Exam #01 - Asthma (Therapeutics)

Question 1

List the (6) goals of asthma management therapy

Answer 1

1. prevent symptoms
2. maintain near normal pulmonary function
3. maintain normal activity levels
4. prevent recurrent exacerbations and minimize hospital visits
5. provide optimal pharmacotherapy with minimal AE
6. meet patients’ and families’ expectations of and satisfaction with asthma care

Question 2

What (2) vaccines should be given annually to patients with persistent asthma?

Answer 2

1. influenza vaccine

2. pneumococcal vaccine (every 5 yrs, unless >65 y/o then given only once)

Question 3

What (3) types of medication are used as QUICK RELIEF medication for asthma?

Answer 3

1. SABA (short-acting bronchodilator)
2. SAMA (short-acting anti-cholinergic)
3. Systemic corticosteroids

Question 4

What (6) medication types/specific medications are used as LONG-TERM CONTROL medications?

Answer 4

1. Inhaled corticosteroids (best drug for long-term)
2. LABA
3. Leukotriene modifiers
4. Theophylline
5. Mast cell stabilizers
6. IgE antibodies

Question 5

How can a patient determine if they’re having an acute asthma exacerbation at home?

Answer 5

A PEF of <80% of personal best suggests an acute asthma exacerbation

Patient can also note S/S (i.e. degree of cough, breathlessness, wheeze, chest tightness, use of accessory muscles)

Question 6

What is the initial home treatment for a patient experiencing an acute asthma exacerbation?

Answer 6

Inhaled SABA: up to (3) treatments of 2-4 puffs at 20 minute intervals OR a single nebulizer treatment

Question 7

After symptoms of acute asthma exacerbation and initial treatment with SABA, what (3) categories of response to therapy can patients fall into? For each category be sure to indicate what type of exacerbation, PEF, S/S, any modifications to therapy, and follow up.

Answer 7

1. Good Response
   - mild exacerbation
   - PEF >80%
   - No wheezing or SOB
   - continue SABA q3-4hr for 48 hrs
   - Call MD for follow-up
2. Incomplete Response
   - moderate exacerbation
   - PEF 50-80%
   - persistent wheeze or SOB
   - Add oral corticosteroids (short-burst)
   - continue SABA q3-4hr for 48 hrs
   - Call MD urgently for instructions
3. Poor Response
   - severe exacerbation
   - PEF

Question 8

True or False - When giving systemic corticosteroids for treatment of asthma, it’s better to use IV b/c of their quicker onset?

Answer 8

False - corticosteroids whether IV or PO have the same onset (4-6 hours).

Inhaled corticosteroids would have a faster onset, however.

Question 9

Which medication for the treatment of acute asthma exacerbation is only used in the ER and SHOULD NOT be administered if patient is admitted or after discharge?

Answer 9

Ipratropium bromide (Atrovent)

Question 10

True or False - ALL patients at ANY step should use a SABA prn for symptoms?

Answer 10

True

Question 11

Regarding the stepwise approach to managing asthma in adults and children > or equal to 12 y/o, indicate the preferred treatment for each step.

Answer 11

Step 1 - SABA prn

Step 2 - Low-dose ICS and SABA

Step 3 - Medium-dose ICS and SABA
OR - Low-dose ICS + LABA and SABA

Step 4 - Medium-dose ICS + LABA and SABA

Step 5 - High-dose ICS + LABA and SABA AND consider Omalizumab for patients who have allergies

Step 6 - High-dose ICS + LABA + oral corticosteroid (daily dose) and SABA AND consider Omalizumab for patients who have allergies

Question 12

Step 2 preferred therapy is low-dose ICS and SABA. What is the alternative therapy in Step 2 for patients who can’t take ICS (for irrational reasons i.e. parents think they’ll severely harm their children)?

Answer 12

1. Cromolyn (mast cell stabilizer)
2. Nedocromil (mast cell stabilizer)
3. Leukotriene receptor antagonist (LTRA)
4. Theophylline

Question 13

Step 3 preferred therapy is medium-dose ICS and SABA OR low-dose ICS + LABA and SABA. What is the alternative therapy in Step 3?

Answer 13

Low-dose ICS + either LTRA or Theophylline

Question 14

Step 4 preferred therapy is medium-dose ICS + LABA and SABA What is the alternative therapy in Step 4?

Answer 14

Medium-dose ICS + either LTRA or Theophylline

Question 15

List the (3) categories patients can fall under when evaluating a patient’s response to therapy based on symptoms, nighttime awakenings, lung function, etc? Indicate the recommended action for treatment for each category

Answer 15

1. Well controlled
   - maintain current Step of therapy
   - Regular follow-up in 1-6 months
2. Not well controlled
   - Consider short-burst oral corticosteroids
   - step up ONE step and reevaluate in 2-6 weeks
3. Poorly controlled
   - Consider short-burst oral corticosteroids
   - step up TWO step and reevaluate in 2-6 weeks

Question 16

Evaluate patient response to therapy for the following patient with chronic asthma.

