Module 9 Questions Flashcards
The following are precipitating factors/triggers for which respiratory disease?
- Exercise
- Respiratory infections
- Environmental/occupational allergens
- Smoking
- Irritants
- Emotions
- Stress
- Food additives or preservatives
- Endocrine factors
- Changes in weather
- Exposure to cold air
- Comorbid conditions
1) COPD
2) Asthma
3) Allergic Rhinitis
2) Asthma
Pathophysiology
- Airflow obstruction
- Bronchospasm
- Edema
- Hypersecretion
- Bronchial hyperresponsiveness
- IgE immune response to aeroallergens strongest identifiable predisposing factor for developing this
- Partly due to and correlates with extent of airway inflammation
- Airway inflammation
- Acute
- Chronic
- Airway remodeling (in some)
Which disease is this?
1) Allergic Rhinitis
2) Asthma
3) COPD
2) Asthma
These drugs are relative (not absolute) contraindications for which disease?
- Aspirin
- NSAIDs
- Beta Blockers
1) Asthma
2) COPD
3) Allergic Rhinitis
Asthma
There are situations when the benefits outweigh the risk of using some of these classes of medications for asthma. One example is the use of certain _______ in patients with heart failure as they have demonstrated significant improvement in patient mortality and outcomes.
Which drug class is this?
1) Statins
2) Beta-Blockers
3) PPIs
4) Quinolones
2) Beta Blockers
Regarding asthma:
For patients with reactive airway disease, use cardio-selective _______ when possible.
1) Statins
2) H2RAs
3) TCAs
4) Beta Blockers
4) Beta Blockers
Also known as “Aspirin Exacerbated Respiratory Disease,” ____________________ is a condition in which an individual has asthma, sinus inflammation with recurring nasal polyps, and sensitivity to aspirin and some other NSAIDs. When aspirin or a similar drug is taken, people with this have a severe reaction with both upper and lower respiratory symptoms.
1) Asthma
2) Samter’s Triad
3) COPD
4) Allergic Rhinitis
2) Samter’s Triad
_____________ is a chronic medical condition that consists of three clinical features:
- Asthma
- Sinus disease with nasal polyps
- Sensitivity to aspirin and other NSAIDs
Which disease is this?
1) Samter’s Triad/AERD
2) COPD
3) Asthma
4) Allergic Rhinitis
1) Samter’s Triad/AERD
Doctors may perform an aspirin challenge to confirm a ___________ diagnosis.
1) COPD
2) AERD
3) PNA
4) Allergic rhinitis
5) Asthma
2) AERD (Aspirin-Exacerbated Respiratory Disease)
Diagnostic for asthma if obstruction reversed following an inhaled short-acting bronchodilator (SABA) ≥12% improvement in FEV1.
What is this?
1) Stress test
2) Blood culture
3) Spirometry
4) Pulse oximetry
3) Spirometry
Taken on a daily basis to maintain control of persistent asthma and should not be used for rescue therapy (With the possible exception of a SMART regimen as defined by GINA).
1) Medium-term control (maintenance) medications
2) Short-term control (maintenance) medications
3) Long-term control (maintenance) medications
4) Antibiotics
3) Long-term control (maintenance) medications
ICSs (Inhaled Corticosteroids) are the most effective medications for long-term control of persistent asthma.
True or False?
True
ICSs (Inhaled Corticosteroids) are not the most effective medications for long-term control of persistent asthma.
True or False?
False
All adults and adolescents with asthma should receive ICS-containing controller treatment to reduce their risk of serious exacerbations and to control symptoms.
True or False?
True
All adults and adolescents with asthma should not receive ICS-containing controller treatment to reduce their risk of serious exacerbations and to control symptoms.
True or False?
False
ICS-containing controller can be delivered either with regular daily treatment or, in mild asthma, with as-needed ICS-formoterol taken whenever needed for symptom relief.
True or False?
True
ICS-containing controller can not be delivered either with regular daily treatment, nor can it be used in mild asthma, with as-needed ICS-formoterol taken whenever needed for symptom relief.
True or False?
False
ICSs (Inhaled Corticosteroids)
improve asthma control more effectively in both children and adults than leukotriene receptor antagonists (LTRAs) or any other single, long-term control medication do.
True or False?
True
Leukotriene receptor antagonists (LTRAs) improve asthma control more effectively in both children and adults than ICSs (Inhaled Corticosteroids) or any other single, long-term control medication do.
True or False?
False
The potential risks of ICSs are well balanced by their benefits.
True or False?
True
The potential risks of ICSs are not well balanced by their benefits.
True or False?
False
Spacer/holding chamber devices recommended.
True or False?
True
Spacer/holding chamber devices are not recommended.
True or False?
False
Rinse mouth and spit after use of inhaled corticosteroids.
True or False?
True
There’s no need to rinse mouth and spit after use of inhaled corticosteroids.
True or False?
False
Inhalation preparations are NOT interchangeable on a mcg/puff basis.
True or False?
True
Inhalation preparations are interchangeable on a mcg/puff basis.
True or False?
False
Which drug is this?
- Limited usefulness for asthma.
- Therapeutic response usually occurs within 2 weeks, but 4-6 weeks of use may be necessary to see full effect.
- Primary advantage is safety (children, pregnancy)
- SEE AR
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
4) Cromolyn
Which drug is this?
- Alternative therapy to low doses of inhaled corticosteroids or cromolyn for patients with mild-moderate persistent asthma
- May be given in combination with inhaled corticosteroids in moderate persistent asthma
- Not for acute asthma. (NO INDICATION IN COPD)
- Used for exercise-induced bronchoconstriction and aspirin-induced asthma
- Also indicated in AR
- Allow 4-6 week trial to determine efficacy
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
1) Leukotriene Modifiers
Which drug is this?
