Module 3 Flashcards
What are the two types of immunity?
There is natural immunity also called innate/native and specific acquired immunity
Which type of immunity involves physical barriers such as skin, phagocytic cells, and natural killer cells and occur before exposure and respond non specifically?
Innate or natural immunity
Which type of immunity occurs after exposure to foreign substance and becomes more rapid and intense?
Specific acquired immunity
What is an antigen?
A foreign substance
What are two types of specific required immunity?
Cell mediated immunity and antibody mediated/humoral immunity
Which immunity involves antibodies?
Humoral immunity
What cells make antibodies?
B lymphocytes or B cells
All these cells are made from bone marrow
Lymphocytes (b cells, cytolytic t cells, helper T cells) , macrophages, dendritic cell
Which type of cells are attacked and HIV and AIDS patients?
Helper T cells
Which cells release factors that promote type 4 sensitivity reactions— delayed hypersensitivity reactions?
Helper T cells, CD4 cells
What are immune related actions of macrophages?
- are antigen presenting cells which promotes proliferation and differentiation of helper T cells and cytotoxic T cells
- involved in delayed type 4 hypersensitivity reaction (they are the final mediators)
- phagocytize cells tagged with antibodies
What are the two antigen presenting cells?
Macrophages and dendritic cells
Mast cells are derived from what cell?
Basophils
What sells involved in the immediate hypersensitivity reaction?
Mast cells
Neutrophils of ourselves I have been tag with antibodies of what immunoglobulin class?
IgG
Also mediate inflammation and phagocytize bacteria
Eosinophils attack and destroy foreign particles That have been coated with which antibody class?
IgE
What cells usually target helminiths or parasitic worms?
Eosinophils
Which cells are involved in immediate hypersensitivity?
Mast cells,
Basophils, and eosinophils
What are the five classes of antibodies?
IgA, IgD, IgE, IgG, IgM
Name this antibody:
Located in mucous membranes of GI tract and lungs, in secretions. Serves as first line defense against microbes. Transferred to infants via breast milk, not absorbed from the GI tract but protects the infant against microbes in the GI tract
IgA
Name this antibody:
Found on surface of Mature B cells
Serves as a receptor for antigen recognition along with igM
IgD
Name this antibody :
Binds to surface of Mast cells; stimulates release of histamine and other mediators of mast cells
Binds to parasitic worms to help to Lyse the worms
IgE
Name this antibody:
Promotes target cell lysis; transferred across placenta to fetal circulation providing neonatal immunity; it is the major antibody in blood
IgG
Name this antibody:
First antibody that is produced in response to an antigen, present on nature B cells
Works with IgD and serves as antigen recognition
IgM
The discrimination between self and nonself is made possible by what?
By the major histocompatibility complex molecules
When the histocompatibility complex fails, what results?
When the disability discriminate between self and non-self fails, or immune system attacks her own cells
Autoimmune disease
MHC class I
Where are they found?
Who do they help imitate immune response?
Found on mostly all cells except Rbcs
can initiate responses by presenting antigens to cytotoxic T cells
MHC class 2 Where are they found cancer
Who do they help initiate an immune response ?
Found on B cells and antigen presenting cells (macrophages and dendritic cells)
Initiate immune response by presenting antigen to helper T cells
What antigens (2) Can antibodies neutralize without help?
Bacterial toxins and viruses
What is opsonization?
It is antibodies’ way of promoting phagocytosis of resistant bacteria
by providing a handle for phagocytes to “grab”
Most of the anybody’s the act as a
Opsonins belong to what antibodies class?
IgG
What are the actions of histamine?
5 actions
Vasculature (2), lungs, stomach, CNS
Dilate small blood vessels, Produces smooth muscle construction in the lung, Stimulates the secretion of acid, acts as a neurotransmitter
Histamine is synthesized in what two cells?
Mast cells and basophils
Where are mast cells present in the body?
In the skin and soft tissues
Where are basophils present in the body?
In the blood
What immunoglobulin antibody class is involved in allergic release?
IgE
To have an allergic reaction and you have to have a prior exposure
True or false
True
For a non-allergic release of histamine, what type of agents can act directly on my cells to trigger a histamine release?
Remember no prior sensitization is needed, so injury can also cause direct release
Certain drugs, radio contrast media, plasma expanders
H1 antagonists or blockers Are used to treat what disorder?
