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ND Ontario Prescribing Exam > Respiratory Disorders > Flashcards

Respiratory Disorders Flashcards

1
Q

Which of the following is INCORRECT regarding asthma therapy in infants and children?
a) Adult doses of inhaled medication may be required in children
b) Formoterol, a LABA, has a similar onset of action to salbutamol
c) Children on ICS therapy have restricted height as adults
d) Montelukast may allow a lower dose of an ICS
e) Use of salbutamol >4 times per week indicates suboptimal asthma control

A

C. Drug deposition with an MDI and spacer device can be as little as 10 to 20% of that in adults, resulting in adult doses. There is an initial decrease in growth rate, but it is not sustained with long-term therapy; ICS use doesn’t affect final adult height. Formoterol, though it is long-acting, has a rapid onset and can be used as prn therapy. Leukotriene Receptor Antagonists (LTRAs) such as zafirlukast and montelukast, have steroid-sparing properties allowing improved control of asthma at a reduced dose of ICS (page 633, CTC, 7th edn). Use of salbutamol on a prn basis provides valuable information on asthma control and use of 4 or more times per week indicates suboptimal control.

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2
Q

Which of the following is CORRECT regarding the treatment of asthma in children?
a) Inhaled corticosteroids (ICS) can be safely stopped once symptoms are under control
b) Salbutamol prevents exercise-induced bronchospasm for up to 10 hours
c) Formoterol can be used to treat bronchospasm
d) Montelukast will allow an ASA-sensitive asthmatic to take ibuprofen safely
e) Long-acting theophylline is an effective agent for routine maintenance in asthma

A

C. Regular use of an ICS reduces mortality and asthma exacerbations, improves pulmonary function and controls symptoms; cessation may result in the return of airway hyperactivity to previous levels (page 633, CTC, 7th edn). Salbutamol is a SABA that only prevents exercise-induced bronchospasm for 2-4 hours. Formoterol is a LABA that has a rapid onset of action similar to salbutamol which makes it an effective treatment for bronchospasm. Even though montelukast may provide bronchoprotection in an ASA-sensitive asthmatic, NSAIDs should still be avoided in these patients. Theophylline is only used as add-on therapy because of its potential for toxicity and the large number of drug interactions involving this agent (page 632, CTC, 7th edn).

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3
Q

Red Flags by condition and drug induced conditions: Allergic Rhinitis

ANTIHISTAMINES (1ST GEN)

A

Avoid in narrow-angle glaucoma (↑ IOP), urinary obstruction, bladder neck obstruction, urinary retention, GI obstruction. Observe children for paradoxical excitation.

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4
Q

Red Flags by condition and drug induced conditions: Allergic Rhinitis

INT Antihistamines –
1st Gen (Diphenhydramine, Chlorpheniramine)

A

● Additive CNS depressant (alcohol, sedatives, tranquilizers, barbiturates)
● ↑ Anticholinergic effects of TCAs, scopolamine
● If combined w/phenothiazines (anti-emetics, antipsychotics, antihistmaines), monitor for ventricular arrhythmia
● Moderate CYP3A4 inhibitors may ↑ levels (grapefruit, erythromycin)
● AVOID w/strong inhibitors (clarithromycin, ketoconazole)

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5
Q

Red Flags by condition and drug induced conditions: Allergic Rhinitis

INT DECONGESTANTS (Phenylephrine, Pseudoephedrine)

A
    • ↓ Antihypertensive effect of ß-blockers
    • DO NOT use w/MAOI, or w/in 14days of discontinuation
    • SNRIs may ↑ tachycardic and vasopressive effects
      ● Hyperthyroidism
      ● Ischemic ht dz
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6
Q

Red Flags by condition and drug induced conditions: Allergic Rhinitis

INT DEXTROMETHORPHAN

A
  • Caution w/CNS depressants
  • Do NOT use with MAOI, or for 2 weeks following discontinuation
    • SSRIs may enhance adverse effects (nausea, drowsiness, dizziness) and serotonin syndrome
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7
Q

Red Flags by condition and drug induced conditions: Allergic Rhinitis

Decongestants

A

Use with caution in those with HTN, hyperthyroid or ischemic heart disease (although may be fine if the condition is controlled)

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8
Q

Red Flags by condition and drug induced conditions: Asthma

Theophylline

A

Very narrow therap window; therap drug monitoring
Theophylline (10-20mcg/ml – therap. range)
Serum concentrations should be monitored when cimetidine, propranol, allopurinol, erythromycin, phenytoin caused by drug pharmacokinetics