- Used for long-term prevention of asthma symptoms
- β2 agonist (Bronchodilation by smooth muscle relaxation)
- Does not eliminate need for an ICS
- Should not be used to relieve symptoms or treat exacerbation (With the possible exception of a SMART regimen containing formoterol)
- Adjunct to anti-inflammatory therapy
- In patients (≥ 12yo) with moderate persistent asthma or asthma inadequately controlled on low-dose ICS [Step 2], the option to increase the ICS dose should be given equal weight to the option of adding this med.
- Used only if patients have not responded to other controller medications
- This med should not be used as monotherapy for long-term control, but in combination with ICS
- Associated with increase in asthma related deaths when used as monotherapy.
- The addition of this med to ICS provides greater control than increasing the ICS alone and reduces the frequency of exacerbations (Ducharme F, et al. Cochrane Database Syst Rev 2010;(5):CD005535)
- (Note this will not be the case with COPD).
- Prevention of EIB, but decreased duration of protection with regular use
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
3) LABAs (Long-Acting Beta Agonists)
Which drug class is this? (Tiotropium)
- Add-on therapy (to ICS) for patients aged ≥12 years with a history of exacerbations (GINA).
- Step 4/5
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
5) LAMAs (Long-Acting Muscarinic
Which drug class is this? (Theophylline)
- Current place in therapy : Adjunct/Alternative in mild-moderate or persistent asthma.
- Second line overall
- Narrow therapeutic index
- Increases in theophylline concentrations have disproportional bronchodilatory effects
- Serious toxicity can occur without preceding signs of less serious toxicity
- Many drug-drug, drug-disease interactions, including smoking. (See COPD for greater discussion)
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
6) Methylxanthines
Has many drug-drug, drug-disease interactions, including smoking.
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
6) Methylxanthines (Theophylline)
Regarding this drug class, serious toxicity can occur without preceding signs of less serious toxicity.
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
6) Methylxanthines (Theophylline)
Regarding this drug class, increases in theophylline concentrations have disproportional bronchodilating effects.
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
6) Methylxanthines
Add-on therapy (to ICS) for patients aged ≥12 years with a history of exacerbations .
1) Leukotriene modifiers
X) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
5) LAMAs (Long-Acting Muscarinic
Should not be used as monotherapy for long-term control, but in combination with ICSs.
1) Leukotriene modifiers
X) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
3) LABAs (Long-Acting Beta Agonists)
-
-
Not for acute asthma. (NO INDICATION IN COPD.)
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
1) Leukotriene modifiers
-
-
Allow 4-6 week trial to determine efficacy.
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABA (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
1) Leukotriene modifiers
Therapeutic response usually occurs within 2 weeks, but 4-6 weeks of use may be necessary to see full effect.
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
4) Cromolyn
All adults and adolescents with asthma should receive _______________-containing controller treatment to reduce their risk of serious exacerbations and to control symptoms.
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
2) Inhaled Corticosteroids
These are the most effective medications for long-term control of persistent asthma.
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
2) Inhaled Corticosteroids
Primary advantage is safety (children, pregnancy).
1) Leukotriene modifiers
2) Inhaled Corticosteroids
3) LABAs (Long-Acting Beta Agonists)
4) Cromolyn
5) LAMAs (Long-Acting Muscarinic Antagonists)
6) Methylxanthines
4) Cromolyn
These provide prompt relief of bronchoconstriction and its accompanying symptoms:
1) Long-term control (maintenance) medications
2) Quick relief (rescue) medications
3) Immunoglobulin E (IgE) Inhibitors
2) Quick relief (rescue) medications
ALL patients should have a SABA (Short-Acting Beta Agonist) available for PRN use [STEP 1]
- Or if prescribed budesonide/formoterol or beclemathosone/formoterol as maintenance therapy, they can also be used as the “rescue.”
[SMART regimen outlined in GINA]
True or False?
True
ALL patients should not have a SABA (Short-Acting Beta Agonist) available for PRN use [STEP 1]
- Or if prescribed budesonide/formoterol or beclemathosone/formoterol as maintenance therapy, they can also be used as the “rescue.”
[SMART regimen outlined in GINA]
True or False?
False
Which drug class?
- Bursts given to establish control when initiating therapy or during periods of deterioration
- Deaths caused by adrenal insufficiency have occurred in asthmatic patients during and after transfer from these to inhaled corticosteroids
- In order to prevent this situation for years we were taught to taper corticosteroid treatment after short term “burst” course treatments. The key to avoiding adrenal suppression after a short course of corticosteroids is not tapering, but to keeping the course of therapy as short as possible (Eg. 6o mg of prednisone daily for up to 7 days is really safer than taking 10-21 days to taper off the high dose)
- If treated with a course of prednisone, even in moderate or low doses, for more that about 3 weeks you are likely to need a prednisone taper. Many experts would use the 3 week time frame for this, although some would use as little as 2 weeks.
- Some indications for steroids benefit from a taper in dosage to avoid a flare in the disease process being treated
1) Systemic Corticosteroids
2) SABAs (Short-Acting Beta Agonists)
3) SAMAs (Short-Acting Muscarinic Antagonists)
1) Systemic Corticosteroids
Which drug class?
