Corticosteroids

Question 0

Asthma step guide to ICS

Answer 0

Step 1: SABA
Step 2: Low-dose ICS
Step 3: ICS+LABA or medium dose ICS
Step 4: Medium dose ICS+LABA
Step 5: High dose ICS+LABA and consider omalizumab
Step 6: same as 5 plus oral corticosteroid

Question 1

Indications for use of inhaled corticosteroids

Answer 1

Maintenance, control therapy for asthma and COPD

Intranasal agents for seasonal and perennial allergic and nonallergic rhinitis

Question 2

GOLD guidelines for COPD

Answer 2

Group A: SABA
Group B: LABA
Group C: LABA+ICS or LAMA (consider roflumilast)
Group D: LABA+ICS and/or LAMA (consider roflumilast)

Question 3

HPA axis

Answer 3

Physical stress excites the hypothalamus cause impulses to be sent to median eminence, where CRF is released. CRF acts on the anterior pituitary gland where corticotropin is released into the bloodstream. Corticotropin (ACTH) stimulates adrenal cortex to secrete glucocorticoids, like cortisol

Body cannot distinguish between endogenous and exogenous steroids
Administration of corticosteroids inhibits HPA axis activity

Question 4

Inflammation in Asthma

Answer 4

Hyperresponsiveness

• mediated by mast cells and eosinophils
• release of mediators causing smooth muscle contraction, swelling and remodeling, and mucus secretion.

Reactions are biphasic (Early and late)

Early- IgE (peaks at 15 mins)
Late-mast cell mediators (occurs 6-8hrs after, can last 24hrs)

Question 5

Asthma vs COPD airflow limitation

Answer 5

Asthma- Mast cells, CD4 cells and eosinophils lead to bronchoconstriction and reversible airflow obstruction

COPD- macrophages, CD8 cells and neutrophils lead to small airway narrowing and alveolar destruction and irreversible obstruction

Question 6

Corticosteroids mode of action

Answer 6

To induce gene expression for anti-inflammatory proteins and receptors

To supress gene expression for proinflammatory proteins

Question 7

Beclomethasone (MDI)

Answer 7

QVAR 50-60% lung deposition

Low first pass effect, swallowed portion may become active in systemic circulation.

Question 8

Flunisolide (MDI)

Answer 8

AeroSpan

80ug/puff BID

Question 9

Budesonide (DPI and solution)

Answer 9

PULMICORT (Turbuhaler or respules)

Question 10

Mometasone

Answer 10

ASMANEX (twisthaler)
Once daily (approved for pts as young as 4years)

Question 11

Ciclesonide

Answer 11

ALVESCO (MDI)

Prodrug to decrease candida infection in mouth

Question 12

Fluticasone (MDI and DPI)

Answer 12

FLOVENT (HFA or diskus)

Therapeutic index of 91 (high first pass effect)

Question 13

Fluticasone + Salmeterol

Answer 13

ADVAIR (MDI or DPI diskus)

Question 14

Budesonide + Formoterol (MDI)

Answer 14

SYMBICORT turbohaler

Question 15

Mometasone + Formoterol (MDI)

Answer 15

DULERA

Question 16

Applications of steroids in COPD and ASTHMA

Answer 16

Asthma- early use, acute severe asthma, inhaled corticosteroids to control.

COPD- relieves symptoms, no effect on FEV1