COPD/Asthma adverse effects and clinical protocols

Question 1

What are the adverse effects for ICS inhalers

Answer 1

oral thrush (candidiasis), cough, dysphonia

Question 2

what are the counseling points for ICS inhalers?

Answer 2

1. rinse mouth and spit after each use to prevent thrush
2. may increase pneumonia risk in pts with COPD
3. titrate to lowest effective dose
4. high doses increase the risk for systemic side effects

Question 2

what is a counseling point for pulmicort respules?

Answer 2

use jet nebulizer and should not mix with other neb medications

Question 3

what are the adverse effects for LABA inhalers?

Answer 3

tachycardia, headache, tremor, hypokalemia

Question 4

what are the clinical pearls for LABAs?

Answer 4

1. prolonged QT seen in intentional overdoses
2. not for acute symptoms
3. may be helpful to exercise for induce bronchospasm
4. formoterol and indacaterol capsules shouldn’t be taken orally

Question 5

what are the black box warnings for LABAs?

Answer 5

1. for increased risk of asthma related death for all monotherapy LABA use should not be used alone for asthma management
2. for increasing hospitalizations in pediatric and adolescent patients

Question 6

what are the adverse effects for LAMAs?

Answer 6

dry mouth, dizziness, blurred vision, upper respiratory infections, and paradoxical bronchospasms

Question 7

what is a clinical pearl for LAMA inhaler Spiriva?

Answer 7

has been approved for asthma > or equal to 12yo

Question 8

what are some clincal pearls for ICS/LABA combo inhalers?

Answer 8

1. guidelines recommend combo LABA/ICS in asthma, as LABA shouldn’t be used as monotherapy
2. combo products developed to create convenient packaging and adherence

Question 9

what is the clinical pearl for LABA/LAMA combo?

Answer 9

not indicated in use for asthma

Question 10

what are the adverse effects for leukotriene modifiers?

Answer 10

neuropsych events (agitation, anxiety, hallucinations, depression), Churg-Strauss syndrome (rare), increased hepatic transaminases (zafirlukast/ zileuton)

Question 11

what are the clinical pearls for leukotriene modifiers?

Answer 11

1. less effective than low dose ICS and ICS/LABA in athma
2. have not been adequately trailed in COPD

Question 12

what are the specific clinical pearls for monteukast?

Answer 12

1. minor substrate CYP2C8/9 and 3A4
2. not for acute asthma relief
3. boxed warning: neuropsych events

Question 13

what are the specific clinical pearls for zafirlukast?

Answer 13

1. take at least 1 hr b4 or 2 hrs after meals
2. can increase INR
3. major substrate: minor inhibitor of CYP2C9

Question 14

what are the specific clinical pearls for zileuton?

Answer 14

1. weak CYP1A2 inhibitor
2. take with food

Question 15

what are the adverse effects of theophylline?

Answer 15

insomnia, GI upset, hyperactivity, hypotension, tremor

Question 16

what are the clinical pearls for theophylline?

Answer 16

1. major GI best; can mess it up
2. lots of interactions with medications
3. can cause seizures, peptic ulcer disease, arrhythmias
4. has dose related toxicity related to nausea, vomiting, tachycardia

Question 17

what are the Adverse effects for omalizumab?

Answer 17

headache, injection site reactions, arthralgias, thrombocytopenia, pharyngitis, sinusitis, upper respiratory tract infections

Question 18

what are the clinical pearls for omalizumab?

Answer 18

1. no more than 150mg per injection site
2. monitor for anaphylaxis b4 and after inj
3. BLACK BOX: anaphylaxis
4. FDA approved for moderate to severe persistent asthma in patients with positive skin test or reactivity to a perennial aeroallergen and symptom’s inadequately controlled with ICS

Question 19

what are the adverse effects for mepolizumab?

Answer 19

headache, injection site reactions, arthralgias, herpes zoster infection

Question 20

what are the adverse effects for reslizumab?

Answer 20

injections site reactions, myalgias, increased creatine phosphokinase

Question 21

what are the clinical pearls for mepolizumab?

Answer 21

1. PREcaution: anaphylaxis
2. available in clinic or at home injections
3. indicated for add on maintenance treatment of patients with severe asthma with an eosinophilic phenotype
4. monitor before and after for anaphylaxis

Question 22

what are the clinical pearls for reslizumab?