- Relief of acute asthma symptoms
- Preventive for exercise-induced bronchoconstriction
- β2 agonist (Bronchodilation by smooth muscle relaxation)(p 254)
- In addition to asthma monitoring (eg. FEV1 , FVC, etc.), monitoring should include BP, HR and IOP
- Given prior to exercise and as needed (exercise induced bronchospasm, formerly exercise induced asthma)
- When administered in equipotent doses, beta agonists produce same intensity of response
- Increasing use or lack of expected effect indicates inadequate asthma control
- Greater than 1 canister/month may indicate over-reliance on drug
- Greater than 2 canisters/month creates additional adverse risk
- ≥3 canisters dispensed in a year is associated with an increased risk of severe exacerbations
- ≥12 canisters in a year is associated with increased risk of asthma-related death.
- Use of this > twice a week is an indication of poor control. Controller medication should be readdressed
- Note the components of severity and components of control charts below
1) Systemic Corticosteroids
2) SABAs (Short-Acting Beta Agonists)
3) SAMAs (Short-Acting Muscarinic Antagonists)
2) SABAs (Short-Acting Beta Agonists)
Which drug class is this?
- Alternative for patients who do not tolerate SABA, due to less cardiac effects or as add on therapy.
- Use for asthma is indicated in ED setting with albuterol
- (Greater role in COPD)
1) Systemic Corticosteroids
2) SABAs (Short-Acting Beta Agonists)
3) SAMAs (Short-Acting Muscarinic Antagonists)
3) SAMAs (Short-Acting Muscarinic Antagonists)
GINA (Global Initiate for Asthma) determines severity based on therapeutics necessary to maintain control (ie. retrospectively from medications needed to maintain control).
True or False?
True
GINA (Global Initiate for Asthma) does not determine severity based on therapeutics necessary to maintain control (ie. retrospectively from medications needed to maintain control).
True or False?
False
Mild asthma is treated with which steps?
GINA (Global Initiate for Asthma) determines severity based on therapeutics necessary to maintain control (ie. retrospectively from medications needed to maintain control).
1) Steps 1 or 2 (as-needed SABA or low dose ICS).
2) Step 3 (low-dose ICS/LABA).
3) Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment.
1) Steps 1 or 2 (as-needed SABA or low dose ICS).
Moderate asthma is treated with which steps?
GINA (Global Initiate for Asthma) determines severity based on therapeutics necessary to maintain control (ie. retrospectively from medications needed to maintain control).
1) Steps 1 or 2 (as-needed SABA or low dose ICS).
2) Step 3 (low-dose ICS/LABA).
3) Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment.
2) Step 3 (low-dose ICS/LABA).
3) Step 4/5 (moderate or high dose ICS/LABA
Severe asthma is treated with which steps?
GINA (Global Initiate for Asthma) determines severity based on therapeutics necessary to maintain control (ie. retrospectively from medications needed to maintain control).
1) Steps 1 or 2 (as-needed SABA or low dose ICS).
2) Step 3 (low-dose ICS/LABA).
3) Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment.
3) Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment.
Mild asthma is asthma that can be controlled with Step 1 or 2 treatment.
True or False?
True
Moderate asthma is asthma that can be controlled with step 3 or 4.
True or False?
True
Severe asthma is asthma that requires Step 5 treatment.
True or False?
True
Asthma severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations.
True or False?
True
“GINA Stepwise Approach to Control Symptoms and Minimize Future Risk”
Which option for step 1?
A) No controller (PRN SABA)
B) Low-Dose ICS
C) Low-Dose ICS = LABA
D) Medium/high dose ICS/LABA
E) Refer to specialist for consideration of add-on treatment such as tiotropium, anti-IGE, anti-ILS
A) No controller (PRN SABA)
“GINA Stepwise Approach to Control Symptoms and Minimize Future Risk”
Which option for step 2?
A) No controller (PRN SABA)
B) Low-Dose ICS
C) Low-Dose ICS = LABA
D) Medium/high dose ICS/LABA
E) Refer to specialist for consideration of add-on treatment such as tiotropium, anti-IGE, anti-ILS
B) Low-Dose ICS
“GINA Stepwise Approach to Control Symptoms and Minimize Future Risk”
Which option for step 3?
A) No controller (PRN SABA)
B) Low-Dose ICS
C) Low-Dose ICS = LABA
D) Medium/high dose ICS/LABA
E) Refer to specialist for consideration of add-on treatment such as tiotropium, anti-IGE, anti-ILS
C) Low-Dose ICS = LABA
“GINA Stepwise Approach to Control Symptoms and Minimize Future Risk”
Which option for step 4?
A) No controller (PRN SABA)
B) Low-Dose ICS
C) Low-Dose ICS = LABA
D) Medium/high dose ICS/LABA
E) Refer to specialist for consideration of add-on treatment such as tiotropium, anti-IGE, anti-ILS
D) Medium/high dose ICS/LABA
“GINA Stepwise Approach to Control Symptoms and Minimize Future Risk”
Which option for step 5?
A) No controller (PRN SABA)
B) Low-Dose ICS
C) Low-Dose ICS = LABA
D) Medium/high dose ICS/LABA
E) Refer to specialist for consideration of add-on treatment such as tiotropium, anti-IGE, anti-ILS
E) Refer to specialist for consideration of add-on treatment such as tiotropium, anti-IGE, anti-ILS
- Preferred: High-dose ICS + LABA + oral corticosteroid
~AND~ - Consider: Omalizumab for patients who have allergies
Which step?
