LECTURES 27 & 28 - asthma Flashcards
List factors that increase the risk for asthma exacerbation
SABA overuse
Inadequate ICS exposure
Concurrent medical conditions
Environmental exposures (air quality)
Low FEV1 (<60% predicted)
Higher blood eosinophils
>/= 1 severe exacerbations in the last year
Define maintenance therapy / treatment
Asthma treatment that is prescribed for daily use - treatment is intended to be used daily regardless of symptoms
Define “reliever” (treatment/therapy)
Treatment taken PRN for relief of symptoms
Define MART (maintenance & reliever therapy)
Treatment of ICS/formoterol for daily use (maintenance tx) and for use in asthma symptom relief
What are the goals of therapy for obtaining asthma control?
Asthma symptom control
Exacerbation risk reduction
When initiating pharmacotherapy for asthma, what “step” would a patient be if they:
experience symptoms < 3-5 days/week
do NOT experience nighttime awakenings
have NOT had a recent exacerbation
step 1-2
When initiating pharmacotherapy for asthma, what “step” would a patient be if they:
experience symptoms most days
experience nighttime awakenings once a week or more
have NOT had a recent exacerbation
step 3
When initiating pharmacotherapy for asthma, what “step” would a patient be if they:
experience symptoms daily
experience nighttime awakenings once a week or more
have had a recent exacerbation
step 4
What is an important patient counseling point for inhaled corticosteroids?
Rinse mouth out and spit after each use
List common side effects of inhaled corticosteroids
dysphonia, oral candidiasis (thrush), cough, HA, hoarseness
What is the dosing of inhaled corticosteroids based on?
based on low, medium, and high intensity steroid dose
List the brand names of inhaled corticosteroids (ICS)
Alvesco
Arnuity
Asmanex
Flovent
Pulmicort
QVAR
List the generic names of inhaled corticosteroids (ICS)
ciclesonide
fluticasone furoate
mometasone furoate
fluticasone propionate
budesonide
beclomethasone dipropionate
List the brand/generic names for ICSs
Alvesco (ciclesonide)
Arnuity (fluticasone furoate)
Asmanex (mometasone furoate)
Flovent (fluticasone propionate)
Pulmicort (budesonide)
QVAR (beclomethasone dipropionate)
What is Alvesco (ciclesonide) available as?
HFA
What is Arnuity (fluticasone furoate) available as?
Ellipta
What is Asmanex (mometasone furoate) available as?
HFA, Twisthaler
What is Flovent (fluticasone propionate) available as?
HFA, Diskus
What is Pulmicort (budesonide) available as?
Flexhaler
What is QVAR (beclomethasone dipropionate) available as?
Redihaler
List the brand/generic names of SABAs
albuterol
ProAir (albuterol)
Proventil (albuterol)
Ventolin (albuterol)
Xopenex (levalbuterol)
What is albuterol (generic) available as?
HFA, nebulizer
What is ProAir (albuterol) available as?
HFA, RespiClick, Digihaler
What is Proventil (albuterol) available as?
HFA
What is Ventolin (albuterol) available as?
HFA
What is Xopenex (levalbuterol) available as?
HFA, nebulizer
List the brand/generic of LABAs
Serevent (salmeterol)
What is Serevent (salmeterol) available as?
Diskus
What is the box warning for LABAs?
increased risk for asthma-related death (monotherapy)
only for use in combination with an ICS
What are the side effects of beta-2 agonists?
Nervousness
Tremor
Tachycardia
Palpitations
Cough
Hyperglycemia
Decreased K+
What should be monitored for a patient taking an beta-2 agonists?
BP, HR
blood glucose & K levels
SABA only → frequency of use
List the brand/generic of LAMAs
Spiriva (tiotropium)
What is Spiriva (tiotropium) available as?
Respimat (1.25 mcg)
What is important to note about the use of LAMAs for asthma treatment?
Reserved as step 5 treatment for asthma – add-on therapy
(more common in COPD treatment)
Describe the “review” portion of personalized asthma management
review: symptoms, exacerbations, side-effects, lung function, comorbidities, satisfactions
Describe the “assess” portion of personalized asthma management
assess…
Confirmation of diagnosis if necessary
Symptom control & modifiable risk factors
Comorbidities
Inhaler technique & adherence
Patient preferences & goals
Describe the “adjust” portion of personalized asthma management
adjust…
Treatment of modifiable risk factors & comorbidities
Non-pharmacological strategies
Asthma medications including ICS (as below)
Education & skills training
What is the reliever used in track 1: preferred controller & reliever?
as-needed low-dose ICS-formoterol
Why is ICS-formoterol the preferred reliever?
Using ICS-formoterol as the reliever reduces the risk of exacerbations compared with using a SABA reliever, and is a simpler regimen
What are the options for ICS/formoterol?
Symbicort (budesonide/formoterol)
Dulera (mometasone/formoterol)
For a step 1-2 patient on track 1: preferred controller & reliever, what is the controller used?
As-needed-only low dose ICS-formoterol
(only reliever)
For a step 3 patient on track 1: preferred controller & reliever, what is the controller used?
Low-dose maintenance ICS-formoterol
For a step 4 patient on track 1: preferred controller & reliever, what is the controller used?
Medium dose maintenance ICS-formoterol
What are the next steps for a step 5 patient on track 1: preferred controller & reliever?
Add-on LAMA
Refer for assessment of phenotype
Consider high dose maintenance ICS-formoterol +/- anti-IgE, anti-IL5/5R, anti-IL4R𝝰, anti-TSLP
See GINA severe asthma guide
What is the reliever used in track 2: alternative controller & reliever?
as-needed ICS-SABA, or as-needed SABA
What is important to consider before considering a regimen with a SABA reliever?
whether or not the patient is likely to adhere to daily controller treatment
For a step 1 patient on track 2: alternative controller & reliever, what is the controller used?
Take ICS whenever SABA taken
For a step 2 patient on track 2: alternative controller & reliever, what is the controller used?
Low dose maintenance ICS
For a step 3 patient on track 2: alternative controller & reliever, what is the controller used?
Low dose maintenance ICS-LABA
For a step 4 patient on track 2: alternative controller & reliever, what is the controller used?
Medium/high dose maintenance ICS-LABA
What are the next steps for a step 5 patient on track 2: alternative controller & reliever?
Add-on LAMA
Refer for assessment of phenotype
Consider high dose maintenance ICS-formoterol +/- anti-IgE, anti-IL5/5R, anti-IL4R𝝰, anti-TSLP
See GINA severe asthma guide
What is the follow-up timeframe for a patient what just initiated treatment or had a change in their regimen?
1-3 months after initiating treatment or change
What is the follow-up timeframe for a patient established on an asthma treatment regimen?
3-12 months
What should be considered before considering escalating therapy?
Prior to escalating therapy due to seemingly uncontrolled asthma, consider assessment of:
Inhaler technique
Adherence
Trigger exposure
Describe the process of approaching de-escalating therapy
Can be considered after 2-3 months of maintained asthma control
Patient-specific approach
General principle → reduce ICS dose by 25-50% at 3-month intervals