Answer 22

1. BLACK BOX warning: malignancies, anaphylaxis
2. monitor for anaphylaxis before and after inj
3. indicated for add on maintenance treatment of patients with severe asthma with an eosinophilic phenotype

Question 23

what are the adverse effects for benrralizumab?

Answer 23

injection site reactions, antibody development, headaches, fever, pharyngitis

Question 24

what are the clinical pearls for benralizumab?

Answer 24

1. PREcaution: anaphylaxis 2. indicated for add on maintenance treatment of patients with severe asthma with an eosinophilic phenotype 3. available in clinic or at home injection 4. acts on IL-5R while others act on IL-5

Question 25

what are the adverse effects for dupixent?

Answer 25

injection site reactions, antibody development, arthralgias, conjunctivitis

Question 26

what are the clinical pearls for dupixent?

Answer 26

1. PREcaution: anaphylaxis 2. available in pre-filled syringe for in office or at home admin 3. indicated as add on maintenance in moderate-severe asthma ages 12 and older with eosinophilic phenotype or with oral corticosteroid dependent asthma

Question 27

what are the adverse effects for daliresp?

Answer 27

Headache, weight loss, diarrhea, nausea

Question 28

what are the adverse effects for inhaled short acting B2 agonists (albuterol)?

Answer 28

tachycardia, tremor, hypokalemia, irritability

Question 28

what are the clinical pearls for daliresp?

Answer 28

1. monitoring: weight, liver function test 2. DI: CYP3A4 (major), CYP1A2 (minor) CI: child-pugh class B or C

Question 29

what are the clinical pearls for inhaled short acting B2 agonists (albuterol)?

Answer 29

1. chronic use (>2x a day) indicated poor asthma control 2. may mix neb sol with cromolyn sol, budesonide inhalent suspension or ipratropium sol 3. in mild to mod exacerbations, MDI plus valved holding chamber is as effective as neb therapy with appropriate admin technique and coaching by trained personnel

Question 30

what are the adverse effects for inhaled short acting B2 agonists (levoalbuterol)?

Answer 30

tachycardia, tremor, hypokalemia, irritability

Question 31

what are the clinical pearls for inhaled short acting B2 agonists (levoalbuterol)?

Answer 31

1. reserved for pts who do not respond to albuterol quickly 2. neb sol compatible with budesonide inhalant suspension 3. has not been evaluated by continuous neb 4. levoalbuterol admin in 1/2 mg dose of albuterol provides comparable efficacy and safety

Question 32

what are the adverse effects for short acting anticholinergics (ipratropium)?

Answer 32

dry mouth, urinary retention, infection, sinuitits, bronchitits

Question 33

what are the clinical pearls for short acting anticholinergics (ipratropium)?

Answer 33

1. used in combo with albuterol for asthma exacerbation treatment 2. may mix in same neb with albuterol 3. should not be used as first line therapy; should be added as SABA therapy for severe exacerbations

Question 34

what is another clinical pearl specific to duoneb?

Answer 34

may be used for up to 3 hrs in initial management of severe exacerbations

Question 35

what are the adverse effects of systemic corticosteroids?

Answer 35

hyperglycemia, increased appetite, fluid retention, demmargination of WBCs, psych disturbances

Question 36

what are the clinical pearls for inhaled corticosteroids?

Answer 36

1. CI: systemic fungal infections, admin of live vaccines if immunocompromised 2. DI: warfarin INR inc. ; dec. efficacy of inactivated vaccines 3. may be used with ICS if already taking before hospitalization 4. may be used for chronic therapy in both asthma COPD only in severe stages 5. bursts effective for establishing control when initiating therapy or during period of gradual deterioration 6. injection may be used in place of burst if adherence is an issue or patient is vomiting

Question 37

what are the additional comments related to epinephrine in the use of asthma exacerbations?

Answer 37

1. no proven advantage of systemic therapy over aerosol 2. indicated in addition to standard therapy for acute asthma associated with anaphylaxis and angioedema

Question 38

what are the additional comments related to terbutaline in the use of asthma exacerbations?

Answer 38

no proven advantage of systemic therapy over aerosol

Question 39

what are the adverse effects for magnesium sulfate in the use for asthma exacerbations?

Answer 39

flushing, hypotension, vasodilation

Question 40

what are the additional comments for magnesium sulfate in the use for asthma exacerbations?

Answer 40

1. CI: heart block, caution in renal dysfunction 2. consider if patient remains life threatening exacerbations after 1 hour of therapy