Chapter 34: Asthma

Question 1

What is the brand name of salmeterol + fluticasone?

Answer 1

Advair®

Question 2

What is the brand name of formoterol + budesonide?

Answer 2

Symbicort®

Question 3

What is the brand name of formoterol + mometasone?

Answer 3

Dulera®

Question 4

Formoterol is a LABA called Foradil® that comes as capsule for use in an aerolizer DPI inhaler. The typical dose is inhale 1 capsule BID via aerolizer. How are these capsules stored?

Answer 4

Formoterol (Foradil®) capsules are stored in the refrigerator while in the pharmacy. However, patients can keep the capsules at room temperature for up to 4 months without affecting stability.

Question 5

Why is Asthmaneferin® SABA not recommended for asthma patients?

Answer 5

Asthmaneferin® is an OTC SABA that should not be used in asthma patients due to it being non-selective.

Question 6

A patient is using her Proventil® HFA 3x/week. Is a change in maintenance therapy required for this patient?

Answer 6

Maybe. Prior to adjusting maintenance therapy, the patient’s adherence and inhalation technique should be assessed. If these two check out, maintenance therapy should be adjusted.

If using SABA > 2 days/week for Sx control, asthma is not considered controlled and maintenance therapy should be increased.

Question 7

What is the brand name of Beclomethasone HFA?

Answer 7

QVAR®

Question 8

What are the generic components of Symbicort®?

Answer 8

Formoterol + Budesonide (Symbicort®)

Question 9

What are the generic components of Advair Diskus®?

Answer 9

Salmeterol + Fluticasone (Advair®)

Question 10

What is the brand name of budesonide inhaled corticosteroid?

Answer 10

Pulmicort®

Question 11

What are two different brands name of fluticasone inhaled corticosteroid?

Answer 11

1. Flovent®

2. Arnuity Ellipta®

Question 12

What is the brand name of mometasone inhaled corticosteroid?

Answer 12

Asmanex®

Question 13

What is the brand name of vilanterol + fluticasone?

Answer 13

Breo Ellipta®

Question 14

What is the brand name of ciclesonide inhaled corticosteroid?

Answer 14

Alvesco®

Question 15

What are the 4 classic S/Sx of asthma?

Answer 15

1. SOB
2. wheezing
3. coughing
4. chest tightness

Question 16

What boxed warning do all LABA have?

Answer 16

increased risk of asthma-related deaths

LABA should only be used as adjunctive therapy in patients already taking long-term asthma control medication such as inhaled corticosteroid

Question 17

T/F:

A spacer device helps prevent oral thrush when used with inhaled corticosteroids?

Answer 17

True

Question 18

Which of the following are leukotriene modifying agents used in the treatment of asthma?

A. Accolate®
B. Montelukast
C. Alvesco®
D. Zafirlukast
E. Breo Ellipta®

Answer 18

A, B, D are all leukotriene modifying agents

Zafirlukast (Accolate®) and montelukast (Singulair®) are leukotriene receptor antagonists. Alevsco® is the brand name for ciclesonide, an ICS, and Breo Ellipta is the combination of vilanterol and fluticasone, a LABA + ICS.

The other leukotriene modifying agent not listed is Zileuton (Zyflo®) which is a 5-lipooxygenase inhibitor which inhibits leukotriene formation. Leukotriene modifying agents help decrease airway edema, constriction, and inflammation.

Question 19

When is Singular® taken when used chronically for asthma?

Answer 19

Montelukast (Singulair®) is dosed 10mg PO daily in the evening. The most common SE are HA, URTI, dizziness, and stomach pain

Question 20

What is the therapeutic range for theophylline?

Answer 20

5-15 mcg/mL

Measure trough levels after 3 days of oral dosing at steady state. Peak levels are less reliable b/c of delayed absorption with most oral products (unless you suspect patient is having toxicity)

Question 21

What are the signs of theophylline toxicity?

Answer 21

Persistent and repetitive vomiting, seizures, and ventricular tachycardias

Question 22

Advair® is available as a diskus and an HFA. Is there any difference in dosing between these 2 inhalers?

Answer 22

Yes

Advair® Diskus is dosed 1 inhalation BID
Advair® HFA is dosed 2 inhalations BID

Both inhalers come as 30-day supplies. The HFA has 120 metered doses while the diskus has 60 capsules loaded

Question 23

What are the generics of the following:

Asmanex®
Arnuity Ellipta®
Symbicort®
Breo Ellipta®

Answer 23

Asmanex® - mometasone
Arnuity Ellipta® - fluticasone
Symbicort® - formoterol + budesonide
Breo Ellipta® - vilanterol + fluticasone

Question 24

Common SE of ICS include which of the following: (Select all that apply)

A. Tachycardia
B. Oral candidiasis
C. Dysphonia
D. Hyperglycemia
E. Cough

Answer 24

B, C, D, E

All the above are SE of ICS except (A) tachycardia. This is a SE of LABA and SABA. Also, long term, high dose use of ICS is associated with increased risk of fractures, and pneumonia.