A) Step 1
B) Step 2
C) Step 3
D) Step 4
E) Step 5
F) Step 6
F
___
A) Step 1:
- Preferred: SABA PRN (intermittent asthma)
B) Step 2:
- Preferred: Low-dose ICS
- Alternative: Cromolyn, LTRA, Nedocromil, Theophylline
C) Step 3:
- Preferred: Low-dose ICS + LABA OR medium-dose ICS
- Alternative: Low-dose ICS + either LTRA, Theophylline, or Zilleuton
D) Step 4:
- Preferred: Medium-dose ICS + LABA
- Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton
E) Step 5:
- Preferred: High-dose ICS + LABA
~AND~
- Consider: Omalizumab for patients who have allergies
F) Step 6:
- Preferred: High-dose ICS + LABA + oral corticosteroid
~AND~
- Consider: Omalizumab for patients who have allergies
____________________
INFO:
- Each step: patient education, environmental control, and management of comorbidities.
- Steps 2-4: Consider subcutaneous allergen immunopathy for patients who have allergic asthma.
- Consult with specialist if step 4 care or higher is required.
- Consider consultation at step 3.
- Preferred: High-dose ICS + LABA
~AND~ - Consider: Omalizumab for patients who have allergies
Which step?
A) Step 1
B) Step 2
C) Step 3
D) Step 4
E) Step 5
F) Step 6
E
___
A) Step 1:
- Preferred: SABA PRN (intermittent asthma)
B) Step 2:
- Preferred: Low-dose ICS
- Alternative: Cromolyn, LTRA, Nedocromil, Theophylline
C) Step 3:
- Preferred: Low-dose ICS + LABA OR medium-dose ICS
- Alternative: Low-dose ICS + either LTRA, Theophylline, or Zilleuton
D) Step 4:
- Preferred: Medium-dose ICS + LABA
- Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton
E) Step 5:
- Preferred: High-dose ICS + LABA
~AND~
- Consider: Omalizumab for patients who have allergies
F) Step 6:
- Preferred: High-dose ICS + LABA + oral corticosteroid
~AND~
- Consider: Omalizumab for patients who have allergies
____________________
INFO:
- Each step: patient education, environmental control, and management of comorbidities.
- Steps 2-4: Consider subcutaneous allergen immunopathy for patients who have allergic asthma.
- Consult with specialist if step 4 care or higher is required.
- Consider consultation at step 3.
- Preferred: Medium-dose ICS + LABA
- Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton
Which step?
A) Step 1
B) Step 2
C) Step 3
D) Step 4
E) Step 5
F) Step 6
D
___
A) Step 1:
- Preferred: SABA PRN (intermittent asthma)
B) Step 2:
- Preferred: Low-dose ICS
- Alternative: Cromolyn, LTRA, Nedocromil, Theophylline
C) Step 3:
- Preferred: Low-dose ICS + LABA OR medium-dose ICS
- Alternative: Low-dose ICS + either LTRA, Theophylline, or Zilleuton
D) Step 4:
- Preferred: Medium-dose ICS + LABA
- Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton
E) Step 5:
- Preferred: High-dose ICS + LABA
~AND~
- Consider: Omalizumab for patients who have allergies
F) Step 6:
- Preferred: High-dose ICS + LABA + oral corticosteroid
~AND~
- Consider: Omalizumab for patients who have allergies
____________________
INFO:
- Each step: patient education, environmental control, and management of comorbidities.
- Steps 2-4: Consider subcutaneous allergen immunopathy for patients who have allergic asthma.
- Consult with specialist if step 4 care or higher is required.
- Consider consultation at step 3.
- Preferred: Low-dose ICS + LABA OR medium-dose ICS
- Alternative: Low-dose ICS + either LTRA, Theophylline, or Zilleuton
Which step?
A) Step 1
B) Step 2
C) Step 3
D) Step 4
E) Step 5
F) Step 6
C
___
A) Step 1:
- Preferred: SABA PRN (intermittent asthma)
B) Step 2:
- Preferred: Low-dose ICS
- Alternative: Cromolyn, LTRA, Nedocromil, Theophylline
C) Step 3:
- Preferred: Low-dose ICS + LABA OR medium-dose ICS
- Alternative: Low-dose ICS + either LTRA, Theophylline, or Zilleuton
D) Step 4:
- Preferred: Medium-dose ICS + LABA
- Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton
E) Step 5:
- Preferred: High-dose ICS + LABA
~AND~
- Consider: Omalizumab for patients who have allergies
F) Step 6:
- Preferred: High-dose ICS + LABA + oral corticosteroid
~AND~
- Consider: Omalizumab for patients who have allergies
____________________
INFO:
- Each step: patient education, environmental control, and management of comorbidities.
- Steps 2-4: Consider subcutaneous allergen immunopathy for patients who have allergic asthma.
- Consult with specialist if step 4 care or higher is required.
- Consider consultation at step 3.
- Preferred: Low-dose ICS
- Alternative: Cromolyn, LTRA, Nedocromil, Theophylline
Which step?
A) Step 1
B) Step 2
C) Step 3
D) Step 4
E) Step 5
F) Step 6
B
___
A) Step 1:
- Preferred: SABA PRN (intermittent asthma)
B) Step 2:
- Preferred: Low-dose ICS
- Alternative: Cromolyn, LTRA, Nedocromil, Theophylline
C) Step 3:
- Preferred: Low-dose ICS + LABA OR medium-dose ICS
- Alternative: Low-dose ICS + either LTRA, Theophylline, or Zilleuton
D) Step 4:
- Preferred: Medium-dose ICS + LABA
- Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton
E) Step 5:
- Preferred: High-dose ICS + LABA
~AND~
- Consider: Omalizumab for patients who have allergies
F) Step 6:
- Preferred: High-dose ICS + LABA + oral corticosteroid
~AND~
- Consider: Omalizumab for patients who have allergies
____________________
INFO:
- Each step: patient education, environmental control, and management of comorbidities.
