Respiratory: PCOL + Asthma 2 Flashcards
DPI
Dry powder inhalers
EIB
Exercise induced bronchospasm
HFA
Hydrofluoroalkane
ICS
Inhaled Corticosteroids
LTRA
Leukotriene Receptor Antagonists
LABA
Long acting B2 agonists
LAMA
Long acting muscarinic antagonists
MDI
Metered dose inhaler
OCS
Oral corticosteroids
SABA
Short acting B2 agonist
SAMA
Short acting Muscarinic Antagonists
SMI
Soft mist inhaler
Albuterol brand
ProAir, Proventil, Ventolin
Ipratropium brand
Atrovent
Salmeterol brand
Servant diskus
Theophylline brand
Theo-24, Theo-Dur
Montelukast brand
Singulair
Fluticasone brand
Flonase
Beclomethasone brand
Qvar
Budesonide brand
Pulmicort, Rhinocort
Prednisone brand
Deltasone
Fluticasone/salmeterol brand
Advair
Budesonide/formoterol brand
Symbicort
Mometasone/formoterol brand
Dulera
Omalizumab brand
Xolair
Mepolizumab brand
Nucala
Dupilumab brand
Dupixent
SABA MOA
Act on B2 receptor, activating cytoplasmic G proteins which activate adenylyl cyclase to produce cAMP which decreased unbound intracellular calcium, producing smooth muscle relaxation and mast cell membrane stabilization
What does mast cell membrane stabilization do?
Decreases histamine release
SABA treatment options
“-erol are beta agonists”
albuterol - onset quick 5-10min
Levalbuterol
OTC: Epinephrine and Ephedrine
SABA adverse drug reactions
Tremor Anxiety Tachycardia Hypokalemia Hypomagnesemia Hyperglycemia
SABA drug interactions
Beta blockers (using B1 selective will reduce SE)
diuretics
Sympathomimetics
Things to monitor with SABA?
Symptoms
HR
K
SABA patient education
Place in therapy
inhalation device technique
SAMA Mechanism of Action
competitive inhibition of muscarinic receptors in airways thereby preventing bronchoconstriction mediated by vagal nerve
SAMA Treatment options
Ipratropium - slower onset 15-30min compared to albuterol…used as add on
Any benefit of using Levalbuterol vs Albuterol
Not really
Costs much $$$$
not really worth it
SAMA adverse effects
Dry mouth
abnormal taste
SAMA precautions
Narrow-angle Glaucoma
Prostatic hyperplasia
Bladder-neck obstruction
Drug interactions SAMA
Anticholinergic meds
SAMA Monitoring
Symptoms
Urinary retention in older men
Pt education for SAMA
Place in therapy
inhalation device technique
LABA mechanism of action
same as SABA but longer acting
LABA treatment options
** Salmeterol, olodaterol, formoterol **
Albuterol tab, arfomoterol, indacaterol
Salmeterol
< 20 min onset of action
Duration: 12hrs
Formoterol
<5 min onset
Duration: 12hrs
mixed between albuterol (fast onset) and long duration like Salmeterol
LABA Adverse reactions
Tremor Anxiety Tachycardia Hypokalemia Hypomagnesemia Hyperglycemia Cough w/ indacterol
LABA Drug interactions
Other meds that prolong QTc
What to monitor LABA
Symptoms
ADR (HR, K+, Mg, Glucose)
PT education for LABA
Inhalation device training, rationale for use (controller therapy)
Not for acute SOB (potential exception with formoterol in the beclomethasone/formoterol combination which may be used as a maintenance and reliever treatment in asthma)
LAMA Mechanism of action
Inhibition of M1-5 receptors, bronchodilator due to M3 activity in lungs
LAMA treatment options
Tiotropium
Bronchodilator medications
Albuterol Ipratropium Ipratropium/Albuterol Salmeterol Olodaterol Tiotropium Theophylline
Anti-inflammatory agents
Montelukast Roflumilast Azithromycin Fluticasone Beclomethasone Budesonide Prednisone
Combination Therapy meds
tiotropium/olodaterol
fluticasone/salmeterol
budesonide/formoterol
fluticasone/umeclidinium/ vilanterol
Biologics
omalizumab
mepolizumab
dupilumab
trezepelumab
LAMA adverse reactions
Dry mouth Bitter/metalic taste Constipation Urinary Retention Worsened narrow-angle glaucoma
LAMA drug interactions
Anti-cholinergic medications
What to monitor LAMA
symptoms, ADR
Patient education LAMA
role in therapy
inhalation device training
LAMA/LABA Treatment options
Tiotropium/Olodaterol (Stilt Respimat)
Methylxanthine Mechanism of Action
