PT of Bronchial Asthma Flashcards
Goals of treatment:
- Achieve good control of symptoms
- Maintain normal activities level
- minimize risk of asthma related death
- Minimize exacerbations
- Minimize S/E
Nonpharmacologic therapy
- Teach self management skill
- Avoid allergenic triggers
- Smoking cessation
Pharmacotherapy
- Reliever
- Controller/preventer
Reliever
- Rapid onset - LABA
- SABA
- SAMA
- Short acting Theophylline
Controller/Preventers
- Corticosteroid
- LABA
- Leukotrine Modifier
- Immunomodulator
- LAMA
- Sustained release theophylline
SABA
Albuterol (salbutamol), isoproterenol, metaproterenol, terbuline
Frequent use of SABA associated with:
- increase risk of severe exacerbation
- Hospital admission
- Increase level of airway inflammation
- Death
Anticholinergic
Effective but not as potent as B2 agonist
Example of Anticholinergic SAMA and LAMA
- Ipratropium bromide - 4-8 H
- Triotropium bromide - 24 H
Inhaled ipratropium bromide- SAMA
- Only indicated as adjunctive in severe acute asthma
- does not imrpove outcome in chronic asthma
Why Tiotropium- LAMA should not be used as monotherapy (without ICS)
Increase risk of severe exacerbation
Adding LAMA to ICS-LABA
-No clinically important benefit for symptom
Methylxanthines - Theophylline
Bronchodilator & anti-inflammatory
Theophylline : Adverse effect
Potential DDI
-V&M, tachycardia, insomnia, tachyarrythmia
-plasma conc. should be monitored
SAMA potential alternative for SABa BUT,
Slower onset of action and higher risk of A/E- Not recommended for routine use
Sustained release theophylline
less effective than ICS and no more effective than oral sustained released b2 Agonist , Cromolyn, LT antagonist
Management with CS
Most potent and effective anti-inflammatory mdx available
Benefit ICS
-reduce symptom
-improve lung function and QOL
-reduce BHR
-reduce exacerbation
-reduce mortality
Mild desease
control with twice daily dosing
How to initiate CS?
Start with higher / more frequent dose - then tapered down once under control
Response to ICS
3-6 weeks
ICS adverse effect ?
Oropharyngeal candidiasis (dose dependant)- reduce by gargle after using ICS & dysphonia - minimize using spacer
Short term systemic CS are indicated in?
acute asthma/ exacerbation
Pt with severe persistent asthma/ require chronic systemic CS…should use
Lowest possible dose-provide most clinical benefit (eg: Budesonide 200-400 mcg)
ICS : preffered theraphy should be combined with ..
LABA , formoterol, salmeterol, arformoterol (never used alone)
pt with mild asthma should start with…
Low dose ICS - Formeterol
Can LABA provide significant protection against EIB?
Yes for 8-12 hours initially. but decrease with chronic regular use
Nocturnal asthma is indicator of ?
Inadequate anti-inflammatory treatment
Example of MCS
Cromolyn sodium , nedocromil sodium
Discontinuation because:
Low efficacy
effect of nsaid in asthma
Aspirin and other NSAIDs can induce bronchospasm and, in rare cases, this reaction can lead to death
The main types of NSAIDs include:
aspirin
ibuprofen.
naproxen.
diclofenac.
mefenamic acid.
indomethacin.
LT Modifier: LTR. Antagonist. Example?
Zafirlukast and Montelukast (oral), Zileuton
Indication?
Reduce proinflammatory and BC effect of LT
ICS vs LT modifier?
LTM less effective than ICS
Montelukast adverse effect?
Neuropsychiatric events
Zileuton
(oral) 5-lipoxygenase inhibitor - inhibit synthesis of LT . used on for 12 and >12 y/o
Use of zileuton is limited because :
potential elevated hepatic enzyme and inhibit metabolism of some drugs (eg: theophylline and warfarin)
when Use of zileuton, what should be monitored?
serum alanine aminotransferase
Other controller : Immunomodulators. Example?
Omalizumab (anti-IgE)
Omalizumab:
1. Indication
2. Dosage and Dosage form
3. DISADVANTAGE
- Monoclonal ab , prevent binding of IgE to basophil and mast cell (used in pt 6/>6 y/o)
- SC : 150 -375 mg (2-4 weeks interval)
- High cost (step 5) , combine with high dose ICS and LABA
Other controller : Immunomodulators. Example?
Mepolizumab SC, Reslizumab IV, Benralizumab SC (anti-IL5)
Indications??
Severe eosinophilic (allergy) asthma
Combination ICS + LABA (more effective)
Varied dose ICS + fixed dose LABA
Combination theraphy : 1st agent
Budesonide/Formoterol (DPI)
200/6
Relief and maintenance
Assessment of Asthma control
-assess risk factor
-measure FEV1 at start of tx
–>potential risk factor: low FEV1 (<60%)
-blood eosinophils –>elevated FeNO ; in pt with allergic asthma taking ICS
Types of inhaler:
MDI CS (preventer)
MDI B2 Agonist (reliever)
Brown
Blue
DPI
drawn into lung when breath in
Exacerbation of Asthma / Acute asthma
… can also happen to pt who dependant on SABA
Evaluation of TE outcome: acute asthma
- monitor morning peak flow
- lung function –> spirometry/ peak flow –> 5-10 mins after each tx
- oxygen saturation