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9
Q

Red Flags by condition and drug induced conditions: Asthma

Theophylline INTX WITH QUINOLONES

A

Ciprofloxacin will increase the level or effect of theophylline by affecting hepatic enzyme CYP1A2 metabolism. Serious - Use Alternative. Concomitant use of theophylline and ciprofloxacin has decreased theophylline clearance and increased plasma levels and symptoms of toxicity. Serious and fatal reactions have included cardiac arrest, seizure, status epilepticus, and respiratory failure. If concomitant use cannot be avoided, monitor theophylline levels and adjust dosage as needed

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10
Q

Red Flags by condition and drug induced conditions: Asthma

THEOPHYLLINE INTX WITH FLUVOXAMINE

A

fluvoxamine will increase the level or effect of theophylline by affecting hepatic enzyme CYP1A2 metabolism. Serious - Use Alternative

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11
Q

Red Flags by condition and drug induced conditions: Asthma

Drug induced
Asthma/ SOB

A

● Aspirin
● NSAIDs (cyclooxygenase inhibitors)
● Sulfites
● benzalkonium chloride
β-blockers

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12
Q

What is the main cause of COPD?

A

Smoking

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13
Q

What are the manifestations of COPD?

A

-partially reversible airway limitation
-increasing frequency and severity of exacerbations
-acute SOB
-activity limitation

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14
Q

T/F: exercise should be limited in a COPD patient?

A

F: they should increase exercise and use SABA if needed prior to activity

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15
Q

What are the goals of therapy for COPD?

A

-prevent progression
- decrease breathlessness
-reduce exacerbations
-improve QOL
-reduce disability
-reduce mortality

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16
Q

Which of the following is a risk factor for COPD?
a. smoking
b. exposure to occupational dust/chemicals/pollution
c.alpha1-antityrpsin deficiency
d. family history
e. all of the above

A

E – all of the above

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17
Q

Which of the following is NOT a co-morbidity or suggestive of systemic manifestation of COPD?
a. CVD
b. Osteoporosis
c. Pulmonary embolism
d. Malignancy
e. Anxiety

A

e- anxiety (depression is a co-morbidity) also:
- altered nutrition, metabolic syndrome, pneumonia

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18
Q

T/F: physical exam is the gold standard for diagnosis for COPD?

A

F – it is an insensitive method of dx

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19
Q

Which of the following is INCORRECT?:
a. Early clinical findings of COPD are hyperinflation, hypoxemia and pulmonary hypertension
b. Spirometry is the gold standard for diagnosis
c. Post-bronchodilator of FEV1 <80% & FEV1/GVC <0.7 are both necessary to diagnose COPD
d. Chest x-ray should be done to rule out lung cancer, TB, bronchiectasis
e. CBC should be done for polycythemia indicated anemia or chronic hypoxia

A

A – these are LATE clinical findings

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20
Q

What should be tested in COPD patients <45 yoa or with a strong family history of COPD?

A

Alpha1-antitrypsin

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21
Q

T/F: if a patient has COPD, there is no point in recommending smoking cessation?

A

F: always recommend and look at using Nortryptline (SSRIs are ineffective)

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22
Q

What should NOT be used as a monotherapy for COPD patients?
a. LABA
b. SABA
c. ICS
d. All of the above

A

C: ICS may increase risk of pneumonia and should be combined with a LABA (although CTC says there is still an increased risk)
* Recall in asthma that a LABA can’t be used on it’s own

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23
Q

What is the best initial drug therapy for COPD?
a. LABA (salmeterol/formoterol)
b. SABA (salbutamol)
c. ICS
d. oral steroids
e. LAMA/tiotropium

A

B: SABA should be used as needed and supplemented with LABA

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24
Q

T/F: ICS has the same anti-inflammatory effects in COPD patients as it does in asthma patients

A

F: it does not affect the neutrophilic response as significantly as in asthma and should be combined with a LABA

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25
Q

T/F: a SABA (salbutamol) is recommended in all stages of disease for symptom relief

A

True

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26
Q

What is the duration of action of a SABA?

