Drugs for Asthma and Chronic Obstructive Pulmonary Disease Flashcards
Asthma Pathophysiology REVIEW
chronic disorder of airway obstruction with airway inflammation r/t antigen-IgE antibody and mast cell binding ultimately resulting in bronchoconstriction and constant activation of inflammatory mediators
What are the management goals for asthma?
Reduce impairment, reduce recurrence risk, DECREASE SABA use.
Global Initiative for Asthma (GINA) recommends what for adults and adolescents
NO LONGER recommends treating asthma for adults or adolescents with SABA (short acting broncodialators) alone.
Should also receive symptom driven tx such as daily inhaled corticosteroids PRN to reduce exacerbation risk
Adverse effects of regular or FREQUENT use of Short Acting Beta Agonist (SABA)?
B receptor downreg, rebound response, decreased bronchodilator response, increased allergic response, increased inflammation.
ACUTE Severe Asthmatic Exacerbation Tx?
“SHOOIM”
Systemic glucocorticoid - reduce inflammation
High dose SABA - nebulized to reduce airflow obstruction
Oxygen - relieve hypoxemia
Oral glucocorticoid - for 5-10 days post exacerbation
Ipratopium - nebulized to reduce airway obstruction
Magnesium IV
Inhaled SABA with spacers vs alone?
Spacers INCREASED by 57% reaching lungs from only 10% admin alone
Glucocorticoids such as Budesonide or Fluticasone are used for what? MOA?
Asthma: prophylaxis, acute exacerbations, inhaled safer than oral
Suppress inflammation by decreasing mucous production and bronchial activity
MAY increase beta 2 receptors & response
Glucocorticoids such as Budesonide or Fluticasone a/e?
INHALED - Adrenal suppression, oral candidas, dysphonia
ORAL - PROFOUND adrenal suppresion - sudden withdrawal could lead to death
LONG TERM USE - both loss (greater with oral)
Leukotriene modifiers (Montelukast) can also be used for what? MOA? a/e?
Asthma, can help w/ tx by suppressing effects of leukotrienes
BLACK BOX WARNING - neuropsychiatric effects
Montelukast MOA & use?
BLOCKS leukotriene receptors.
Prevent exercise induced bronchospasm - if given 2 hours prior, noctural asthma, improves lung functioning,
What medication interacts with Montelukast?
Phenytoin – can DECREASE PLASMA LEVELS of montelukast.
A/e of Montelukast?
Can cause…
Neuropsychiatric events – suicide, nightmares and behavioral problems with children.
FDA ADVISES RESTRICTING USE FOR ALLERGIC RHINITIS & CONSIDERING MENTAL HEALTH OF PATIENT PRIOR TO ADMIN
Mast Cell Stabilizer (Cromolyn) MOA and Use?
MOA: suppresses inflammation, stabilizing mast cells, prevents histamine
Use: Prophylaxis for seasonal allergies r/t asthma, exercise induced bronchospasm, asthma
SAFEST OF ALL ANTI-ASTHMA MEDICATIONS
Omalizumab MOA, use, a/e?
MOA: binds free IgE reducing amount in body
Use: moderate to severe asthma
A/e: Viral infx, URI, anaphylaxis, monitor patients for two hours after first 3 doses
Beta 2 Adrenergic Agonists (Bronchodilators) MOA, Use, types?
Use: symptomatic relief of asthma, MOST EFFECTIVE for acute bronchospasm, prevents exercise induced bronchospasm.
MOA: activates beta 2 receptors initiating bronchodilation
LABA – long acting beta 2 agonists (used for increased risk of severe asthma or asmathic related death)
SABA – short acting beta 2 agonists
LABAs for Asthma examples?
anything ending in - terol
Salmeterol, Formoterol, Arfomoterol… etc
Theophylline MOA, use, a/e?
MOA: relaxes smooth muscle blocking adenosine receptors - decreasing frequency of attacks, LESS EFFECTIVE than beta-2 agonists.
Use: in COPD if patient cannot afford long term therapy.
What accelerates/decreases metabolism of Theophylline?
Smoking INCREASES
Fluoroquinolones DECREASE
Phenobarb, Phenytion, Rifampin INCREASE
Why would you CLOSELY monitor theophylline plasma levels?
