COPD & Asthma Flashcards
What is Asthma?
- chronic inflammatory disease of resp tract
- airway hyper-responsiveness
- Symptoms: wheezing, SOB, chest tightness, cough. bronchoconstriction and thickened bronchial wall and increased mucus secretion
Often worsened by: cigarette smoke, exercise, stress and certain medications e.g. aspirin or beta blockers
What are the asthma phenotypes?
- Allergic asthma: most common- associated with childhood, family history etc
- Non allergic asthma
- Adult onset asthma
- Asthma with persistent airflow limitation
- Asthma with obesity
How is asthma controlled?
- control asthma symptoms
- prevent future risk and exacerbations
How is asthma severity assessed? What type drugs are used for each type?
- mild: Step 1 or 2
- Step 1: low dose ICS
- Step 2: low dose ICS plus SABA
- moderate: Step 3
- low dose ICS and LABA
- severe: Step 4 or 5
- high dose ICS and LABA
What may be possible reasons for uncontrolled symptoms and/or exacerbations despite 2-3 months of controller treatment?
- incorrect inhaler usage
- poor adherence
- persistent exposure to allergens, tobacco smoke, air pollution etc.
- other comorbidities
- incorrect diagnosis
What are the medical categories for treatment of asthma?
- controller medication: reduce airway inflammation, control symptoms and reduce risk of exacerbation or decline in lung function
- Reliever medication: relief of breakthrough symptoms, also during worsening asthma or exacerbation
- Add on therapy for severe asthma: persistent symptoms and/or exacerbations despite optimised therapy with high dose controller medications (Step 4 or 5)
What points are important to consider when starting asthma therapy?
- goal of administering lowest effective dose of ICS to provide satisfactory therapeutic response
- correct monitoring of patient to identify correct dose
- ICS are initial therapy for symptom control in elderly patients and adolescents
- either in combo with LABA or alone
What is Stepping Up Treatment in Asthma?
- Sustained step up: 2-3 months increased maintenance dose to medium dosage
- Short term step up: 1-2 weeks increased maintenance ICS dosage during viral infection or seasonal allergen exposure
- Day to day: according to patient symptoms doses may be adjusted while continuing maintenance dosage
What is Stepping Down Treatment in Asthma?
- Once asthma is well controlled and maintained for 3 months and lung function has reached plateau, treatment can be reduced
Stepping down to:
- find patients minimum effective treatment
- maintain good control of symptoms and exacerbations
- minimize costs of treatment and possible adverse effects
What is COPD?
- preventable and treatable disease
- persistent respiratory symptoms and airflow limitations due to airway and/or alveolar abnormalities due to exposure to gases or noxious particles
What is the difference in pharmacotherapy approach in asthma and COPD?
Asthma:
- ICS either alone or in combo with LABA
- NOT recommended to use LABA/LAMA alone
COPD:
- LABA/LAMA with as-needed SABA (WITHOUT ICS)
Both Asthma & COPD:
- treat as asthma
- ICS containing therapy to reduce risk of exacerbations
- not recommended to use LABA or LAMA alone without ICS
Why is it essential to use ICS in asthma?
- ICS formoterol or SABA
- ICS formoterol is preferred reliever due to reduced risk of serious exacerbations
- research suggests not to use SABA w/o ICS- does not protect against exacerbations
What are ICS? MOA? AE? Contraindications?
e.g.
In combo with LABA:
- beclamethasone, budesonide (both combined with formoterol)
- fluticasone-salmeterol
- mometasone - formoterol
MOA: inhibit release of arachidonic acid through inhibition of phospholipase A2- anti inflammatory function
AE: not many experience AE’s- oropharyngeal candidiasis and dysphonia : can be reduced with the use of a spacer
* long term usage- increased risk of osteoporosis, cataract and glaucoma
Why use LABA with ICS?
- low dose of ICS alone fails to achieve good control of asthma
- LABA combo improves ICS symptoms, lung function and reduces exacerbation in more patients, more rapidly than x2ing the dose of ICS
What are the 2 regimens available for ICS combination with LABA?
1) low dose beclamethasone or budesonide with low dose formoterol (for maintenance and reliever treatment- MART)
2) Maintenance ICS-LABA with SABA as reliever
What are LABA AE?
- tachycardia, headache or cramps
- LABA should not be used alone in asthma due to increased risk of adverse effects
What are leukotriene modifiers (leukotriene receptor antagonist- LTRA)? AE?
- Montelukast, zafirlukast, pranlukast
- less effective than ICS in monotherapy
- less effective than ICS-LABA with put in combo with ICS
AE: elevated liver function tests (zilueton and zafirlukast)
What Long acting muscarinic antagonists (LAMA) are used in add-on controller medication for maintenance treatment?
- tiotropium
- glycopyrronium
- umeclidinium
*add on at Step 5 for patient with uncontrolled asthma despite ICS-LABA
What anti-IgE are used in add-on controller medication for maintenance treatment?
- Omalizumab
- in patients older than 6
- add on for severe allergic asthma, uncontrolled despite high dose ICS-LABA
What anti- IL5 & anti- IL5R are used in add-on controller medication for maintenance treatment?
- anti-IL5: mepolizumab
- subcutaneous older than 6
- reslizumab IV for patients > 18
- anti-IL5R: benralizumab
- subcutaneous in patients > 12 in severe persistent eosinophilic asthma
*add on option for patients with severe eosinophilic asthma, uncontrolled despite high dose ICS-LABA
What anti- IL4R are used in add-on controller medication for maintenance treatment?
-DUPLIMAB
- subcutaneous in patients > 6
*add on option for patients with severe eosinophilic asthma, uncontrolled despite high dose ICS-LABA
What systemic corticosteroids are used in add-on controller medication for maintenance treatment?
- prednisolone, prednisone, methyprednisolone, dexamethasone & hydrocortisone
- short term treatment (5-7 days) key for severe acute exacerbations with main effects seen after 4-6 hours
- effective preventing relapse OCS
- as last resort, patients with long term treatment with OCS may be required for some severe asthma patients
What are the AE of OCS?
- short course: sepsis, thromboembolism, sleep disturbance, reflux, hyperglycemia
maintenance use: cataract. glaucoma, diabetes, hypertension, adrenal suppression and osteoporosis
What are SABA? Use? AE?
- short acting inhaled beta-2 agonist bronchodilators
- e.g. salbutamol, terbutaline
- provide quick relief of asthma symptoms and bronchoconstriction
- should only be used for “as needed” basis and at lowest dose and frequency required
- SABA ONLY treatment no recommended due to severe exacerbation risks
AE: tremor, tachycardia
- tolerance develops rapidly within 1-2 weeks of regular use