A

4-6hrs

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27
Q

What has a slower onset, but lasts up to 8hrs and can be 2x-3x dose without notable side effects?
a. LAMA/tiotropium
b. LABA
c. Ipratropium bromide (short acting anticholinergic)

A

C

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28
Q

T/F: combining Ipratropium + Salbutamol produces a greater degree of bronchodilation, but has increase side effects

A

F: it does produce greater benefit than monotherapy, BUT has lower or similar incidence of S/E of either drug alone

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29
Q

T/F: oral B2-agonists (vs inhaled) are a good treatment option for COPD

A

F: increased side effects and NO role in COPD

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30
Q

Name the 2 classes of Long Acting bronchodilators that are available

A
  1. Long acting muscarinic antagonists (anti-cholinergics) – LAMA
  2. Long-acting B2 agonists (LABA)
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31
Q

What is the first line for managing persistent symptoms and moderate to severe airflow
a. Tiotropium bromide (LAMA)
b. Salbutamol (SABA)
c. Budenoside
d. amoxicillan

A

a. compared with ipratropium, it deposits well in airway and 1 dose lasts for 24hrs

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32
Q

What are the concerns when using LAMAs (tio and ipratropium)?
* further study concluded these were not risks, but did find that ipratropium has increased cardiovascular events*

A

Increased risk of CV death, MI or stroke

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33
Q

Which LAMA has a faster onset than tiotropium and is in phase III of studies?

A

Glycopyrronium bromide

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34
Q

T/F: Inhaled LABA’s offer sustained improvements in pulmonary function, dyspnea and QOL compared with SABAs

A

T

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35
Q

Which LABA (salmeterol or formoterol) has the advantage of a rapid onset and 12 hrs duration?
a. Salmeterol
b. Formoterol
c. Indacterol

A

B. formoterol (Fast acting)
Salmeterol (Slow acting)

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36
Q

T/F: Indacaterol is a rapid acting, ultra long acting B2-adrenergic agonist and requires BID dosing

A

F: it is the first to ONLY require QD dosisng
-use for those who can’t adhere to BID dosing or can’t tolerate anticholinergics

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37
Q

Which of the following is false regarding the LAMA+LABA combo therapy?
a. It should be used if disability persists despite monotherapy in mod/severe disease and persistent symptoms with infrequent exacerbations (<1/year for 2 consec. Years)
b. It has an unacceptable safety profile
c. It offers superior bronchodilation vs. monotherapy
d. Cardiovascular safety was questionable after a 24 and 52 week study
e. Both b & d

A

e.it has an acceptable safety profile and cardiovascular studies showed safety

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38
Q

T/F: ICS is not recommended as a monotherapy, but the combination of LABA + ICS is safe

A

F: there was also an increase in pneumonia, but no increase in morbidity and mortality – so they do recommend this combo

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39
Q

What are the drugs used in triple therapy for those with severe symptoms and repeated exacerbations (>1/year for 2 consec years

A

ICS/LABA added to tiotropium

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40
Q

Which of the following is TRUE regarding triple therapy
a. It is commonly prescribed
b. There is strong evidence to support its use clinically
c. It is clinically superior to dual bronchodilator therapy or ICS/LABA therapy

A

a-it IS commonly prescribed, but there is insufficient evidence proving that it is superior

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41
Q

Which of the following statements is false regarding Rofumilast
a. It suppreses the release of inflammatory mediators by inhibiting cAMP breakdown
b. It is an add-on therapy with bronchodilators for severe COPD
c. It improve quality of life and decreases exacerbations by 23%
d. It is CONTRAINDICATED in those with history of depression or suicidal ideation
e. It can cause weight loss, nausea and diarrhea

A

c.while it does decrease exacerbations, it has NO impact on QOL

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42
Q

T/F: theophylline is not often used because of its narrow therapeutic index, significant drug interactions and required serum monitoring to minimize adverse effects

A

True

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43
Q

Theophylline serum levels shoud be kept between _______ to minimize adverse effects

A

55-85 umol/L

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44
Q

Which of the following is false regarding oxygen therapy?
a. Does not reduce the risk of death in patients
b. It may prolong life by 6-7 years
c. Flow rates should be increased by 3or4 L/min during exercise and sleep
d. It may worsen hypercarbic hypoxia in patients with hypoventilation a-it does reduce the risk of death

A

c. Flow rates should be increased by 1-2L /min

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45
Q

What is the overall benefit for the influenza vaccine in COPD patients
a. 0.5 RR
b. 0.25RR
c. 0.75RR

A

C. 0.75RR (reduces chances by 25%)

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46
Q

T/F: the pneumococcal vaccine should be given to COPD patients to prevent pneumonia and repeated every 5-10years in high risk patients

A

T: although our class notes say NO DIFFERENCE in RR of exacerbations per year, and NO difference in MORTALITY

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47
Q

T/F: ICS has only modest benefit in preventing exacerbations and its effects have been overstated in regards to prevention of exacerbations

A

T: in course notes pack

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48
Q

T/F: each agent on its own has benefit and the benefit increases when you continue to add new, proven therapies

A

F: on their own, have benefit, but the benefits decrease as you add in more therapies

