Module 6: Unit B: Asthma and COPD

Question 1

Beta 2-agonists example

Answer 1

Short-acting (SABA)
Albuterol
Levalbuterol 
Xopenex
Ventolin

Long-acting (LABA)
Formoterol
Perforomist
Serevent
salmeterol

Question 2

Indications Beta-2 agonists

Answer 2

Bronchodilator for the treatment of reversible airway obstruction due to asthma or COPD

Question 3

MOA beta-2 agonists

Answer 3

Activation of beta-adrenergic receptors leads to relaxation of smooth muscle in the lung and dilation and opening of the airways.

Question 4

Safety/D2D/Cautions with beta-2 agonists

Answer 4

MAO inhibitor use within 14 days
TCA use within 14 days
Caution in individuals with ischemic heart disease, HTN, arrhythmias, hypokalemia, diabetes, seizure disorder, hyperthyroidism, elderly individuals
D2D: Can lead to hyperglycemic events, HTN events, and hypokalemia

Question 5

side effects beta-2 agonists

Answer 5

Can cause bronchospasm

The most common complaint from individuals is nervousness, tremor, and palpitations.

Question 6

Inhaled Glucocorticoids (ICS) example

Answer 6

Flovent (fluticasone propionate)
Arnuity (fluticasone furoate)
Budesonide
Qvar (beclomethasone dipropionate)

Question 7

Inhaled Glucocorticoid indication

Answer 7

Asthma

Off label:
COPD
Eosinophilic esophagitis

Question 8

MOA inhaled glucocorticoids

Answer 8

The exact mechanism of anti-inflammatory action is unknown; it inhibits multiple inflammatory cytokines; produces multiple glucocorticoids and mineralocorticoid effects.

Question 9

Caution/D2D inhaled glucocorticoids

Answer 9

Severe hypersensitivity to milk protein
Don’t use as rescue inhaler
Caution in pediatric or adolescent patients
Caution in individuals with hepatic impairment, immunosuppressed, active infection, glaucoma, cataracts, osteoporosis

D2D: CYP3A4 substrate & immunosuppressive effects

Question 10

Inhaled glucocorticoids monitoring and reactions

Answer 10

BMD if osteoporosis risk factors; height in children/adolescents; oral cavity exam; consider ophthalmic exam if long-term use, change in vision, IOP/glaucoma/cataracts hx

Advise individuals to rinse their mouth after each use to avoid developing thrush

Can cause hypersensitivity reaction, anaphylaxis, bronchospasms, eosinophilia, Churg-Strauss syndrome

In long-term use, individuals may develop: adrenal suppression, hypercorticism, immunosuppression, glaucoma, cataracts, osteoporosis, growth suppression (peds pts)

Question 11

Oral Glucocorticoids example

Answer 11

Prednisone

Dexamethasone

Question 12

Prednisone and Dexamethasone Indication

Answer 12

Anti-inflammatory or immunosuppressant agent in the treatment of a variety of diseases, including allergic, hematologic, dermatologic, GI, inflammatory, etc.

Question 13

MOA prednisone and dexamethasone

Answer 13

The exact mechanism of anti-inflammatory action is unknown; it inhibits multiple inflammatory cytokines; produces multiple glucocorticoids and mineralocorticoid effects

Question 14

Safety/D2d/Cautions with oral glucocoritcoids (prednisone and dexa)

Answer 14

Systemic fungal infection
Don’t use for Cerebral malaria
Caution in individuals with HTN, CHF, recent MI, diabetes, PUD, ulcerative colitis, diverticulitis, psychiatric disorders, thyroid disorders, osteoporosis, cirrhosis
D2D: 11-beta-hydroxysteroid dehydrogenase type 1 substrate, CYP3A4 substrate, CYP3A4 inducer, affects growth hormone, hyperglycemic effects, hypertensive effects, hypokalemia, immunosuppressive effects, lowers the seizure threshold

Question 15

Oral glucocorticoid monitoring and long term use implications

Answer 15

Electrolytes; BP; weight; 2h postprandial glucose, height (peds), chest x-ray if prolonged tx; ophthalmic exam if tx >6 wk; BMD if prolonged tx or in pts 65 yo and older; consider upper GI x-ray if PUD history or significant dyspepsia
Avoid abrupt withdrawal (high-dose or long-term use)
Can cause Cushing syndrome
Can cause diabetes
Long-term use can lead to osteoporosis, glaucoma, cataracts, immunosuppression, Kaposi sarcoma

Question 16

Methylxanthines example

Answer 16

Theophylline

Theo-24

Question 17

Indication Theophylline and Theo-24

Answer 17

Reversible airflow obstruction

Question 18

MOA Theo-24

Answer 18

The exact mechanism of action is unknown; increases cAMP; antagonizes adenosine receptors (methylxanthine)

Question 19

Safety/D2D/Caution with Theo-24

Answer 19

Caution if: PUD (active), seizure disorder, arrhythmias, CHF, pulmonary edema, cor pulmonale, renal impairment, hepatic impairment, hypothyroidism, smoking habits change
D2D: CYP1A2 substrate, CYP3A4 substrate, hypokalemia, lowers the seizure threshold

Question 20

Monitoring and side effects Theo-24

Answer 20

Monitor therapeutic drug levels
Seizures, arrhythmia, hypotension, shock, exfoliative dermatitis
An old drug that has been around forever but can be difficult to find.