Question 25

Which (2) MDIs do NOT need to be shaken prior to use?

Answer 25

1. Ciclesonide (Alvesco®) | 2. Beclomethasone (QVAR®)

Question 26

What is the generic for Asmanex® Twisthaler?

Answer 26

mometasone (Asmanex Twisthaler®)

Question 27

What are the generic components of Dulera®

Answer 27

formoterol + mometasone

Question 28

What is a common SE of the leukotriene modifying agents?

Answer 28

Headache Leukotriene modifying agents include: Zafirlukast (Accolate®) Montelukast (Singulair®) Zileuton (Zyflo®)

Question 29

T/F: | Zafirlukast (Accolate®) can be taken without regard to meals?

Answer 29

False Zafirlukast (Accolate®) must be taken 1 hr before or 2 hrs after meals (empty stomach). This drug is a leukotriene receptor antagonist used in the treatment of asthma by helping to decrease airway edema, constriction, and inflammation

Question 30

What is the MOA of theophylline?

Answer 30

Theophylline blocks phosphodiesterase causing an increase in cAMP which promotes release of epinephrine causing bronchodilation and many other effects such as reduced inflammation, diuresis, CNS and cardiac stimulation, and gastric acid secretion

Question 31

How do you convert IV aminophylline to oral theophylline dose?

Answer 31

Multiply IV aminophylline daily dose by 0.8 to get the oral theophylline equivalent dose.

Question 32

What are some counseling points that can help reduce the risk of oral thrush in patients taking ICS? (Select all that apply) A. Drink 8oz of water after taking his medications B. Gargle with warm water and spit out the rinse after using this medication C. Purchase a spacer device and use with Foradil D. Purchase a spacer device and use with Flovent HFA E. Do not kiss others with oral thrush infection b/c it is contagious

Answer 32

B,D Oral thrush is not contagious

Question 33

Which of the following are correct statements regarding Asthmanefrin? (Select all that apply) A. This medication contains the R-isomer of epinephrine B. This medication is available OTC C. This medication is not preferred in patients with asthma D. This medication can cause more thrush than others on the market E. This medication is preferred in patients with cardiac disease

Answer 33

B, C Asthmanefrin is a racemic mixture of epinephrine that is available OTC. Since it is not beta-2 selective, it is not preferred as a SABA in asthma.

Question 34

Which of the following medications can decrease theophylline levels? ``` A. Allopurinol B. Citalopram C. Carbamazepine D. Primidone E. Quinidine ```

Answer 34

C,D Carbamazepine and primidone can increase the metabolism of theophylline decreasing the level. Primidone is an anticonvulsant used in the treatment of seizure disorder Allopurinol would INCREASE levels of theophylline

Question 35

Which leukotriene modifying agent can cause hepatotoxicity not seen with the other agents?

Answer 35

Zileuton (Zyflo®) Zilueton is a 5-lipoxygenase inhibitor which inhibits leukotriene formation. This class of medications (leukotriene modifying agents) is also implicated in causing neuropsychiatric events like aggressive behavior, hostility, agitation; and systemic eosinophilia (Churg-Strauss syndrome) Churg-Strauss syndrome, also called allergic granulomatosis is an autoimmune condition that causes vasculitis (inflammation of blood vessels). It manifests as (3) stages: 1. Allergic stage characterized by asthma or allergic rhinitis 2. Eosinophilic stage characterized by abnormally high level of eosinophils which can cause tissue damage 3. Vasculitis stage characterized by inflammation of blood vessels (hallmark of Churg-Strauss) with reduced blood flow to organs, risk of clots, cell death, and fatalities.

Question 36

At what time of day should montelukast be dosed? ``` A. In the AM B. In the PM C. It doesn't matter D. At bedtime with a snack E. None of the above ```

Answer 36

B. Montelukast (Singulair®) should be dosed 10mg PO in the evening for adults

Question 37

Which of the following statements about Theo-24 are correct? (Select all that apply) A. Signs of toxicity include persistent/repetitive vomiting, ventricular tachycardias, and seizure B. Dosing is always based on TBW C. Therapeutic range is 5-15 mcg/L D. Two active metabolites are caffeine and 3-methylxanthine E. Common SE include nausea, loose stools, HA, tachycardia, and tremor

Answer 37

A, D, E are correct B and C are incorrect Theophylline dosing is always based on IBW, not TBW. The therapeutic range for theophylline is 5-15 mcg/mL, not 5-15 mcg/L (always check your units!)

Question 38

A patient is admitted to the hospital for seizure disorder and it is found that they are taking theophylline outpatient for management of asthma, along with other ICS and SABA. The patient is currently NPO and the physician asks the pharmacists to convert the patient's oral theophylline dose to IV aminophylline. How should you as the pharmacist proceed?