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49
Q

Which of the following is true regarding acute exacerbations:
a. they are the most frequent cause of med visits, hospitalizations, & death in COPD
b. it is not advised to increase the dose/frequency of existing bronchodilator treatment during an exacerbation
c. antibiotics offer no benefit in an acute exacerbation
d. systemic corticosteroids should be avoided in COPD patients due to the risk of fracture

A

a. true
b. it IS advised to increase doses/frequency of SABA/ipratropium
c. ABX help with purulent discharge
d. Use systemic corticosteroids short term

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50
Q

T/F: systemic corticosteroids should always been weaned vs. abrupt discontinuation

A

F: no need to wean if used <2 weeks (textbook), <3 weeks (course notes)

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51
Q

Which is FALSE regarding Oral-steroids
a. a 14 day course of 30-40mg/day is recommended during exacerbations
b. a 5 day course offers equivalent benefit
c. it improves lung function, shortens hospital stay and reduces risk of relapse
d. it can be used as maintenance therapy for COPD patients

A

D. there is NO role for oral CS in maintenance therapy for COPD

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52
Q

Which of the following is FALSE regarding antibiotic therapy:
a. Bacterial infections are the most common cause of exacerbations
b. Viruses are the most common cause and should be treated with anti-virals for the flu in flu season
c. Routine use of acute exacerbations is NOT recommended because of inconclusive evidence and ABX resistence
d. ABX is indicated if pt requires invasive mechanical intervention, or has

A

a. Viruses are the most common cause of exacerbations

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53
Q

When are ABX is indicated for COPD patients?

A

indicated if pt requires invasive mechanical intervention, or has 2/3 of:
increased dyspnea
increase sputum
increase sputum purulence

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54
Q

What are the most common bacterial infections in COPD?

A

H. influenza
Moraxella catarrhalis
S. pneumonia

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55
Q

When should you re-evaluate a COPD patient on ABX and consider a change in your prescription?

A

If no change in 24-36 hours

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56
Q

What antibiotics are recommended for H. influenza, M. catarrhalsi or s.pneumoniae?
a. Amoxicillin
b. Doxycycline
c. TMP/SMX
d. Extended spectrum macrolide
e. All of the above

A

E. all of the above

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57
Q

What is the gold standard test to assess oxygenation during an acute exacerbation

A

Arterial blood gas

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58
Q

What is the therapeutic order of treatment suggested by James?

A
  1. SABA for sx
  2. LABA or tiotrop.
    Then:
  3. ICS or ABX
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59
Q

What does James recommend for an exacerbation

A
  1. Salbutamol (SABA)
  2. Steroids (prednisone)
  3. Any ABX
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59
Q

What does James recommend for an exacerbation

A
  1. Salbutamol (SABA)
  2. Steroids (prednisone)
  3. Any ABX
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60
Q

T/F: continuous macrolides are recommended in severe COPD to prevent exacerbations

A

F: not recommended d/t ABX resistance and s/e such as hearing loss

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61
Q

What does the evidence show to be the best long acting treatment for COPD?
a. LAMA
b. LABA
c. SABA
d. Tiotropium

A

D – tiotropium

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62
Q

T/F: Salbutamol (SABA) has little effect vs. placebo on dyspnea and wheezing

A

F: 57% of patients preferred SABA vs. 9% of placebo.
Absolute difference of 48%

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63
Q

A diagnosis of acute bronchitis is made when a cough persists for
a. 2 weeks, with prurulent sputum
b. less than 3 weeks, with or without prurulent sputum
c. 4 weeks, without prurulent sputum
d. all of the above

A

b

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64
Q

T/F antibiotics are the first line treatment for acute bronchitis

A

F, not recommended if uncomplicated

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65
Q

In severe and prurulent coughs, you should
a) take NSAIDs, they reduce the duration of cough
b) take a bronchodilator, they reduce the duration
c) take a mucolytic expectorant, they reduce the severity
d) take an anti-tussive, they offer short term symptom relief

A

d

66
Q

When a patient has prolonged or repeated bronchitis, you should
a. Consider allergy testing
b. Do a work up for lung cancer
c. Give prescribe a SABA and ICS
d. Consider asthma or COPD

A

D. also consider bronchiectasis and medications that cause cough (ACEI)

67
Q

T/F Fever is not typical of acute bronchitis, therefore NSAIDs and Tylenol should not be used

A

F, fevers can present

68
Q

In Pregnancy, which of the following are Correct?
a) fever and discomfort can be managed with Tylenol
b) Fever and discomfort can be managed with advil
c) Opioids can be used, but should be used with caution near term
d) Detromorphan should not be used

A

A,C
B) Advil can only be used in the in T1 and T2
D) Dextromorphan is safe

69
Q

2 bronchodilators may have therapeutic benefit in acute bronchitis, they are?