- Steps 2-4: Consider subcutaneous allergen immunopathy for patients who have allergic asthma.
- Consult with specialist if step 4 care or higher is required.
- Consider consultation at step 3.
- Preferred: SABA PRN (intermittent asthma)
Which step?
A) Step 1
B) Step 2
C) Step 3
D) Step 4
E) Step 5
F) Step 6
A
___
A) Step 1:
- Preferred: SABA PRN (intermittent asthma)
B) Step 2:
- Preferred: Low-dose ICS
- Alternative: Cromolyn, LTRA, Nedocromil, Theophylline
C) Step 3:
- Preferred: Low-dose ICS + LABA OR medium-dose ICS
- Alternative: Low-dose ICS + either LTRA, Theophylline, or Zilleuton
D) Step 4:
- Preferred: Medium-dose ICS + LABA
- Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton
E) Step 5:
- Preferred: High-dose ICS + LABA
~AND~
- Consider: Omalizumab for patients who have allergies
F) Step 6:
- Preferred: High-dose ICS + LABA + oral corticosteroid
~AND~
- Consider: Omalizumab for patients who have allergies
____________________
INFO:
- Each step: patient education, environmental control, and management of comorbidities.
- Steps 2-4: Consider subcutaneous allergen immunopathy for patients who have allergic asthma.
- Consult with specialist if step 4 care or higher is required.
- Consider consultation at step 3.
For a few asthma patients, controller treatment can be started with either as-needed low dose ICS-formoterol (or, if not available, low dose ICS whenever SABA is taken) or with regular daily low dose ICS.
True or False?
False
Once a diagnosis has been established, it is important to:
- Identify precipitating factors or comorbidities that may aggravate the asthma.
- Assess the patient’s knowledge and skill for self management.
- Classify the severity (intermittent or persistent [mild, moderate or severe]) based on impairment and risk.
- Begin a stepwise treatment plan based on severity, stepping up or down depending on level of control.
Which disease is this?
1) COPD
2) Allergic Rhinitis
3) Asthma
Asthma
Treatment goals for an acute ________________ are to rapidly correct hypoxemia and reverse airflow obstruction.
1) Asthmatic episode
2) COPD
3) Allergic Rhinitis
Asthmatic episode
What are two drug classes in the study guide that may worsen asthma?
NSAIDs
Beta Blockers
What drug class is Methylprednisolone?
1) LABA (Long-Acting Beta Agonist)
2) Xanthine Oxidase Inhibitors
3) Systemic Corticosteroids
4) SAMA (Short-Acting Muscarinic Antagonist)
3) Systemic Corticosteroids
Use of this med more than twice a week is an indication of poor control of asthma. Which drug class is this?
1) LAMAs
2) LABAs
3) SAMAs
4) SABAs
4) SABAs
This drug class should not be used as monotherapy for long-term control, but in combination with inhaled corticosteroids (ICs). Which drug class?
1) LAMAs
2) LABAs
3) SAMAs
4) SABAs
2) LABAs
Serious toxicity can occur without preceding signs of less serious toxicity. Which medication is this?
1) Tiotropium
2) Prednisolone
3) Cromolyn
4) Theophylline
4) Theophylline
Your asthma patient has none of these four symptoms. This means this athma is:
1) Well-controlled
2) Partly-controlled
3) Uncontrolled
______________________
*Assessment of Asthma Control in Adults, Adolescents, and Children
**There are four symptoms:
- Daytime asthma symptoms more than twice per week.
- Nighttime awakening due to asthma.
- Reliever needed for symptoms more than twice per week.
- Activity limitation due to asthma.
Well-controlled.
_____
- If yes to none of these = well controlled.
- If yes to 1-2 of these = partly controlled.
- If yes to 3-4 of these = uncontrolled.
Your asthma patient has daytime astham symptoms more than twice a week, awakens from asthma at night, and uses a reliever more than twice a week. This means this athma is:
1) Well-controlled
2) Partly-controlled
3) Uncontrolled
______________________
*Assessment of Asthma Control in Adults, Adolescents, and Children
**There are four symptoms:
- Daytime asthma symptoms more than twice per week.
- Nighttime awakening due to asthma.
- Reliever needed for symptoms more than twice per week.
- Activity limitation due to asthma.
3) Uncontrolled
_____
- If yes to none of these = well controlled.
- If yes to 1-2 of these = partly controlled.
- If yes to 3-4 of these = uncontrolled.
Your asthma patient has limited activty due to asthma and uses her reliever more than twice a week. This means this athma is:
1) Well-controlled
2) Partly-controlled
3) Uncontrolled
______________________
*Assessment of Asthma Control in Adults, Adolescents, and Children
**There are four symptoms:
- Daytime asthma symptoms more than twice per week.
- Nighttime awakening due to asthma.
- Reliever needed for symptoms more than twice per week.
- Activity limitation due to asthma.
2) Partly-controlled
_____
- If yes to none of these = well controlled.
- If yes to 1-2 of these = partly controlled.
- If yes to 3-4 of these = uncontrolled.
Step-up therapy if very poorly controlled (1-2 steps) or poorly controlled (1 step) in ___-___ weeks on preferred regimen
- Review response after ___-___ months, or according to clinical urgency
Which one?