Narrow therapeutic index (can see adverse effects with >30 mcg/ml causing V-fib and/or convulsions
Anticollinergic Medications that can help with Asthma? MOA? a/e?
MOA: block muscarinic receptors in brochi preventing bronchospasm
Use: Ipratropium approved for COPD, off label asthma
LESS EFFECTIVE than beta agonists
SHORT duration
a/e: Increased IOP, CV events
DPI and MDI are an ancronym for?
dry powdered inhaler (DPI)
metered dose inhaler (MDI)
Tiotropium (anticholinergic) is used for what? A/e?
Used off label for asthma use, long lasting, long term maintenance
A/e: dry mouth
Aclidinium bromide (bronchodilator) is used for what?
COPD Bronchospasm, long term maintenance
Umeclidinium (bronchodilator - anticholinergic) is used for what?
NOT asthma, used for COPD
Patients with asthma and COVID-19 considerations…
- Continue taking inhaled/oral corticosteroids & biological therapy
- Written asthma plan if symptoms worsen
- Prescribed a short course of oral corticosteroids if exacerbations occur
- ENSURE WHEN THEY KNOW WHEN TO SEEK MEDICAL HELP!!!! (What to do when it gets worse?!)
- Avoid nebulizers & spirometry with confirmed covid-19
Can patients have both COPD and asthma?
YES!!!! Not a single ailment, but a descriptor for overlapping conditions.
What are special considerations for patients w/ Asthma?
NEVER tx with bronchodilators solely alone ( THIS CAN INCREASE RISK FOR EXACERBATIONS, HOSPITALIZATION AND/OR DEATH!!!)
What are special considerations for patients w/ COPD?
START tx with LABA (long acting beta 2 agonist) w/o ICS (inhaled corticosteroids)
What are special considerations for patients w/ COPD & Asthma concurrently?
More likely to die/hospitalized w LABA vs ICS & LABA!
HIGH doses of ICS may be needed for SEVERE asthma, but if COPD is present it can increase risk of pneumonia!
Why is LABA treatment ALONE dangerous?
It can MASK certain disease processes such as asthma exacerbations not addressing the underlying inflammation with delay in addressing the real problem
THUS using LABA & ICS is important to help decreasing inflammation as well as relaxing smooth muscle.
COPD diagnosis is determined with what?
Spirometry!
A post-bronchodilator FEV1/FVC < 0.70 confirms presence of persistent airflow limitations confirming COPD
When would you advise against ICS treatment?
Repeated pneumonia events
Blood eosinophils <100 cell/uL
Hx of mycobacterial infxs
COPD Exacerbation Treatment recommendations?
SABA Inhalation (preferred for bronchodilation)
Oral glucocorticoids
Abx if infection is present
O2 Supp (Keep 88-92%)
Roflumilast (phosphodiesterase type 4 inhibitor [PDE4]) MOA, use, a/e?
MOA: PED4 breaks down cyclic adenosine monophosphate preventing inflammation, decreasing lung damage, improving pulmonary function
Use: SEVERE COPD w/ chronic bronchitis
COMBO with Tiotropium
A/e: psychiatric effects (worsens depression, insomnia, HA).
Purpose of asthma tx?
Decrease impairment & decrease risk of asthma
Purpose of a pulmonary function test for asthma and COPD?
Used with spirometer to assess lung function
Forced expiration volume (FEV1) is what?
Forced vital capacity (FVC) is what?
FEV1: Most useful test in a hospital setting
Inhale completely, forcefully exhale into spirometer
Value is based on sex, age, height, weight
Reported in a percentage
FVC: total volume of air which can be exaled after full inhalation
FEV1/FVC = you want HIGHER than 70-85%
<70% is consistent with COPD diagnosis
Pneumonic for Initial tx of asthma?
“ILLS”
ICS #1 place to start for for tx
Leukotriene mods
LABA
SABA
What is the go-to drug for asthma?
ICS (budesonide) as inflammation is the key common factor of asthma
Common side effects for ICS?
PNEUMONIC “HOCUS”
Hoarseness
Oral thrush
Cough
URI
Soreness