A

Salbutamol
Fenoterol

70
Q

In acute Bronchitis in kids, which of the following is false
a) Tylenol can be given for fever
b) Advil can be given for chest pain
c) Tylenol can be give for chest pain
d) ASA can be given for the fever

A

D, 90 % of fevers are viral in nature, there is a risk for Reye’s

71
Q

Antitussives include which drugs?
a) codeine
b) dextromorphan
c) suboxone
d) Hydrocodone

A

A, b, d

72
Q

With respect to codeine,
a) Most people metabolize codeine at the same rate
b) If you are a fast metabolizer, there is little effect because you clear it quickly
c) If you are a fast metabolizer, you form morphine, in potentially toxic levels
d) People metabolize morphine at variable rates, but this doesn’t affect the theraputic outcome

A

c. Conversley, if you are a slow metabolizer, you make morphine at a slower rate and may not produce enough morphine for efficacy

73
Q

What two drugs can precipitate asthma?

A

ASA, beta-blockers

74
Q

Name two SABA.

A

Salbutamol and terbutaline

75
Q

What’s the first choice for acute exacerbations and for prevention of exercise-induced asthma?

A

SABA

76
Q

How would you dose SABA?

A

PRN

77
Q

SABA are bronchodilatros that have an effect on the inflammatory phase of exacerbation. (T/F)

A

F

78
Q

When would you initiate therapy with an anti-inflammatory agent?

A

If using SABA 4 or more times per week

79
Q

How would you dose LABA?

A

Regular twice daily treatment WITH ICS ONLY

80
Q

What’s good to prevent nocturnal symptoms and exercise-induced bronchospasm?

A

LABA

81
Q

Which LABA is effective for rescue therapy?

A

Formoterol in combo with budesonide

82
Q

Oral beta2 agonists are better than inhaled ones.

A

F. more systemic s/e and slower onset of action

83
Q

What kind of drug is ipratropium and when is it used?

A

It’s an anticholingeric and it not routinely used in asthma but may be useful alternative for patients who are unusually susceptible to tremor or tachycardia from beta2 agonists. Bronchodilation lasts longer and useful in beta-blocker-induced bronchospasm

84
Q

Which of these two drugs is not indicated for acute bronchospasm:
A. Ipatropium
B. Tiotropium

A

B- as maintenance therapy only

85
Q

How frequently are ipratropium vs. tiotropium dosed?

A

Tiotropium is administered once a day instead of 3-4 times a day for iptratropium.

86
Q

This drug is no longer used for asthma due to systemic toxicity

A

Theophylline products

87
Q

ICS is a fearful thing to use.

A

F. they are safe, effective and cost-effective

88
Q

What component of asthma do ICS treat?

A

Inflammatory component

89
Q

How are ICS prescribed?

A

Used regularly at lowest effective dose rather than PRN

90
Q

What side effects do ICS have?

A

Pharyngeal candidiasis and dysphonia

91
Q

What do you recommend to a patient with oral candidiasis from ICS use?

A

Rinse mouth with water after use or use a spacer device

92
Q

Doubling the dose of ICS is a good strategy.

A

F. no demonstrated benefit, no longer recommended

93
Q

All of these are side effects of systemic corticosteroids, except?
a. Fluid retention
b. Glucose intolerance
c. Hypertension
d. Increased appetite
e. Mood alterations
f. Weight gain
g. Dry mouth
h. Adrenal axis suppression
i. Avascular necrosis of the hip
j. Cataracts
k. Dermal thinning
l. Diabetes
m. Glaucoma
n. Myopathy
o. Osteoporosis

A

G

94
Q

Beta2 agonists, theophylline, montelukast and ICS are safe in pregnancy

A

T. however theophylline can worsen GERD and cause nausea

95
Q

Which ICS is best in pregnancy?

A

Budesonide

96
Q

ICS and oral corticostaroids are safe in breastfeeding mothers

A

T

97
Q

Which two agents can be used conconmitantly in emergency situations?

A

Ipratropium bromide and beta2 agonists

98
Q

Which is true in regards to testing for allergy
a. Serum IgE or eosinophils should always be tested in allergic patients
b. Antihistiamines can be continued prior to skin test
c. Skin testing is NOT the preferred allergy test
d. Tricyclic anti-depressants and phenothiazines have an antihistaminic effect and will affect the testing

A

d.

antihistamines must be d/c for 3 days prior to test
skin testing is the preferred test and there is no need to test serum total IgE

99
Q

T/F: air conditioning reduces pollen exposure

A

T

100
Q

T/F: reducing dust mite exposure is beneficial for allergy

A

F: no evidence that it reduces sx

101
Q

What symptom almost always present with nasal polyps:
a. anosmia
b. reduced taste
c. sore throat
d. conjuctival sx
e. a&b

A

e.

