lectures 27-28 (asthma treatment) Flashcards
exam 3
asthma diagnosis
wheezing
shortness of breath
chest tightness
cough
- some may be more prevalent than others
- don’t need all 4 symptoms for a diagnosis
- varies over time and in intensity
- consider duration
spirometry
FEV1: amount of air that can be forcefully exhaled in one second
FVC: maximum amount of air that is exhaled after taking a deep breath
- FEV1/FVC utilized to assess lung function
- spirometry is standard for objective asthma testing
- done in a healthcare office
- an increase or decrease in FEV1 of >12% and >200mL from baseline in consistent with asthma
peak expiratory flow (PEF)
- non-preferred method of objective testing for asthma, but can be utilized if spirometry is unavailable
- can be done in healthcare office or at home by the patient
- utilized the best of 3 measurements
- recommendation to use the same peak flow meter when measuring (variability between meters can range up to 20%)
- a change in PEF of at least 20% is consistent with asthma
goals of therapy
- asthma symptom control and exacerbation risk reduction
- discuss goals of therapy from patient perspective
risk factors for exacerbation
SABA overuse
inadequate ICS exposure
concurrent medical conditions (obesity, pregnancy, etc.)
environmental exposures (smoke, pollen, etc.)
low FEV1 (<60% predicted)
higher blood eosinophils
> 1 severe exacerbation in the last year
maintenance treatment
asthma treatment that is prescribed for daily/regularly scheduled doses
controller
medication targeting both domains of asthma control (symptoms and future risk)
reliever
asthma inhaler taken as needed for quick relief
anti-inflammatory reliever (AIR)
reliever inhaler that contains both an ICS and a rapid acting bronchodilator
maintenance and reliever therapy (MART)
patient uses an ICS-formoterol inhaler every day and also uses the same medication for PRN relief of symptoms
initiation of pharmacotherapy
step 1-2:
- frequency of symptoms: <3-5 days/week
step 3:
- frequency of symptoms: most days
OR
- nighttime awakenings once a week
step 4:
- frequency of symptoms: daily
OR
- nighttime awakenings once a week or more
OR
- recent exacerbation
ICS info
standard of care in asthma
common side effects:
- dysphonia, thrush, cough, HA, hoarseness
patient counseling:
- rinse mouth and spit after each use (prevent thrush)
dosing based on low, medium, and high intensity steroid dose
ICS drugs
ciclesonide- Alvesco
fluticasone furoate- Arnuity
mometasone furoate- Asmanex
fluticasone propionate- Flovent
budesonide- Pulmicort
beclomethasone dipropionate- QVAR
SABA drugs
albuterol
- ProAir
- Proventil
- Ventolin
levalbuterol (Xopenex)
LABA drugs
salmeterol (serevent)
*ONLY IN COMBINATION WITH ICS- BBW
*SEREVENT THE ONLY LABA-ONLY INHALER APPROVED FOR ASTHMA
β2 agonist (SABA/LABA) info
side effects:
- nervousness
- tremor
- tachycardia
- palpitations
- cough
- hyperglycemia
- decreased potassium
monitoring:
- BP
- HR
- blood glucose
- potassium
- frequency of use (SABAs- increased risk of exacerbations)
LAMA drugs
tiotropium (spiriva)
- spiriva respimat 1.25mcg only LAMA only inhaler approved for asthma
- more common in COPD management
formoterol vs salmeterol
- formoterol and salmeterol both used in combo with ICS +/- LAMA
- formoterol onset of action is 3 minutes –> best for quick relief
- salmeterol onset of action is 30-48 minutes
ICS/formoterol drugs
budesonide/formoterol - symbicort
mometasone/formoterol- dulers
ICS/salmeterol drugs
fluticasone/salmeterol- Advair Diskus/HFA
fluticasone/salmeterol- Airduo RespiClick
fluticasone/salmeterol- Wixela Inhub
Airsupra
albuterol/budesonide
for adults 18+
acute exacerbation:
- initial home management
- 2 inh q 20 min prn for up to 3 doses (6 total inhalations)
OR
- 2 inh q 1-4h PRN
intermittent symptom relief:
- 2 inh PRN; max dose of 12 inh/day
why is SABA only therapy no longer recommended?
patients with seemingly controlled asthma can still have severe or fatal exacerbations
patients classified with ‘intermittent’ or ‘mild’ asthma historically have/had low adherence rated of maintenance ICS therapy
ICS-containing therapy should be initiated ASAP after asthma dx
- decreases risk of severe exacerbations requiring oral corticosteroids by 55% compared to SABA only
- decreases risk of ED visits/hospitalizations by 65% compared to SABA only
- decreases average IC dose compared to maintenance low-dose ICS
leukotriene receptor antagonists (LTRA)
montelukast (singulair)
- BBW: NEURO/PSYCH EVENTS
- dosing dependent on age:
1-5 yo- 4mg PO qd
6-14 yo: 5mg PO qd
15+ yo: 10mg PO qd
patient education
- up to 80% of patients do not use their inhalers correctly
- inhaler technique should be addressed at the start of therapy and at each follow-up visit (after initial training, errors in technique likely within 4-6 weeks)
- teach-back method
follow-up
- follow up 1-3 months after initiating treatment/changes in regimen
- follow-up 3-12 months once established treatment regimen
escalating therapy
prior to escalating therapy due to seemingly uncontrolled asthma, consider assessment of:
- inhaler technique
- adherence
- trigger exposure
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