1) 1-2 weeks, 3-4 months
2) 2-6 weeks, 2-3 months
3) 3-4 weeks, 5-6 months
4) 2-6 weeks, 1-2 months
5) 2-5 weeks, 2-3 months
Step-up therapy if very poorly controlled (1-2 steps) or poorly controlled (1 step) in 2-6 weeks on preferred regimen
- Review response after 2-3 months, or according to clinical urgency
Step-down therapy to use __________ medication necessary to maintain control (if well controlled for 3 months)
- Stopping ICS is NOT advised
- “ICE” at each step - [inhaler technique, compliance, environmental controls]
1) Maximum
3) Average
3) Minimum
4) No
3) Minimum
This medication binds to circulating IgE preventing binding to receptor on basophils and mast cells.
- Risk of anaphylaxis. Must give medication guide.
Which medication?
1) Mepolizumab/Reslizumab
2) Dupilumab
3) Benralizumab
4) Omalizumab
4) Omalizumab
IL-5 antagonist monoclonal antibody that reduces the production and survival of eosinophils by blocking the binding of IL-5 to the alpha chain of the receptor complex on the eosinophil cell surface.
- SEs may include oropharyngeal pain, chest pain, neck pain, muscle spasms, myalgia, extremity pain, and musculoskeletal pain and injection site reactions.
Which medication?
1) Mepolizumab/Reslizumab
2) Dupilumab
3) Benralizumab
4) Omalizumab
1) Mepolizumab/Reslizumab
Blocks the IL-4/IL-13 pathway and decreases markers of Type 2 inflammation.
- As add-on maintenance treatment for patients (12+ years) with moderate-to-severe asthma with an eosinophilic phenotype, or with OCS-dependent asthma regardless of phenotype.
Which medication?
1) Mepolizumab/Reslizumab
2) Dupilumab
3) Benralizumab
4) Omalizumab
2) Dupilumab
Monoclonal antibody that causes apoptosis of eosinophils and basophils through antibody-dependent cell-mediated cytotoxicity.
- Approved as add-on for patients (12+ years) with severe eosinophilic asthma uncontrolled with step 4 treatment.
- SEs may include headache, pharyngitis, pyrexia, and injection site reactions.
Which medication?
1) Mepolizumab/Reslizumab
2) Dupilumab
3) Benralizumab
4) Omalizumab
3) Benralizumab
Regarding immunotherapy and injections of aeroallergen extracts:
They should only be administered in a physician’s office in case of life-threatening reactions.
True or False?
True
Regarding immunotherapy and injections of aeroallergen extracts:
Duration of immunotherapy is usually ___-___ years.
1) 4-6
2) 3-5
3) 2-4
4) 1-3
2) 3-5
Regarding immunotherapy and injections of aeroallergen extracts:
Should be considered when:
- Clear evidence of a relationship between symptoms and exposure to an unavoidable allergen to which the patient is sensitive.
T/F?
T
Regarding immunotherapy and injections of aeroallergen extracts:
Should be considered when:
- Symptoms occur all year long or during major portion of year.
T/F?
T
Regarding immunotherapy and injections of aeroallergen extracts:
Should be considered when:
- Difficulty controlling symptoms with pharmacologic management.
T/F?
T
Regarding immunotherapy and injections of aeroallergen extracts:
Should be considered when:
- Eosinophils in nasal smear.
T/F?
T
Regarding immunotherapy and injections of aeroallergen extracts:
Should be considered when:
- Basophils in nasal smear.
T/F?
F
This disease historically describes a subset of pulmonary diseases with a fixed component of airflow limitation. Differentiating this disease as either bronchitis or emphysema is no longer considered relevant since most patients exhibit features of both
Which disease is this?
1) Samter’s Triad
2) Asthma
3) Allergic Rhinitis
4) COPD
4) COPD
This disease is haracterized by airflow limitation that is not fully reversible.
1) Asthma
2) COPD
3) Samter’s Triad
4) Allergic Rhinitis
2) COPD
Major risks for this disease include:
- Exposure to particles
- Tobacco Smoke
- Occupational dust
- Indoor/outdoor air pollution
- Genetics (a-1 antitrypsin deficiency)
- Gender (M>F)
- Age
1) COPD
2) Samter’s Triad
3) Asthma
4) Allergic Rhinitis
1) COPD
The diagnosis of this disease should be confirmed by spirometry. A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation that is not fully reversible.
Which disease is this?
1) Asthma
2) COPD
3) Samter’s Triad
4) Allergic rhinitis
2) COPD
A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of which disease?
1) Asthma
2) Allergic Rhinitis
3) COPD
4) Samter’s Triad
3) COPD
GOLD Classification for COPD.
- Mild COPD
- FEV-1/FVC <0.7
- FEV-1 >= 80% predicted
- Symptoms of chronic cough and sputum production may be present, but not always. At this stage, the individual is usually unaware that his or her lung function is abnormal. With or without chronic symptoms
Which stage?
1) Stage 1
2) Stage 2
3) Stage 3
4) Stage 4)
1) Stage 1
GOLD Classification for COPD.
- Moderate COPD
- FEV-1/FVC <0.7
- 50% <= FEV-1 <80% predicted
- Shortness of breath typically developing on exertion and cough and sputum production sometimes also present. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease.
Which stage?
1) Stage 1
2) Stage 2
3) Stage 3
4) Stage 4)
2) Stage 2
GOLD Classification for COPD.
- Severe COPD
- FEV-1/FVC <0.7
- 30% <= FEV-1 <50% predicted
- Greater shortness of breath, reduced exercise capacity, fatigue, and repeated
§ Exacerbations that almost always have an impact on patients’ quality of life.
- Greater shortness of breath, reduced exercise capacity, fatigue, and repeated
Which stage?
