in B2 agonist receptor down regulation resulting in resistance to smooth-muscle relaxing effect of B2 agonists?

A

B16 Arg/Arg homozygosity

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43
Q

Name the 5 non-selective B blockers

A

propanolol, timolol, pindolol, nadolol, labetalol (also blocks alpha 1)
Note: associated with blunted response to B2 agonists

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44
Q

Name the 2 cardioselective B blockers

A

metoprolol and atenolol

Note: >20 times more affinity for B1 receptors

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45
Q

What are the effects of leukotriene antagonists in AERD?

A
  1. Improves FEV1
  2. Less need for rescue B agonist
  3. decrease in asthma exacerbations
46
Q

Which leukotriene antagonist can have liver toxicity and can interact with warfarin leading to increased PT time?

A 
zafirlukast
Note: Pregnancy class B
47
Q

Which leukotriene antagonist can increase ALT (liver transaminases), inhibits CYP1A2, and affects the levels of theophylline, warfarin, and propranolol?

A 
Zileuton (5-LO inhibitor)
Note: Pregnancy class C
48
Q

Antileukotriene therapy has been associated with what disease due to unmasking with corticosteroid taper?

A

eosinophilic granulomatosis with polyangiitis (EGPA aka Churg-Strauss)

49
Q

What is the function of the M2 (muscarinic) receptor?

A

inhibitory receptor on parasympathetic nerves, decreases Ach release

50
Q

Which muscarinic receptor is the primary mediator of smooth muscle contraction in human airways?

A

M3 receptor - increases intracellular Ca, causing bronchoconstriction

51
Q

Ipratropium is recommended in the 2007 EPR3 to be used in combination with B agonists in mod-severe asthma exacerbations because it has been shown to decrease…?

A

hospitalization rates

52
Q

Ipratropium blocks M2 and M3 receptors with equal affinity, blocking of M2 receptors can lead to?

A

bronchoconstriction (blocking M2 receptors leads to increase Ach release, thus why you can see paradoxical bronchoconstriction with ipratropium)

53
Q

Theophylline is metabolized by cytochrome P450, what medications can INCREASE its serum levels?

A

macrolide antibiotics, cimetidine, cipro, verapamil, zileuton, allopurinol

54
Q

Theophylline is metabolized by cytochrome P450, what medications can DECREASE its serum levels?

A

carbamazepine, phenobarbital, phenytoin, rifampin, ethanol

55
Q

Adverse effects of theophylline are seen at plasma levels greater than…?

A

> 20 mg/L

56
Q

Steroids cause what type of cataracts?

A

sub capsular posterior cataracts

57
Q

Which phase of antigen challenge do steroids inhibit?

A

late phase only

58
Q

Relative anti-inflammatory potency of ICS

A

mometasone > fluticasone > budesonide = beclomethasone

59
Q

Where does omalizumab bind?

A

CH3 domain (Fc portion) of IgE

60
Q

What happens to total and free IgE with omalizumab?

A

free IgE decreases, total IgE increases

61
Q

What is the difference between the FcERI receptors on mast cells and basophils compared to other cells?

A

FcERI on mast cells & basophils has 4 chains (one alpha, one beta, two gamma chains)

FcERI on other cells has 3 chains: NO BETA CHAIN (one alpha, two gamma chains)
Note: IgE binds to alpha chain

62
Q

What infection has been reported in patients taking mepolizumab?

A

herpes zoster (shingles)

63
Q

What is the dose for omalizumab in asthma?

A

based on weight and total IgE (between 30 - 700 IU/ml)

64
Q

What is the dose for omalizumab in CIU?

A

150mg or 300mg subq every 4 weeks

65
Q

What is the dose for mepolizumab in asthma?

A

100mg subq every 4 weeks

blood eos>150 cells/uL, or 300 in last 12 months

66
Q

What is the dose for reslizumab in asthma?

A

3mg/kg IV every 4 weeks

blood eos >400

67
Q

What is the most common adverse event with reslizumab?

A

oropharyngeal pain

68
Q

Medications that decrease glucocorticoid metabolism

A

OCPs, macrolide antibiotics, ketoconazole

69
Q

What is the incidence of anaphylaxis with omalizumab?

A

0.20%

70
Q

Cyclosporine binds to…?

A

cyclophilin (immunophilin)

71
Q

Tacrolimus binds to…?

A

FK-binding protein (immunophilin)

72
Q

Which interferon is approved for clinical use for CGD and malignant osteopetrosis?

A

IFNgamma-1b

73
Q

Which TNF inhibitor binds both TNFa and TNFb?

A

etanercept (enbrel)

all others bind TNFa only (infliximab, adalimumab, certolizumab pegol, golimumab)

74
Q

A screen for which infectious organism is needed prior to starting TNF inhibitors and annually while on therapy?