CT had 2 nighttime awakenings last month, experienced asthma symptoms 3 days/week for the past 3 weeks. The asthma symptoms have put some limitations on CT’s normal activities.

Designate which category the patient falls under and the recommended action for treatment.

Answer 16

Patient is Not Well Controlled

1. Consider short-burst oral corticosteroids
2. Step up one step
3. Reevaluate in 2-6 weeks

Question 17

Before changing therapy, name (3) other potential reasons for poor asthma control (aside from inadequate medication)?

Answer 17

1. inhaler technique
2. compliance
3. environment

Question 18

Name the (2) SABA (Beta2-selective) used in the therapeutic management of asthma? Indicate ROA, Onset, & DOA for each medication (Hint, there may be more than one for each).

Answer 18

1. Albuterol

INH: <5 min onset with 3-6 hr duration

Question 19

True or False - non-selective beta-agonists are recommended for therapeutic management of asthma?

Answer 19

False

Question 20

Name the (2) LABA used in the therapeutic management of asthma? Indicate ROA, Onset, and DOA. Make sure to name generic and brand for each.

Answer 20

1. Formoterol (Foradil)
   DPI: 5 min onset with 12 hr duration
2. Salmeterol (Serevent)
   DPI: <30 min onset with 12 hr duration

Question 21

Why can’t Foradil be used for acute asthma attacks?

Answer 21

Foradil is a LABA and even though its onset of action is 5 min, SABA have an onset of action < 5 min to be effective for acute asthma attacks

Question 22

List the 4 AE of beta2-agonists.

Answer 22

1. Increased HR
2. tremor
3. shakiness
4. hypokalemia (only common for oral & SC, not inhaled)

Hypokalemia occurs b/c B-agonists shift K+ intracellularly

Question 23

In what situation would you K+ monitoring be required when giving a beta2-agonist in therapeutic management of asthma?

Answer 23

If patient is given a SABA PO or SC then monitor K+ since PO or SC can cause hypokalemia. K+ monitoring is NOT required for inhaled route.

Question 24

What (3) monitoring parameters would you assess to determine efficacy of SABA?

Answer 24

1. PEFR
2. S/S of asthma
3. decrease use of SABA

Question 25

What (3) monitoring parameters would you assess to determine safety of SABA?

Answer 25

1. increased HR 2. tremor 3. shakiness Again only monitor K+ if giving a SABA PO or SC

Question 26

True or False - SAB2A are the most effective medication for relieving acute asthma symptoms?

Answer 26

True

Question 27

What (2) indications are SABA used for?

Answer 27

1. acute exacerbation | 2. prevention of EIA (EIB)

Question 28

Why should a LABA only be used as additional therapy for patients not adequately controlled on other asthma-controller medications or whose disease severity clearly warrants initiation of treatment with two maintenance therapies?

Answer 28

B/c LABA may increase the risk of asthma-related deaths SMART (salmeterol multi-center asthma research trial) saw increased deaths in at risk population (AAM 18-25 y/o)

Question 29

List the (2) mast cell stabilizer drugs for therapeutic management of asthma (brand and generic).

Answer 29

1. Cromolyn (Intal) | 2. Nedocromil (Tilade)

Question 30

What are the (2) indications of mast cell stabilizers? How long before patient sees a therapeutic response?

Answer 30

1. LONG-TERM prevention of asthma symptoms 2. Prevention of allergen induced bronchospasm and EIA Therapeutic response may take 4-6 weeks to see maximal benefit

Question 31

What is the major disadvantage seen with mast cell stabilizers?

Answer 31

needs to be dosed 3-4x/day

Question 32

What is the #1 DOC for treatment of chronic asthma?

Answer 32

corticosteroids

Question 33

Differentiate between indications for inhaled vs systemic corticosteroids for treatment of chronic asthma.

Answer 33

INHALED -indicated for long-term prevention of symptoms SYSTEMIC - Can be used as short-burst therapy (<10 days, no taper), following acute exacerbation OR to gain quick control of poorly controlled asthma - Can be used as long-term prevention of symptoms in Step 6 (risk of AE, though)

Question 34

Why would stopping long-term systemic corticosteroid treatment be a problem?

Answer 34

When patient receives exogenous steroids, body stops decreases or stops making its own steroids. Stopping treatment suddenly shocks the body and can result in HPA-shock (hypothalamic-pituitary-adrenal axis) and body can go into adrenal insufficiency or adrenal crisis

Question 35

What AE are associated with ICS to treat asthma?

Answer 35

1. oral thrush 2. dysphonia (disturbance of normal vocal function) 3. cough 4. URI 5. pneumonia

Question 36

What AE are associated with short burst of systemic corticosteroids in treatment asthma? (7)

Answer 36

1. hyperglycemia 2. increased appetite 3. weight gain 4. edema 5. HTN 6. mood alteration 7. peptic ulcer

Question 37

What AE are associated with chronic systemic corticosteroids in treatment of asthma (5)

Answer 37

All short term AE + 1. adrenal axis suppression 2. growth suppression 3. Cushing's syndrome 4. osteoporosis 5. muscle weakness

Question 38

Name all monitoring parameters for efficacy and toxicity for patients taking corticosteroids for treatment of asthma.