1) Stage 1
2) Stage 2
3) Stage 3
4) Stage 4)
3) Stage 3
GOLD Classification for COPD.
- Very severe COPD
- FEV-1/FVC <0.7
- FEV-1 <30% predicted or FEV-1 <50% predicted plus chronic respiratory failure
- At this stage, quality of life is very appreciably impaired and exacerbations may be life threatening.
Which stage?
1) Stage 1
2) Stage 2
3) Stage 3
4) Stage 4)
4) Stage 4
COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD.
Score < __ is less symptoms
10
mMRC (Modified British Medical Research Council) Breathlessness scale - relates well to other measures of health status and predicts future mortality risk.
- mMRC __-__ is less symptoms
0-1
COPD exacerbations per year.
- __ or more exacerbations per year or 1 hospitalization should be considered high risk.
2
Goals of therapy for COPD:
- __________ ___________
- Remove occupational/environmental risk factors
- Prevent disease progression
- Relieve symptoms
- Improve exercise tolerance and overall health status
- Prevent and treat exacerbations
- Prevent and treat complications
- Reduce morbidity and mortality
Smoking Cessation
Central to symptom management of COPD.
Which drug class?
1) Systemic Corticosteroids
2) Long-term control medications
3) Inhaled corticosteroids
4) Bronchodilators
4) Bronchodilators
- Part of the bronchodilator drug class for COPD treatment.
- SAMA/LAMA
- Considered by many as 1st line for COPD (GOLD doesn’t distinguish)
- Can be used either PRN (and should be available to all patients with COPD) or Scheduled (LABA/LAMA may be more convenient and provide better control)
1) Anticholinergics
2) Sympathomimetics
3) Methylxanthines
1) Anticholinergics
- SABA / LABA In the US, all products containing a LABA, either alone or in combination with ICS, include a black box warring about increase risk of severe asthma attacks and death. This caution applies to patients with asthma, and is strongly recommended that LABAs should always be in combination with another controller (i.e. ICS). This concern applies ONLY to patients with asthma and is NOT relevant concerning the use of LABAs for COPD.
- Many patients with COPD receiving combination therapy with LABA and ICS may be candidates for bronchodilator therapy alone… Although ICSs continue to be a focus of research, including the possibility of mortality benefits
- Consensus guidelines indicate that bronchodilator therapy (one or more (from different classes)) is the focus of treatment for COPD
1) Anticholinergics
2) Sympathomimetics
3) Methylxanthines
2) Sympathomimetics
This drug class should always be in combination with another controller (i.e. ICS). This concern applies ONLY to patients with asthma and is NOT relevant concerning the use of this for COPD,
Which drug class?
1) SABAs
2) LABAs
3) SAMAs
4) LAMAs
2) LABAs
- Historical DOC
- Effective in stable COPD, but due to potential toxicity, others preferred
- Narrow therapeutic index
- Increases in theophylline concentrations have disproportional bronchodilatory effects(ie. higher levels do not provide proportional increase in bronchodilation)
- Serious toxicity can occur without preceding signs of less serious toxicity
- Many drug interactions, including smoking.
Which drug class?
1) Inhaled Corticosteroids
2) Methylxanthines - theophylline
3) Sympathomimetics
4) Anticholinergics
2) Methylxanthines - theophylline
In patients with severe and very severe COPD (GOLD 3 and 4) and a history of exacerbations and chronic bronchitis (Group C and D), the phospodiesterase-4 inhibitor (PDE-4), ___________, reduces exacerbations treated with oral glucocorticosteroids
- NOT indicated in asthma
- NOT indicated in AR
Which medication is this?
1) Theophylline
2) Benralizumab
3) Fluticasone
4) Prednisolone
5) Roflumilast
5) Roflumilast
Regarding COPD:
Used systemically for acute COPD exacerbations.
- Short “burst”
Recent studies have shown improved objective parameters, decreased treatment failures, decreased lengths of stay, and shortened recovery times - Long-term treatment with oral corticosteroids is not recommended as no evidence of benefit and increased ADR’s.
Which drug class?
1) Methylxanthines
2) Sympathomimetics
3) Bronchodilators
4) Corticosteroids
4) Corticosteroids
Oxygen:
- Long-term O2 (>15h/d) in COPD __________ mortality with chronic respiratory failure.
1) increases
2) decreases
2) decreases
Leukotriene modifiers are NOT indicated for COPD
True or False?
True
Can be persistent or intermittent (Seasonal).
1) Asthma
2) COPD
3) Allergic Rhinitis
3) Allergic Rhinitis
Symptoms: sneezing, watery discharge, itching nose/eyes, nasal congestion, postnasal drip.
1) Asthma
2) COPD
3) Allergic Rhinitis
3) Allergic Rhinitis
Mild - All of the following:
- Normal sleep
- Usual daily activities
- No interference with work or school
- No troublesome symptoms
1) Asthma
2) COPD
3) Allergic Rhinitis
3) Allergic Rhinitis
-
-
Moderate-Severe - At least one of the following:
- Disrupted sleep
- Impaired daily activities
- Interference at work or school
- Troublesome symptoms
1) Asthma
2) COPD
3) Allergic Rhinitis
3) Allergic Rhinitis
Goals:
- Minimize or prevent symptoms.
- Allergen avoidance/environmental control.
- Pharmacotherapy for prevention or treatment of symptoms.
1) Asthma
2) COPD
3) Allergic Rhinitis
3) Allergic Rhinitis
1st: Implement environmental controls
Stepwise approach for?