URTI has sore throat / Fever
seasonal: conjuctival sx, paroxysmal sneezing, itching of nasal mucosa or oropharynx

102
Q

Which of the following is false regarding antihistamines:
a. They reduce the allergic symptoms and congestion
b. They are effective fron sneesing and conjunctivitis
c. Most effective if used prophylactically
d. The 2nd gen meds can be dosed once daily

A

a-false
- they do not reduce congestion

103
Q

T/F: 2nd generation antihistamines are sedating and should be used with caution in the elderly

A

F: it is the first generation that have anticholinergic effects

104
Q

Which 2nd gen antihistamine is more likely to cause some sedation?
a. Cetirizine (reactin)
b. Fexofenadine (allegra)
c. Loratedine (Claritin)

A

a

105
Q

Which 2nd gen AH is safe in kids?

A

Loratedine (Claritin)

106
Q

Which first gen antihistamine has sedative effects, but paradoxical excitation in kids?

A

Benadryl

107
Q

Which of the following is false?
a. There is no loss of effectiveness in the meds for up to 1 year in studies
b. Patients with hepatic impairment may require dose adjustments
c. Decongestants are all sedating
d. Rebound congestion (rhinitis medicamentosa) may occur after 2 weeks of topical nasal application
e. C&D

A

e.
decongestants can have stimulant effecst
- topical use for 3-7 days can cause rebound congestion – avoid these meds as LT therapy m/b required

108
Q

T/F: combination meds of non-sedating second generation AH with a decongestant is the preferred form of medication

A

T: but avoid other ingredients like analgesics – these do not help
(ceterizine + pseudoephedrine)
( fexofenadine/pseudoephed)
(loratedine/pseudoephed)

109
Q

What is the mainstay of therapy for moderate to severe rhinitis symptoms?
a. combo of anti-histamine/decongestant (pseudoephed)
b. monotherapy with either AH or decongestant
c. intranasal corticosteroids (INCS)
d. antihistamine + leukotriene antagonist

A

c.-INCS monotherapy more effective than AH+LTRA and more effective in managing ocular symptoms

110
Q

Which of the following is false:
a. INCS acts locally and does not cause adrenal suppression
b. High dose beclomethasone has no impact on growth in children
c. Mometasone & fluticasone nasal spray had no effect on growth over 1 year
d. Septal perforation is a risk of INCS
e. Sprays should be aimed at the turbinates and not the septum

A

b-beclo nasal spray at 168ug bid has caused average growth suppression of 0.9cm after 1 year
Mometasone and fluticasone did not effect growth

111
Q

Which of the following is false regarding sodium cromoglycate?
a. It has an excellent safety profile
b. It takes 2 weeks for onset of action
c. It requires QID dosing
d. It is less effective than INCS

A

b. Onset of action in 4-7 hours, but full benefit takes weeks

112
Q

Which drug is best for skiers nose to reduce the volume of water nasal discharge?
a. INCS
b. Sodium cromoglycate
c. Montelukast (LTRA)
d. Intranasal ipratropium

A

D

113
Q

Which of the following is false about Montelukast?
a. it is a 1st line therapy for allergic rhinitis
b. it may be helpful in asthma patients or those with polyps
c. it can be used for allergic rhinitis when other meds are
poorly tolerated
d. it has similar benefit as AH but less than INCS

A

a. It is not used as a first line therapy

114
Q

What can be used for ocular symptoms?

A

AH, INCS and LTRA are all effective, but topical AH can be used to provide relief in minutes (olopatadine or ketotifen)

115
Q

T/F: topical cromoglycate can be used for ocular symptoms, but must be discarded within 1 month of opening

A

T

116
Q

Which of the following is false regarding immunotherapy?
a. Allergy shots are most useful for pollen/dust mite allergy
b. Only indicated with evidence of IgE-dependent sensitivity to a specific antigen that cannot be avoided
c. There is no benefit to reducing the risk of asthma
d. Can be administered at home after instruction

A

c- false
- reduced risk of asthma for up to 7 years after cessation of therapy

117
Q

Which of the following is true regarding allergies in kids?
a. Allergies have not been shown to impact learning
b. 1st gen AH are just as safe as 2nd gen AH
c. Decongestants should not be used in children <6yoa
d. Budenoside is the preferred ICS for children
e. You can reduce the risk of growth suppression using 1 QD dosing

A

C and E are true

-budenoside is the INCS that causes growth suppression
-1st gen AH cause sedation and should be avoided

118
Q

What is the first line treatment of rhinitis in pregnancy?