It is used for the treatment of mild allergic disorders
What is the big difference between H1 antagonists in the first generation from the 2nd generation?
First generation anti-histamines are highly sedating and second generation anti-histamines aren’t that sedating
Does H1 blockers Block the release of histamine from mast cells or basophils?
They do not block
Anti-histamines are really effective when given before an allergic reaction occurs it can take them a while to control the signs and symptoms when there is an allergic reaction occurring
Overdosing with anti-histamines Can produce what?
It can produce CNS stimulation and seizures frequently result
What is the most common side effect of an anti-histamine?
Sedation
The degree of impairment is the same when anti-histamine equals that when alcohol level exceeds the legal limit
Patient should avoid alcohol and other CNS depressants which will intensify the depressant effects of the H1 antagonist
What can be done for patients who have daytime sedation While taking an H1 antagonist?
Daytime sedation can be minimized by administering the entire daily dose at night
Which generation of anti-histamines have a low solubility, can’t cross the blood brain barrier, and a low affinity to type H1 receptors found in the brain?
Second generation anti-histamines
Which generation of anti-histamines have a hi lipid solubility, can cross the blood brain barrier, and have a high affinity for H1 receptors of the CNS?
First generation antihistamines
In regards to antihistamines, what population can have a paradoxical side effect Which can result in insomnia, nervousness tremors and even seizures?
Older patients are sensitive to these actions.
Children can have CNS stimulation after an overdose
What similar anticholinergic effects does H1 antagonist possess?
It can produce drying of mucous membranes or dry mouth, Urinary hesitancy, constipation and palpitations
Which generation is anti-cholinergic affects more common in among the anti-histamines?
First generation antihistamines
What is the black box warning for promethazine or Phenergan?
What population is it contraindicated in?
What generation of histamine is this drug in?
It can cause severe respiratory depression
Should not be used in Children younger than two years old
It is a first generation H1 blocker
Can antihistamines be used during pregnancy? When should they be avoided?
Anti-histamines should only be used when clearly necessary and
Should be avoided in late third trimester Because newborns are sensitive to the adverse effects of these drugs
Are anti-histamines excreted in the milk and should they be avoided by women who are breast-feeding?
Yes they are excreted in the milk posing a risk to the nursing infant and Should be avoided by women who are breast-feeding because it can interfere with milk production
What is fexofenadine’s brand name?
Allegra
Certain fruit juices such as apple, orange, grapefruit juice can reduce fexofenadine’s absorption, To ensure proper absorption patient should do what?
Patient should not drink fruit juices within four hours before dosing or One or two hours after dosing
For antihistamines, who are high risk patients?
Treating young children, older adults and patients with conditions that may be aggravated by the muscarinic blockade which include asthma, urinary retention, open angle glaucoma and prostatic hypertrophy
What’s special to know about alkylamines?
Brompheniramine, chloroheniramine, and dexchlorpheniramine
They are first generation H1 anti-histamines antagonists and are the least sedating among.
Diphenhydramine and Clemastine are apart of what 1st generating agents of H1 antihistamine blockers?
Ethanolamines
Cetirizine, levocetrizine, fexofenadine, Loratadine, and desloratadine are also of what generation of H1 blockers?
2nd generation (nonsedating) agents
What is the main difference between seasonal allergic rhinitis also called a fever and perennial Allergic rhinitis?
Seasonal rhinitis occurs and reaction to outdoor allergens like pollen, weeds grasses, and trees.
Perennial or nonseasonal allergic Granados is triggered by indoor allergens that you can’t get away from such as house dust, Dogs, cat dander, roaches etc.
What is the most effective drug for prevention and treatment of seasonal and perennial allergic Rhinitis?
What do these drugs do?
Intranasal glucocorticoids are the most effective drugs for prevention and treatment of season one perennial rhinitis
These drugs can prevent or suppress the major signs and symptoms of allergic rhinitis such as rhinorrhea, congestion, sneezing ,nasal itching, and erythema
What three medications are available without prescription that are intranasal glucocorticoids?
Budesonide (rhinocort aqua), fluticasone propionate(Flonase), and triamvinolone (nasocort allergy 24 hrs)
For patients using intranasal glucocorticoids, patients with seasonal allergic rhinitis will start seeing effects in how much time versus a patient who has perennial allergic rhinitis?