1) COPD
2) Allergic Rhinitis
3) Asthma
2) Allergic Rhinitis
2nd: If not effective, select a single-drug treatment based on symptoms.
- Always consider comorbidities such as hypertension, BPH, thyroid disease, pregnancy, etc… when making choices.
Stepwise approach for?
1) COPD
2) Allergic Rhinitis
3) Asthma
2) Allergic Rhinitis
3rd: If symptoms are not controlled, assess adherence first, then consider Adjusting dosage, switching medications, or adding a second agent from different therapeutic category. May also change medications or adjust dosage if adverse effects are not tolerated.
Stepwise approach for?
1) COPD
2) Allergic Rhinitis
3) Asthma
2) Allergic Rhinitis
Mild or episodic symptoms — Patients with mild or episodic symptoms, or episodic symptoms that are related to predictable allergen exposures (visiting a relative’s house with a pet), can be managed with one of the following options:
- A second-generation oral antihistamine, administered regularly or as needed (ideally two to five hours before an exposure).
- An antihistamine nasal spray
- A glucocorticoid nasal spray (more effective than antihistamines), administered regularly or as needed. For predictable exposures, initiate therapy two days before, continuing through, and for two days after the end of exposure
- Cromolyn
1) Allergic Rhinitis
2) COPD
3) Asthma
1) Allergic Rhinitis
Persistent or moderate-to-severe symptoms — Glucocorticoid nasal sprays are the most effective single pharmacologic therapy and considered the best initial therapy. For patients with moderate-to-severe symptoms and/or in those who fail to respond adequately to initial therapy with glucocorticoid nasal sprays, a second agent can be added.
1) Asthma
2) COPD
3) Allergic Rhinitis
3) Allergic Rhinitis
Regarding allergic rhinitis.
Cross the BBB making them useful for motion sickness, insomnia, anxiety, EPRs, etc
1) 1st-generation antihistamine
2) 2nd-generation antihistamine
1) 1st-generation antihistamine
Regarding allergic rhinitis.
Does not cross the blood brain barrier; recommended due to less sedation and anticholinergic effects.
1) 1st-generation antihistamine
2) 2nd-generation antihistamine
2) 2nd-generation antihistamine
Intranasal antihistamine: sneezing, rhinorrhea, nasal itching/congestion, ocular
- less effective than intranasal corticosteroid in terms of global relief of symptoms
1) COPD
2) Asthma
3) Allergic Rhinitis
3) Allergic Rhinitis
Decongestant (oral, intranasal)
Given for nasal congestion.
- Oral: Slower onset/longer acting,
- Systemic absorption(many precautions) - CNS stimulation (eg insomnia), hypertension, tachycardia, anxiety, etc
- Not associated with rebound congestion (rhinitis medicamentosa)
- Should avoid during first trimester (otherwise category C), but generally considered safe during pregnancy
- eg. pseudoephedrine
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
- Intranasal decongestant: Fast onset/shorter acting, Low systemic absorption, Local irritation, Rebound congestion
- (Limit use to 3-5 d .. not for routine use)
- eg. oxymetazoline
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
Limit use of intranasal decongestants to __-__ days for allergic rhinitis.
1) 1-3
2) 2-4
3) 3-5
4) 4-6
3) 3-5
Intranasal corticosteroid
- Sneezing, itching, rhinorrhea, nasal congestion, ocular
- Most effective monotherapy for all symptoms of AR (p 970,971 key concept(s)
- - Category C for pregnancy (Most evidence with budesonide)
- - lowest systemic bioavailability with mometasone and fluticasone
- Onset of action within 12 hours
- Adverse effects - Usually limited to local effects - dryness, burning, stinging, sneezing, headache, epistaxis
- eg. fluticasone, mometasone
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
Intranasal mast cell stabilizer (prevention) - Cromolyn
- Sneezing, itching, rhinorrhea
- Less effective than intranasal corticosteroids, boasts safety (in children and pregnancy), but delayed onset (up to several weeks)
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
Intranasal anticholinergic
o § Rhinorrhea
o § Adverse effects - anticholinergic in nature
Avoid in glaucoma, urinary retention, BPH and other conditions where anticholinergics may be problematic
(Refer to M/W health and recall the acronym SLUD)
o eg. ipratopium
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
Leukotriene modifier
o § Nasal and ocular symptoms
o § As effective as 2nd gen antihistamine, but more effective when used in combo
o § Less effective than intranasal corticosteroid
o § Safe in pregnancy
o Also see asthma above
o eg. montelukast
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
- Immunotherapy -Should only be considered in those with a strong history of severe symptoms not well-controlled with traditional therapy.
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
Saline Irrigation - Efficacy has been shown for viral upper respiratory symptoms, acute and chronic sinusitis, allergic rhinitis, and pregnancy rhinitis
- No side effects outside of mild and transient discomfort in the nose and ears
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
Anti-infectives are used in the management of allergic rhinitis.
True or False?
False
Anti-infectives are not used in the management of allergic rhinitis.
True or False?
True
SLIT: Sublingual immunotherapy (SLIT) involves the application of allergen to the sublingual tissue
- Each of the SLIT-tablet products are indicated for the treatment of allergic rhinitis (with or without conjunctivitis) induced by the allergen contained in the product.
- Ragweed pollen sublingual tablet (Ragwitek)
- House dust mite sublingual tablet (Odactra)
- Contraindicated in patients with severe, unstable, or uncontrolled asthma
1) Allergic rhinitis
2) Asthma
3) COPD
1) Allergic rhinitis
Asthma is __________ airway narrowing.
reversible
COPD involves reversible airway narrowing.
True or False?
False
