Pharm 4 Resp pt4

Question 1

Leukotriene Inhibitors

Mechanism, Indications

Answer 1

Mechanism:
5-LO modifier
Cysteinyl leukotriene receptor antagonist
Indications:
Long-term control therapy in mild-persistent asthma
Improves lung functions (PF and FEV1)
Reduces need for short-acting beta2-agonists
Prevents acute exacerbations

Question 2

*Clinical Pearl: what patients would you consider putting on a Leukotriene inhibitor?

Answer 2

the individual who has more of an allergic component (rhinitis) will be the person who sees the greatest improvement with a Leukotriene Inhibitor

Question 3

the 4 steps of asthma therapy
Step down when possible, up when necessary.
Consider specialist at steps 3-4

Answer 3

Step 1: Quick-relief meds, no daily long-term control needed
PRN max. 1-2 times weekly
Step 2: Daily long-term control: low-dose ICS (or long-acting beta2-agonist depending upon symptoms)
Step 3: Daily long-term control: medium-dose ICS AND long-acting beta2-agonist
Step 4: Daily long-term control: medium- to high-dose ICS and long-acting beta2-agonist and leukotriene inhibitor or Mast cell wall stabilizer; oral steroids.

Question 4

PA: How many canisters of Albuterol did you use last year?
Pt: Three.
PA: That’s too many. We need to add another medication, ______
Pt: Great. Goodbye!

Answer 4

ICS

Question 5

NIH Guidelines indicate that you should step up from Step 1 to Step 2 whenever your patients are using albuterol more often than:

Answer 5

1-2x week

Question 6

How many puffs/doses is in a canister of albuterol?

Answer 6

200 puffs/100 doses

2 puffs per use

Question 7

Managing Exercise-Induced Bronchospasm (EIB)
Short term (1), long term (2)

Answer 7

Consider short-acting beta2-agonists immediately before exercise
Alternatively, depending upon severity of exacerbations consider:
long-term MAST cell wall stabilizer therapy
long-term long-acting beta2-agonist therapy which may control EIB better than short-acting agents

Question 8

Managing Seasonal Asthma Symptoms

Answer 8

Just before allergy season begin (or step-up) anti-inflammatory therapy
During allergy season, use Step Therapy (take max dose) to control symptoms

Question 9

If their asthma worsens with seasonal allergies. Have them escalade their therapy, but for how long?

Answer 9

Only during that period of time

Question 10

Asthma often presents atypically (no wheezes). What’s the most common atypical presentation of asthma?

Answer 10

Cough - and cough-variant asthma or cough as the initial presenting symptom of asthma is much more common than previously recognized

Question 11

Mechanism of beta-adrenergic agonist bronchodilators

Answer 11

stimulates -receptors, which in turn increases the cyclic AMP, producing functional antagonism to the broncho-constriction, ultimately relaxing the smooth muscle of the airways and causing bronchodilation

Question 12

4 b-Adrenergic Agonists

Answer 12

Albuterol (short acting)
Levalbuterol
Metaproterenol
Salmeterol (long acting)

Question 13

Relief, prevention of bronchospasm w/ reversible obstructive airway disease; prevention of exercise-induced asthma

Answer 13

Albuterol

short acting

Question 14

Bronchodilator for bronchial asthma, reversible bronchospasm associated with COPD

Answer 14

Metaproterenol

Question 15

MAINTENANCE treatment of asthma, prevention of bronchospasm in patients with reversible obstructive airway disease, prevention of exercise-induced bronchospasm

Answer 15

Salmeterol

long acting

Question 16

Prototypical Short-Acting b2-Agonist
Example
Indication
Forms it exists as
How long does it work?

Answer 16

Albuterol
Indicated in: bronchospasm
Available as: Inhaler or Syrup
5-8 hours

Question 17

What would make you want to prescribe a syrup Albuterol instead of a MDI Albuterol?

Answer 17

If there’s a 9 month old child who needs an MDI.

Doses must be in mg instead of mcg

Question 18

What’s useful in an acute/early phase bronchospasm?

What about late phase?

Answer 18

Acute/Early phase: Albuterol

Late: ICS

Question 19

Albuterol

Contraindications, Precautions, Side Effects

Answer 19

Avoid excessive use
Discontinue w/ paradoxical bronchospasm (wheezing/breathing gets even worse), cardiac effects occur
Caution in CAD, htn, arrhythmias
Pregnancy Cat. C (breathing is pretty important though..)
Nursing mothers: not recommended
Avoid MAOIs, TCAs w/in 14 days
Antagonizes b-blockers
Monitor digoxin levels
May cause tremor, h/a, nervousness, insomnia, tachycardia, hypokalemia

Question 20

A patient with mild asthma should use their albuterol no more often than (2)

Answer 20

1-2x week
or
4 puffs per week

Question 21

If a patient uses albuterol two time a week, their prescription should last how long?

Answer 21

1 year

When a patient gets refills more than once a year, their asthma is not well-controlled

Question 22

Prototypical Long-Acting b2-Agonist
Example
Indications

Answer 22

Salmeterol
Indications: Maintenance treatment in asthma (esp. noctural asthma), bronchospastic disease including COPD-associated bronchospasm

Question 23

Details of Salmetrol

Answer 23

Very selective b2 over b1 (therefore far fewer side effects, unlike albuterol)
Slow onset of action of > 30 minutes or longer
Used to treat late-phase response
Long duration of action (12 hours) may result in significant bronchodilation in spite of not using short-acting agents and block symptomatic expression
Not a substitute for steroids

Question 24

Salmeterol

Contraindications, Precautions, Side Effects

Answer 24

Not for use of acute attacks
Caution in CAD, hypertension, seizure disorders, arrhythmias
Pregnancy Cat. C
Nursing mothers: not recommended
Avoid MAOIs, TCAs w/in 14 days
Antagonized by b-blockers
Caution with potasium-depleting diuretics
May cause h/a, sore throat, GI disturbances, tremor, local upper respiratory irritations