A

INCS d/t best risk/benefit ratio

119
Q

T/F: all antihistamines cross the placenta

A

T

120
Q

T/F: oral decongestants are safe throughout the pregnancy

A

F: should be avoided in 1st trimester

121
Q

T/F: although pseudoephedrine concentrates in breastmilk, recommendations are similar to those for the general population

A

T

122
Q

What should you do if the first line INCS isn’t working?

A

-add an anti-histamine

123
Q

How long should you try an AH before you discontinue d/t lack of effect?

A

2-4 weeks

124
Q

T/F: a 5-7 day course of ORAL CS can be used for very severe nasal symptoms

A

T

125
Q

Which of the following is false:
a. Intranasal corticosteroids will shrink polyps
b. Anosmia can be treated with INCS
c. Meds should be started at the maximum dose and then tapered to minimum effective dose for maintenance
d. BID dosing at the same total dose of INCS may be more effective than once daily dosing

A

b-anosmia is not improved with medications

126
Q

T/F: antihistamines are CI in asthmatic patients

A

F: m/b beneficial

127
Q

When would you refer a pt to an allergist or immunologist?

A

a. Inadequate control
b. Reaction to meds
c. Reduced QOL
d. Identify allergens
e. Co-morbids: asthma or recurrent sinusitis
f. Allergen immunotherapy

128
Q

Asthma in children

T/F: one of the goals of therapy is to reduce SABA use to <5 doses/week

A

F: <4 doses/week

129
Q

Diagnosis of asthma in kids <6yoa depends on hx and phys exam, which of the following are important to consider:
A. Cough worse at night
B. Family history of atopy, food/inhalant allergy, asthma
C. History of RSV
D. Wheeze or chest tightness that limits activities
E. All of the above

A

E – all of the above

*hx of RSV hospital admission increases risk of asthma from 9% to 39%

130
Q

Asthma in children

What are the conditions that should be considered in your ddx?

A
  • CF if associated with failure to thrive
  • Vascular compression of airway or malformation If swallowing difficulties or choking
  • Vocal cord dysfxn: SOB and weak voice and/or absent at night
  • Primary ciliary dyskinesia if recurrent OM and sinusitis
131
Q

Which of the following is NOT a sign of asthma in a PE
a. eczema or allergic rhinitis  cough likely related to asthma
b. hyperexpansion of thorax
c. increased nasal secretion and pale mucosal swelling
d. nasal polyps in a PRE-pubertal child or finger clubbing

A

D: those are symptoms of cystic fibrosis

132
Q

T/F : peak flow rates are an effective measurement to confirm diagnosis of asthma in children

A

F: they are an insensitive indicator of airflow limitation. Airflow m/b limited while peak flow still N

133
Q

What should be measured at least annually on all asthmatic children >6yoa who are using medication?

A

spirometry

134
Q

List the non-pharm treatment options

A

-avoid cigarette smoke
-avoid allergens
-annual flu shot
- educate on proper use of inhaler devices

135
Q

T/F: Beta2-agonists provide short term relief from bronchospasm and have no effect on airway inflammation

A

T: need regular use of ICS to treat inflammation

136
Q

T/F: you can use ICS (budenoside / beclamethasone) for a few weeks to reduce inflammation

A

F: weeks to control obstruction, but MONTHS or years to control inflammation

137
Q

Which is the preferred route of administration of corticosteroids for children?

A

Inhaled using pressurized metered dose inhalers (PMDIs)

138
Q

Which of the following is Incorrect?
a. pMDIs demonstrate excellent lung deposition of active ingredients
b. drug deposition using pMDI and spacer in young children is 70-80%
c. adult doses may be required in young children for therapeutic effect
d. in children >5yoa, a dry powder system or pMDI may be used

A

B: drug deposition in young children is 10-20%, thus you may need to use adult doses

139
Q

What is considered regular use of a SABA that would indicate that the child’s asthma is poorly controlled and requires ICS

A

> 4 doses/week

140
Q

What indicators would tell you that the child needs ICS in addition to the SABA?
a. Relief lasts <2hrs
b. >4 doses per week, including exercise induced asthma prevention

A

If relief <2 hrs, urgently assess child and may need systemic CS

141
Q

Which of the following statements is Incorrect for LABA
a. Provide up to 5 hrs of symptom control for exercise induced asthma
b. should always be used in combo with ICS
c. those who have not used steroids, may have effective control without combination therapy and using ICS alone
d. in children <6yoa, role of LABAs is uncertain
e. budenoside + formoterol as maintenance and rescue therapy is superior to either drug+terbutaline rescue therapy

A

a. it provides 10-12 hours of prevention of exercise induced asthma

142
Q

What should be assessed before adding a LABA to ICS?