For Patients with Seasonal allergic rhinitis it can take up to one week or more to see an initial responses though can be seen in hours,
for a patient with perennial allergic rhinitis, it can take 2 to 3 weeks to develop because they are more congested and it’s a continuous year round thing for them
Oral histamines and intranasal glucocorticoids are effective therapy for first line drugs for allergic rhinitis
Oral histamines differ by how
Oral histamines are more effective when taking prophylactically and are less helpful after s/s appear.
Oral histamines don’t relieve nasal congestion!! Which makes them less effective than glucocorticoids
Which class of drugs used to treat allergic rhinitis has no adverse effects but is moderately effective but extremely safe?
Cromolyn
Or intranasal cromolyn sodium
Sympathomimetics or decongestants are used in allergic rhinitis to do what?
They only relieve nasal decongestion
Topical administration with sympathomimetics can cause what?
Vasoconstriction that is both rapid and intense
Sympathomimetics or decongestants given orally, can cause what kind of response?
Delayed, moderate and prolonged response
What are adverse effects of sympathomimetics (decongestants)?
Rebound congestion, CNS stimulation (restlessness irritability anxiety and insomnia), systemic vasoconstriction.
What sympathomimetic is associated with abuse as it can have similar effects to those of amphetamines as it can be readily converted to methamphetamine?
Pseudoephedrine
Topical sympathomimetics should not be used for no more than how many days consecutively?
3 to 5 days
Why is Phenylephrine not very effective orally but is topically?
It is not very effective or early because of the first pass effect metabolism, It is no better than a placebo but widely used
What anti-cholinergic agent is used in allergic Rhinitis but also used in COPD?
What does it do?
Ipratropium bromide (atrovent)
Blocks secretions and decreases rhinorrhea (runny nose)
What drug class to use for allergic rhinitis causes rare neuropsychiatric affects and is used to reduce nasal congestion?
Leukotriene antagonist or anti-leukotriene
Montelukast or Singulair
What drug is the most effective over the counter none of your cough medicine and is widely used?
Dextromethorphan
What is important to know about dextromethorphan (nonopioid antussive)?
Can cause euphoria and physical dependence
Does not depress respiration
Can enhance analgesic effects of opioids
What can occur when a child takes benzonatate (tessalon pearls)?
In children below two years of age accidental ingestion of just 1 or 2 capsules can be fatal
Cold remedies in children should not be used:
List
Potential AE, age restrictions
Restrict use a cough and cold medicines to children above the age of six years old
Potential adverse effects are convulsions, tachycardia, hallucination, and impaired consciousness
What is cyclooxygenase?
It is an enzyme that promotes conversion of compounds that promote Inflammation and sensitize nerves to painful stimuli
What are the three used for facts of Cox inhibitors?
They can suppress inflammation, Relieve pain, and reduce fever
Which Cox inhibitor can protect against myocardial infarction and stroke?
Aspirin
Cyclooxyrgenase 1 (COX-1) is found where?
Remember the good Cox
In all tissues
It protects gastric mucosa, Supports renal function, and promotes platelet aggregation
Cyclooxygenase 2 (COX2) is found where and what does it do?
Remember it’s the bad Cox
Mainly at sites of tissue injury where it mediate inflammation And sensitizes receptors to painful stimuli
In the brain—Immediate fever and contributes to perception of pain
In the kidneys—It’s supports renal function
In the blood vessel a promotes vasodilation
In the colon it can contribute to colon cancer
Inhibition of Cox-1 Results results in what negative effects (3)?
What is one beneficial effect of the inhibition of Cox-1?
Gastric erosion and ulceration
Renal impairment
Bleeding tendencies
Protection against Mi and stroke
Inhibition of Cox 2 has what beneficial effects (4)?
What are the 2 adverse effects?
Suppression of inflammation, alleviation of pain, reduction of fever, protection against colorectal cancer.
Renal impairment and promotion of MI and stroke
What common side effect do Cox one inhibitors and Cox 2 inhibitors share?
Renal impairment
What Cox inhibitor blocks anti-inflammatory properties?
It can reduce pain and fever but not suppress inflammation
Acetaminophen or Tylenol
What is the difference between first generation NSAIDs and Second generation NSAIDs?