Answer 38

Use of theophylline is contraindicated in patients with seizure disorder. The patient may be experiencing a seizure due to theophylline toxicity. This order should not be filled and theophylline level should be checked. Remember, therapeutic range for theophylline is 5-15 mcg/mL. If the patient wasn't admitted for seizure disorder and there were no other contraindications the total daily oral theophylline dose would be DIVIDED by 0.8 to get the IV aminophylline dose since aminophylline contains 80% theophylline.

Question 39

Which of the following drugs/food/herbal supplements would increase theophylline levels potentially exposing a patient to theophylline toxicity? (Select all that apply) ``` A. Cipro® B. Charbroiled meats C. Marijuana D. St. John's Wort E. Ortho-Evra ```

Answer 39

A, E B,C,D are incorrect Charbroiled meats, marijuana, and St. John's Wort can all DECREASE theophylline levels as these are enzyme INDUCERS.

Question 40

T/F: Theophylline follows 1st order kinetics, so increasing the dose will increase the concentration in a predictable fashion.

Answer 40

False Theophylline initially follows 1st order kinetics, but then changes to zero-order kinetics. It is based on a 2-compartment model, where the central compartment is the first and the bronchioles are the second compartment. Theophylline toxicity is associated with high concentrations in the central compartment so infusions must be given slowly. Zero-order kinetics means that small increases in dose can lead to large increases in theophylline concentrations.

Question 41

Which of the following statements about Xolair® are correct? (Select all that apply) A. The generic is omalizumab B. It is a monoclonal antibody SC injection used in the treatment of moderate-severe asthma C. Xolair® is administered SC once weekly for asthma treatment maintenance dose D. There is a boxed warning for anaphylaxis E. Xolair® is pregnancy category D

Answer 41

A, B, D are correct omalizumab (Xolair®) is a monoclonal antibody that inhibits IgE binding to the IgE receptor on mast cells and basophils indicated in step 5 or step 6 asthma patients already taking ICS. Xolair® must be administered in a Dr's office due to the boxed warning of anaphylaxis which can occur anytime from the first dose to after 1 year of starting therapy. C and E are incorrect Xolair® is administered by SC injection every 2 - 4 weeks (in a healthcare setting), not once weekly. It is pregnancy category B, not D

Question 42

Which of the following statements about Xolair® are correct? (Select all that apply) A. Xolair® can increase a patient's risk of CV or cerebrovascular events B. Can cause earache, joint pain, and dizziness C. Xolair® does not cause pruritus or dermatitis D. Xolair® is contraindicated in hepatic impairment E. Xolair® must be renally dose adjusted

Answer 42

A, B are correct Xolair® DOES cause pruritus and dermatitis, it is not contraindicated in hepatic impairment (Zafirlukast, a leukotriene modifying agent, is CI in hepatic impairment), and there are no renal dose adjustments recommended in the package labeling.

Question 43

What is the brand name of the new interleukin-5 (IL-5) receptor antagonist monoclonal antibody (IgG1 kappa) mepolizumab indicated as add-on treatment for severe asthma with an eosinophilic phenotype in patients greater than 12 years of age?

Answer 43

Mepolizumab (Nucala®) is dosed 100mg SC once every 4 weeks. Similar to omalizumab (Xolair®) it inhibits IgE binding to the IgE receptor on mast cells and basophils by blocking interleukin-5 receptor.

Question 44

Which inhaled asthma medication class is the DOC for exercise-induced bronchospasm prevention?

Answer 44

SABA SABA should be taken 5-15 minutes prior to exercise. They last 2-3 hours. Montelukast can also be taken for EIB prevention, but must be taken 2 hours prior to exercise. However, montelukast can last up to 24 hours. The downside is that it is only effective in about 50% of patients

Question 45

What is the preferred SABA in pregnancy? What is the preferred ICS in pregnancy?

Answer 45

SABA - albuterol (Proventil®, ProAir®, Ventolin®) ICS - budesonide (Pulmicort® Flexhaler, Pulmicort® Respules) There is simply more data on these agents and therefore designated as preferred agents

Question 46

Which of the following are appropriate uses of Singulair® oral granules for children 6 yrs or older: (Select all that apply) A. Dissolve in 1 tsp of cold or room temp baby formula or breast milk B. Place directly in child's mouth C. Mix with 1 spoonful of mashed carrots D. Mix several oral granule packets with a container of applesauce and store in refrigerator for use of the course of no more than 7 days E. Mix with 1 spoonful of ice cream

Answer 46

A, B, C, E are correct Singulair® oral granules cannot be mixed with any liquid other than baby formula or breast milk...not even water. D is incorrect. Singulair® oral granules should not be stored mixed with food for use at a later time.