A

-avoidance of triggers
-regular use of ICS
-inhalation technique

143
Q

T/F: theophylline is a first line choice in asthma management in kids

A

F: it may have anti-inflamm role in adult patients, but rarely used in children d/t toxicity

144
Q

Which of the following is INCORRECT regarding inhaled corticosteroids?
a. It is the cornerstone of asthma management in infants
b. It may prevent airway remodeling
c. It has no impact on mortality
d. Reduces the need for rescule inhaler
e. It cures asthma

A

C – it DOES reduce mortality
E – it improves symptoms, but does NOT cure asthma

145
Q

T/F: it is safe to stop ICS if you have been using it for a few months

A

F: discontinuation after months of use may result in return of airway hyperreactivity to previous status

146
Q

ICS takes ______ to reduce symptoms, but _______ to reduce inflammation in the airways

A

Days
months

147
Q

T/F: doubling the dose of ICS in response to a viral resp tract infection is common place AND supported by evidence and by Canadian guidelines?

A

F: it is commonplace, but NOT supported by evidence

148
Q

What is the dose of budenoside that provides minimal side effects?

A

<400 ug/day

149
Q

T/F: ICS has a large impact on growth when used in children

A

F: growth reduction seen in first year, but not long term
1 study showed decreased adult height by 1cm

150
Q

Which are correct?
Leukotriene receptor agonists (montelukast):
a. can be used in patients with ASA-sensitive asthma
b. Make NSAIDS safe for those with ASA-sensitive asthma
c. Allow improved control of asthma at a reduced dose of ICS
d. Reduce airway inflammation
e. Are recommended as a FLT as a monotherapy in place of ICS

A

A, C, D are correct

  • Not recommended in place of ICS due to inferior efficacy in preventing acute exacerbations that require oral corticosteroids
151
Q

T/F: LTRAs can be used as an adjunct to moderate to high doses of inhaled corticosteroids for persistent asthma

A

T – can be used in px who cannot or will not use ICS

152
Q

What is the name of the eosinophilic vasculitis that may occur with LTRAs?

A

Churg-Strauss

153
Q

In regards to difficult to control asthma, all of the following are important, EXCEPT:
a. Majority of asthma can be controlled with reg use of ICS and B2 agonists
b. The diagnosis should be reconfirmed, allergies removed, proper use of medications assessed
c. Pertussis and GERD should be ruled out
d. Vitamin D deficiency plays no role in difficult to control asthma

A

D: there is some evidence that low vitamin D can increase exacerbations

154
Q

T/F: use of short courses of SYSTEMIC CS over 2.5 years has no impact on bone health

A

F: 4 short courses over 2.5 years has been associated with increased fracture risk.

155
Q

What should be given for acute asthma management?

A
  1. O2 after puls ox and arterial blood gases measured
  2. frequent, high dose of Inhaled B2 agonist
  3. Systemic corticosteroids
  4. IV Mg+ or salbutamol adjunctive for more severe attacks
156
Q

When should the dx of asthma be questioned?

A

If there is little improvement with B2 agonist or systemic CS

157
Q

T/F: Acetominophen is a major risk factor for exacerbation of asthma

A

F: study showed not associated after adjusting for resp infections

158
Q

T/F: LABAs can be used as a monotherapy

A

F – should not be used as monotherapy – combine with ICS

159
Q

What instruction should be given to patients taking an ICS to prevent thrush?

A

Rinse mouth with water after use and use spacer with pMDI

160
Q

Which of the following are true regarding Anti-IgE therapy (Omalizumab)?
a. It is a recombinant antibody that binds IgE receptors to block the IgE mediated immune response
b. Therapy should be initiated by a speciliast
c. It is safe to use in children <12yoa
d. It has no impact on asthma exacerbations or reducing the dose of ICS
e. A & B

A

E: A& B are correct

It should only be used in those >12yoa
It does reduce exacerbations and decreases need for ICS in those with allergic IgE-mediated asthma

161
Q

What is the acute asthma management protocol?

A
  • O2 to maintain SaO2 >94%
  • Nebulized salbutamol Q20 x 3 (pMDI 6-10puffs Q20 min x 3)
  • Not improved: add ipratropium bromide and prednisone
162
Q
A

ND Ontario Prescribing Exam (22 decks)

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