First generation NSAIDs block both Cox-1 and Cox-2
Second generation blocks only Cox 2
What chemical family does aspirin belong to?
Salicylates
Aspirin provides protection against MIN ischemic stroke by inhibiting which Cox inhibitor one or two?
Cox one
Which NSAID is an irreversible Inhibitor of cyclooxygenase?
Aspirin
It suppresses platelet aggregation (makes blood thin) by inhibiting COX-1 the enzyme that makes thromboxane A
Which NSAID drug can cause reye’s syndrome in children?
Aspirin
Which NSAID Is the safest to use an infant,children and adolescents?
Tylenol or Motrin
Do not give aspirin because Of the risk for reye syndrome
Can NSAIDs be given to pregnant women?
It is contraindicated in third trimester of pregnancy Because it can cause premature closure of the ductus arteriosus
Can NSAIDs be taken in women who are breast-feeding?
Yes they are safe for use for breast-feeding mothers
Heparin and warfarin taken with aspirin can cause what?
It can intensify The anticoagulant effects of these meds
Glucocorticoids and aspirin taken together can cause what?
Gi ulceration
To reduce risk patient can take a proton pump inhibitor or h2 antagonists
Alcohol and aspirin taking together can cause what?
Having more than three alcoholic drinks every day while using aspirin can cause an increase risk for gastric bleeding
ARBs and ACE inhibitors taken with aspirin Can cause what?
Impaired Renal function
High doses of aspirin should be avoided but low doses may be acceptable
How long should a patient wait before taking another NSAID when on aspirin?
They should wait about two hours
Motrin naproxen can reduce antiplatelet effects of aspirin by blocking access of aspirin to Cox one in platelets
Celebrex is a part of which generation of NSAIDs?
Second generation NSAIDS
They Inhibit Cox 2
What is the last choice drug used for long-term management of pain due to the negative cardiovascular affects?
Celebrex
Which NSAID is used for osteoarthritis, Rheumatoid arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, acute pain, and dysmenorrhea
Celebrex
Why is there such an increased risk for an MI or stroke with Cox2 inhibitors?
Because Cox one is not inhibited which promotes platelet aggregation (clotting)
and
Inhibiting Cox 2 Causes vasoconstriction
Patients who have a sulfa allergy can be given any NSAID except?
Celecoxib or Celebrex because it has a sulfur molecule in its compound
Here are some other interactions Celebrex or Cox to inhibitors can have
It can decrease the effects of diuretics and ace inhibitors
Increase lithium levels
Fluconazole can have elevated drug levels
What are some adverse effects with Tylenol (usually in overdose) ?
Severe liver injury
It can raise blood pressure if used daily
Acute generalized exanthematous pustulosis (AGEP)
Steven Johnson syndrome
Toxic epidermal necrolysis (TEN)
Alcoholics should not consume more than how much of Tylenol a day?
No more than 3000 mg
Alcohol induces synthesis of the P450 contain enzyme in the minor metabolic pathway increasing production of acetaminophen’s metabolite
Acetaminophen and NSAIDs should be avoided in vaccines because…
It can blunt the immune response
What is the dosage limit for Tylenol in 24 hour period?
4000 mg
What is the antidote for Tylenol in an overdose?
Mucomyst or acetylcysteine
Best of given within 8 to 10 hours acetaminophen overdose
Reduces injury by converting the toxic metabolite to its nontoxic form
What Are glucocorticoids influence on carbohydrate metabolism?
(4)
Causes elevation of glucose.
They promote storage of glucose in the form of glycogen.
Suppress the synthesis of proteins for the production of glucose.
Simulate lipolysis which is fat breakdown.
Glucocorticoids have to pharmacologic Effects which are?
Anti-inflammatory and immunosuppressive Effects
Glucocorticoid absorption in oral
administration is what?
Rapid and nearly
complete
Intramuscular injection of Glucocorticoids is rapid with which esters?
Sodium phosphate and sodium succinates
Intramuscular injection of glucocorticoids are slow with which Esters?
Acetate and acetonides
What is the difference between biologic half life and plasma half life?
Biologic half life is the time a drug will take to be of cleared from the tissue
Plasma half wife is the time it’ll take for a drug to be cleared from the bloodstream
Glucocorticoids used in asthma is best taken how?