Question 21

Immunomodulators example

Answer 21

Xolair omalizumab
Nucala mepolizumab
Fasenra benralziumab
Cinqair reslizumab
Dupixent dupilumab

Question 22

Indication Xolair omilzumab

Answer 22

Asthma
Chronic idiopathic urticaria
Nasal polyps

Question 23

MOA immunomodulators (xolair)

Answer 23

Inhibits IgE binding to mast cells, basophils, and dendritic cells, down-regulating IgE receptors; in allergic asthma, inhibits IgE-mediated inflammation, decreasing eosinophils and multiple inflammatory mediators.

Question 24

Caution/D2D immunomodulators (xolair)

Answer 24

Not a rescue inhaler
Caution if anaphylaxis history
D2D: None

Question 25

BBW immunomodulators (xolair)

Answer 25

Anaphylaxis

Question 26

Side effects and process with immunomodulators (xolair)

Answer 26

No routine tests recommended Eosinophilia Malignancy risk Subcutaneous injections every 2-4 weeks are given in the office. Must have an elevated IgE level positive RAST test to get approved

Question 27

Indications: Nucala mepolizumab Fasenra benralziumab Cinqair reslizumab

Answer 27

Asthma Eosinophilic granulomatosis with polyangiitis Hypereosinophilic syndrome

Question 28

MOA: Nucala mepolizumab Fasenra benralziumab Cinqair reslizumab

Answer 28

Binds to and interferes with interleukin-5 cytokine, reducing eosinophil production and survival

Question 29

Safety: Nucala mepolizumab Fasenra benralziumab Cinqair reslizumab

Answer 29

``` Not rescue inhaler D2D: None No routine tests recommended Hypersensitivity reaction Anaphylaxis Must have an elevated IgE level positive RAST test to get approved ```

Question 30

Indication Dupixent dupilumab

Answer 30

Asthma Atopic dermatitis rhinosinusitis

Question 31

MOA Dupixent dupilumab

Answer 31

Binds to and inhibits interleukin-4 receptor alpha subunit, interfering with interleukin-4 and interleukin-13 cytokines, reducing inflammation and altering the immune response

Question 32

Safety/D2D Dupixent dupilumab

Answer 32

Patients <12 yo (pen form) not rescue Caution if corticosteroid use D2D: immunosuppressive effects No routine tests recommended Hypersensitivity rxn Anaphylaxis Serum sickness Keratitis Absolute eosinophil count must be 300 or higher, OR the patient be oral steroid-dependent to get approved. Subcutaneous injections every two weeks, can be done from home

Question 33

Anticholinergics/ | Antimuscarinics: Short-acting and Long-acting

Answer 33

Long-acting (LAMA) Spiriva (tiotropium) Incruse (umeclidinium) Short-acting (SAMA) Atrovent (ipratropium)

Question 34

Indication anticholingerics

Answer 34

Asthma | COPD

Question 35

MOA anticholingerics

Answer 35

Antagonizes acetylcholine receptors, producing bronchodilation

Question 36

Safety/D2D anticholingerics

Answer 36

do not give with Bronchospasm, acute Severe hypersensitivity to milk protein Caution if CrCl <60, glaucoma, angle-closure, urinary retention, prostatic hypertrophy, bladder neck obstruction D2D anticholinergic effects Anticholinergic sx if CrCl<60 Hypersensitivity reaction

Question 37

Phosphodiesterase-4 Inhibitors example

Answer 37

Daliresp roflumilast

Question 38

Indication Daliresp roflumilast

Answer 38

COPD: to reduce the risk of COPD exacerbations in patients with severe COPD

Question 39

Daliresp roflumilast MOA

Answer 39

The exact mechanism of action is unknown; it selectively inhibits phosphodiesterase type 4 (PDE4), leading to increased intracellular cAMP levels.

Question 40

BBW Reslizumab (Cinaquir)

Answer 40

Anaphylaxis

Question 41

Side effects LABAs

Answer 41

tachycardia, palpitations, QT prolongation, hypokalemia, tremors, cramping, headaches, insomnia, and increase in serum glucose levels. increased occurrences of angina and myocardial infarctions reported.