A

mycobacterium tuberculosis (PPD test)

75
Q

COX-2 inhibitors

A

celecoxib, etoricoxib, lumiracoxib, parecoxib, rofecoxib, valdecoxib

76
Q

AERD patients typically tolerate acetaminophen at what dose?

A

<1000 mg

77
Q

COX-1 inhibition results in decreased production of?

A

PGE2 - inhibitor of 5-LO

78
Q

When should leukotriene inhibitors be started prior to aspiring challenge/desensitization for AERD?

A

1 week prior

79
Q

At what dose do reactions to aspirin desensitization typically occur?

A

40mg

80
Q

In children or infant CPR, if there are 2 rescuers, what is the compression: breath ratio?

A

15:2
Note: 30:2 for adults or child with 1 rescuer

81
Q

Patient is on b-blocker, first drug given for anaphylaxis?

A

Epinephrine

0.01 mg/kg SC/IM of 1:1000 dilution; 0.01 mg/kg IV of 1:10,000 dilution

82
Q

Name the live vaccines

A

MMR, Nasal flu, Oral polio, Rotavirus, Smallpox (Vaccinia), Varicella, Zoster

83
Q

Live vaccines must be separated by how many days if not given the same day?

A

28 days

84
Q

If a patient does not have a functioning spleen, how should you administer PCV13 and Menactra?

A

administration should be separated by 4 weeks

85
Q

After IVIG or packed RBCs, how long to wait before giving live vaccine?

A

> 3 months for live vaccine

86
Q

After packed RBCs, how long to wait before giving non-live vaccine? After IVIG?

A

6 months after RBC, 8 months after IVIG

87
Q

If a live vaccine is given, how long to wait to give IVIG?

A

2 weeks

exception: no issue with pavlizumab and live vaccine

88
Q

Which vaccines contain egg?

A

Influenza, Yellow fever

89
Q

What are the gelatin containing vaccines?

A

MMR. Varicella-zoster, rabies, and yellow fever

90
Q

Which vaccine causes a delayed urticaria and angioedema?

A

Japanese encephalitis virus (JEV) vaccine

91
Q

Which vaccine can cause eczema vaccinatum?

A

smallpox vaccine

92
Q

If not given the same day, TB skin test and MMR should be spaced by?

A

4 weeks

93
Q

Contraindications to live vaccines

A

pregnancy, immunosuppression

94
Q

Contraindication to vaccination

A

severe allergic reaction (anaphylaxis) to vaccine, encephalopathy <7 days after pertussis vaccine, hx of Guillain-Barre

95
Q

Indications for tympanostomy tubes

A 
OME with structural damage
Recurrent OME (3 or more in 6 months, 4 or more in 1 year)
Persistent OME (3 months bilateral, 6 months unilateral)
Hearing loss
96
Q

Type IVa - cytokines, cells involved, skin findings

A

Th1 (IFNg), monocyte, eczema

97
Q

Type IVb - cytokines, cells involved, skin findings

A

Th2 (IL-4, IL-5), eosinophil, maculopapular or bullous

98
Q

Type IVc - cytokines, cells involved, skin findings

A

CTL (perforin, granzyme), CD4 and CD8, maculopapular/bullous/pustular

99
Q

Type IVd -cytokines, cells involved, skin findings

A

T lymphocytes (IL-8), PMNs, pustular

100
Q

Which MHC marker is associated with abacavir reaction?

A

HLA-B*5701

101
Q

MHC marker associated with carbamazepine reaction?

A

HLA-B*1502

102
Q

What is the major determinant for Penicillin?

A

benzylpenicilloyl polylysine (Prepen)

103
Q

What is the NPV of PCN skin testing?

A

97%

104
Q

Aztreonam cross reacts with what B-lactam?

A

ceftazidime

105
Q

IgE mediated reactions to sulfa antibiotics are due to which determinant?

A

N4-sulfonamidoyl

106
Q

Risks for radio contrast adverse reactions?

A

female, asthma/atopy, CV disease, prior hx of reaction

107
Q

Treatment for SJS/TEN?

A

supportive, IVIG may be helpful.

Note that steroids are contraindicated in TEN

108
Q

Vancomycin is associated with what skin condition?

A

linear IgA bullous dermatitis

109
Q

Mechanism of HIT (heparin induced thrombocytopenia)?

A

IgG to heparin platelet factor 4 immune complexes

110
Q

Most common drug causing serum sickness in kids?

A

cefaclor

111
Q

autoAb in drug induced CUTANEOUS lupus? Most common drugs to cause?

A

anti-Ro (SSA) or anti-La (SSB);

HCTZ, CCB, ACE-I, antifungals

112
Q

AutoAb in drug induced lupus (systemic)? Common offending agents?

A

antihistone;

procainamide, hydralazine, phenytoin, isoniazid

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