Test taken through inhalation because of the direct impact and less systemic affects. These are the most effective anti-asthma agents available
For your review:
Adverse effects of glucocorticoids
Osteoporosis, infection, impaired wound healing, hyperglycemia, myopathy, fluid and electrolyte disturbances, growth delay, psychological disturbances, cataracts and glaucoma, peptic ulcer disease, iatrogenic Cushing syndrome, adrenal suppression
Glucocorticoids have what adverse effects on psychological disturbances?
Patient can experience insomnia anxiety agitation or irritability. Severe reactions include delirium, hallucinations, depression, euphoria, or mania
What is the most dangerous adverse effect of long-term glucocorticoid therapy if not managed properly?
Adrenal suppression
Using exogenous glucocorticoids (meds) they inhibits the release of endogenous glucocorticoids, when prolonged past 2 to 3 weeks the adrenal glands may be unable to produce glucocorticoids themselves
Glucocorticoid should be using caution with digoxin, thiazides, or leave diuretics, because of the rest for what?
Hypokalemia as it can lead to dysrhythmias.
The more mineral corticoid properties a steroid has the more sodium and water is retained and potassium is lost
NSAIDs and glucocorticoids increase the risk for what
Increased risk for ulceration and G.I. bleeding
What interaction can glucocorticoids have with vaccines?
It can decrease the antibody response to vaccines due to immunosuppression
What are contraindications for glucocorticoids?
They are contraindicated in patients with systemic fungal infections and those receiving live virus vaccines
When withdrawing glucocorticoids what would be the best method for patients who have been on oral glucocorticoids for more than 2 to 3 weeks?
Give intermediate acting steroids for 5 to 7 days and stop
No longer necessary to taper off anymore
Can glucocorticoids be used in pregnant women?
They can but not in the first trimester it can cause cleft palate
What is the preferred glucocorticoid in pregnant women?
Hydrocortisone
Can you glucocorticoids be taken While breast-feeding?
They are not good for women who are breast-feeding and taking large doses of glucocorticoids
Short acting glucocorticoids include two meds what are they?
Compared to intermediate and long-acting Glucocorticoids, the biologic half-life, mineral corticoid potency and relative glucocorticoid potency are what?
Cortisone and hydrocortisone
The biologic half life shortest among the glucocorticoids.
It has the highest potency of mineral-corticoids
It has the lowest potency of the glucocorticoids”anti-inflammatory effects”
Long acting glucocorticoids are what 2 meds?
How is there biological half life compared to the other glucocorticoids?
How is there mineralocorticoid potency ?
How is there relative glucocorticoids “anti-inflammatory” potency ?
Dexamethasone and
Bethamethasone
Has the longest biologic half life (36-54)
Very low to no mineralocorticoid potency among the group
The highest relative glucocorticoid potency compared to short acting and intermediate acting
Describe asthma
It is an inflammatory airway disorder that involves an immune response to known allergens and involves bronchoconstriction
Describe COPD
It is a chronic and progressive you reversible one disorder that involves air flow restriction and inflammation
COPD is basically chronic bronchitis and emphysema together, Describe the difference between the two
Chronic bronchitis has a chronic cough and excessive sputum production
Chronic emphysema is due to enlarged air space in the bronchioles that deteriorate
What confirms the diagnosis of COPD?
A post bronchodilator spirometry test is needed that has a ratio of FEV1/FVC less than 0.7
What are the two Drug categories for asthma and COPD?
Anti-inflammatory agents and bronchodilators
What is the difference between metered dose inhaler’s and dry powder inhalers?
Metered dose inhaler’s involve hand-breath coordination, not the best for old people and children
Spacers should be used with MDI
Dry powder inhalers our breath activated and don’t require hand with coordination; spacers aren’t use with DPIs
What is the preferred treatment for asthma and children?
What is an alternative treatment for children?
Inhale glucocorticoids our preferred for long-term treatment for children of all ages and infants.
Alternative treatment would be cromolyn and Leukotriene receptor antagonist (montelukast)—only approved for children 1-5 yrs
In pregnant women with asthma, The first drug choice would be in InhaleD glucocorticoids. What would be the next line of drug and which one is the safest?
Leukotriene receptor antagonists
Montelukast is the safest
Zafirlukast
Are Inhaled glucocorticoids contraindicated in women who breast-feed?