Answer 38

Efficacy: 1. decrease S/S asthma 2. decrease usage of Albuterol Toxicity: 1. oral thrush (ICS) 2. blood sugar, BP, weight gain (systemic)

Question 39

Give the brand names of the following ICS used to treat asthma: ``` Beclomethasone Budesonide Ciclesonide Flunisolide Fluticasone Mometasone Triamcinolone ```

Answer 39

``` Beclomethasone (QVAR) Budesonide (Pulmicort) Ciclesonide (Alvesco) Flunisolide (Aerobid) Fluticasone (Flovent) Mometasone (Asmanex) Triamcinolone (Azmacort) ```

Question 40

Most ICS used to treat asthma have high doses roughly > 400 mcg daily. Which (3) ICS have high doses >>> 400 mcg daily and what are the doses?

Answer 40

1. Budesonide (Pulmicort) - high dose > 1,200 mcg 2. Flunisolide (Aerobid) - high dose > 2,000 mcg 3. Triamcinolone (Azmacort) - high dose >1,500mcg

Question 41

What (2) generics are in Advair?

Answer 41

Fluticasone + Salmeterol

Question 42

What (2) generics are in Symbicort?

Answer 42

Budesonide + Formoterol

Question 43

Name (3) leukotriene modifiers used in the treatment of asthma (generic and brand) AND give their MOA?

Answer 43

1. Montelukast (Singulair) - LTRA 2. Zafirlukast (Accoclate) - LTRA 3. Zileuton (Zyflo) - lipoxygenase inhibitor (decreases production of LT)

Question 44

What are the (2) indications of leukotriene modifiers in treatment of asthma?

Answer 44

1. long-term control and prevention of symptoms in mild or moderate persistent asthma 2. EIA

Question 45

What parameters would you monitor for safety in patients taking Montelukast (Singulair) for asthma?

Answer 45

1. rash from Churg-Strauss | 2. neuropsychiatric events

Question 46

What parameters would you monitor for safety in patients taking Zafirlukast (Accoclate)) for asthma?

Answer 46

1. rash from Churg-Strauss 2. neuropsychiatric events 3. LFT's (can be elevated)

Question 47

What parameters would you monitor for safety in patients taking Zileuton (Zylfo) for asthma?

Answer 47

1. neuropsychiatric events | 2. LFT's (can be elevated)

Question 48

What parameters would you monitor for efficiacy in patients taking Montelukast, Zafirlukast, or Zyleuton for asthma?

Answer 48

1. decrease S/S of asthma 2. decrease usage of albuterol 3. decrease exacerbations

Question 49

What (2) generics are in Combivent?

Answer 49

Albuterol + Ipratropium

Question 50

What is Ipratropium (Atrovent) indicated for?

Answer 50

relief of acute bronchospasm in ER

Question 51

True or False - Ipratropium can be used to reverse bronchospasms caused by beta blockers

Answer 51

True - it will allow beta-2 receptors to be activated again and bronchodilate

Question 52

Name (3) AE associated with Ipratropium

Answer 52

1. dry mouth 2. sore throat 3. increased intraocular pressure

Question 53

Name (4) AE associated with Theophylline?

Answer 53

1. seizures (dose related) 2. tachycardia 3. HA 4. GI upset

Question 54

Name (6) drugs that DECREASE the clearance of Theophylline (inhibits the metabolism)

Answer 54

1. Cimetidine (tagamet) 2. macrolide ABO (-mycins) 3. allopurinol 4. propranolol 5. quinolones (ciprofloxacin) 6. zileuton (zyflo)

Question 55

Name (3) drugs/factors that INCREASE the clearance of Theophylline (induce the metabolism)

Answer 55

1. Smoking 2. Anti-epileptic (carbamazepine, phenobarbital, phenytoin) 3. Rifampin

Question 56

Name (1) IgE inhibitor used in treatment of asthma (generic and brand). Which "steps" is this drug considered in? What is its ROA?

Answer 56

Omalizumab (Xolair) Used in step 5 and 6 of asthma therapy SC Injection every 2-4 weeks

Question 57

What is the dose of Omalizumab (Xolair) based on (2 things)?

Answer 57

1. weight | 2. IgE levels

Question 58

What (2) parameters would you monitor for safety in patients taking Omalizumab (Xolair) for treatment of asthma?

Answer 58

1. infection (b/c inhibiting IgE) | 2. injection site reaction

Question 59

When would Omalizumab (Xolair) be indicated for patients with asthma?

Answer 59

patients with severe asthma who are not responsive to current therapy and have a history of allergic skin reactions only used as ADD ON THERAPY