No they are not but oral glucocorticoids should not breast-feed
What is the most effective drug available for a long-term control of airway inflammation?
Glucocorticoids
Remember they end in “one” except for budesonide
What is the first line therapy for asthma management of information?
Inhale glucocorticoids
They are also primarily used in COPD management of exacerbations
What is the most common side effect of inhaled glucocorticoids?
Candidiasis
You can treat with an anti-fungal
Also teach patients to rinse their mouth and gargle after dosing to minimize Candidiasis and dysphonia
Which drug should they take first:
A short acting beta agonist or a inhaled glucocorticoid?
Patients are inhale a short acting beta agonist 1st , Wait five minutes then take the Glucocorticoid
Leukotriene receptor antagonist end in what?
What do they do?
They end in “kast” except for zileuton
They block leukotriene receptors except for zileuton which blocks leukotriene synthesis
They are anti-inflammatory agents
What are common side effects among the leukotriene receptor antagonist class?
Neuropsychiatric effects such as Depression and suicidal thinking
And liver injury
What is the second line of therapy when An inhaled glucocorticoids can’t be used or could be used as an add on therapy?
Leukotriene receptor antagonists
What is the safest anti-asthma medication?
Cromolyn
Cromolyn is what kind of agent?
What is it used for?
Anti-inflammatory agent
Chronic asthma, seasonal allergy attacks, exercise induced bronchospasm, allergic rhinitis
Interleukin 4 receptor alpha antagonists
Dupilumab (Dupixent)
Class overview
For a moderate to severe asthma
Not a first line drug for asthma,
use should be restricted in eosinophilic asthma
Patience with a parasitic infection or helminth infection Should be treated prior to beginning this med
Phosphodiesterase 4 inhibitors:Roflumilast (Daliresp, Daxas)
General class overview
Approved for management of COPD and decrease exacerbations
Cough an excess of mucus production are reduced
Breast-feeding is not recommended, safety not established in pregnancy
Food can delay absorption but can be taken with or without food
Anti-inflammatory agent
What classes of drugs fall under bronchodilators?
And What do they end in?
Beta 2 adrenergic agonists—end in “ol”
Methylxanthines—end in “lline”
Anticholinergic drugs—end in “ium”
What drug class can be used To abort an copd or asthma exacerbation but not for prolong prophylaxis?
Short acting beta Agonists
What is the black box warning in treating patients with asthma and using a long acting beta 2 Agonist?
There use in asthma is contraindicated because it is associated with increased asthma associated death—LABAs should never be the first line therapy for asthma
What are side effects of beta 2 Agonists?
Tachycardia, chest pain and tremors
Tachycardia is caused by activation of beta1
Tremors is caused by activation of beta 2 in skeletal muscle
ProAir, proventil, levalbuterol, and xopenex are
Short acting or long acting beta beta 2 Agonists?
Short acting beta 2 Agonists
Aclidinium bromide, arformoterol, indacaterol, olodaterol, and salmeterol are short acting or long acting beta 2 agonists?
Long acting beta 2 agonists
Methykxanthines (theophylline) general overview
Think caffeine!
Causes bronchodilation, CNS excitation and cardiac stimulation
Has a NARROW therapeutic range
Recommended only for chronic stable asthma
Smoking tobacco or marijuana can increase metabolism and drug clearance
AE:severe dysthymia, convulsions, can occur if or complains of palpitations, nausea, abdomen discomfort stop med and check level
Approved for all children including neonates
Anticholinergic drugs (ipratropium—atrovent, tiotropium—spirvia, aclidinium—tudorza pressair, umeclidinium—incruse Ellipta)
Overview
Bronco dilator, use for COPD treatment mainly,
adverse effects include dry mouth, increase ocular pressure in pts with glaucoma, urinary retention
Usually first choice for copd
Beta 2 agonist promote bronchodilation how ?
Cholinergic antagonists promote bronchodilation how?
Beta 2 Agonists promote bronchodilation by stimulating or activating adrenergic receptors
Cholinergic antagonist also called anti-cholinergics Promote bronchodilation by blocking cholinergic receptors
Both relax smooth muscle
What are the treatment goals for COPD?
3
To reduce signs and symptoms, improve health status, and increase exercise tolerance
What are the treatment goals for asthma? (2)
Decreased impairment and decrease risk