Smooth muscle relaxation/bronchodilation via inhibition of PDE thereby decreasing the degradation of cAMP to AMP; potentially also mild anti-inflammatory activity via PDE4 inhibition; inhibition of adenosine receptors
Methylxanthine treatment options
Theophylline
Methylxanthine adverse effects
All are dose related, highest risk of LA Bronchodilator
Headache Insomnia Nausea Heartburn Arrhythmias Grand mal convulsions
Methylxanthine drug interactions
CYP3A3 and CYP1A2 drugs
Methylxanthine monitoring paramaters
Theophylline lvls
5-15mcg = adult
5-10 mcg = children
Symptoms
Pt education Methylxanthine
place in therapy
side effects + signs/symptoms of toxicities
Anti-inflammatory medications classes
Steroids (OCS/ICS) Mast cell stabilizers Leukotriene Modifiers Macrolide antibiotics Phosphodiesterase 5 inhibiters (PDE4)
Systemic Corticosteroids (OCS) Mechanism of action
Modifies gene expression of cells leading to gene activation or suppression
Block late reaction to allergen and reduce airway hyperresponsiveness
Inhibit cytokine production, adhesion protein activation, and inflammatory cell migration and activation
Reverse β2 receptor down-regulation
Systemic Corticosteroids Treatment options
Prednisone**
Prednisolone
methylprednisolone
“-one” are systemic corticosteroids
Systemic Corticosteroids Adverse reactions
Negative feedback onto Hypothalamus and Anterior pituitary
long list of side effects
Systemic Corticosteroids Drug-interactions
Fluoroquinolone (inc tendon rupture) oral antidiabetics (inc Hyperglycemia) CYP3A4 interactions
Monitoring paramaters Systemic Corticosteroids
Clinical improvement
SE (BP, BG, mental stauts, electrolyte panels)
Growth
Patient education of Systemic Corticosteroids
All the side effects
Adverse Drug reactions Inhaled Corticosteroids
** Thrush **
Cough
Dysphonia
Delayed childhood growth
Bunch of others
How to reduce adverse drug events ICS
Spacers or valved holding chambers (can reduce thrush)
Rinse after inhalation (to reduce thrush)
use lowest dose possible
Monitoring parameters ICS
Growth
Disease outcomes
Pt education ICS
Use a spacer/holding chamber
rinse mouth after inhalation
Drug interactions with ICS
Protease inhibitors
Ketoconazole
CYP450-CYP3A4
ICS/LABA combo patient education
No need to rinse mouth after PRN ICS/formoterol use in asthma
Max daily dose of Formoterol for MART therapy in asthma
54mcg
When is asthma usually worse?
in the morning or at night
Macrolide antibiotics MOA
Macrolide antibiotics bind to the 50s ribosomal subunit preventing protein synthesis, also has anti-inflammatory effects
Treatment options Macrolide Antibiotics
Azithromycin = add on in asthma COPD = used for prevention of COPD exacerbations
have to balance benefit of risk vs reward of antibiotic resistance
Phosphodiesterase-4 inhibitors MOA
Inhibit phosphodiesterase-4 (PDE-4) causing an increase in cAMP.
decreasing inflammatory cell activity, inhibition of fibrosis, relaxation of smooth muscle
Roflumilast Warnings
Acute bronchospasm
Worsen Psychiatric events
Weight decrease
Don’t use with strong CYP- inducers
Roflumilast ADR
GI disorders = go away over time
infections
muscle spasms
tremors
monitoring parameters Roflumilast
Weight
FEV1
COPD exacerbations
Depression
Patient education Roflumilast
side effects - weight loss, insomnia, depression
Place in therapy
Drug interactions Roflumilast
Extensive CYP3A4 and CYP1A2 metabolism
biologic targeting IgE
Omalizumab (Xolair)
biologic targeting IL-4, IL-13
Dupilumab (Dupixent)
biologic targeting IL-5
Mepolizumab (Nucala)
Biologic targeting TLSP
Tezepelumab-ekko (Tezspire)
Omalizumab (Xolair) mechanism of action
Binds to IgE, preventing it from binding to the high affinity receptors on basophils and mast cells
decreases # of high affinity receptors and mast cell mediated release of inflammatory mediators
What to monitor Omalizumab
IgE levels
reduction in exacerbations and symptoms
improvements in FEV1
Side effects = anaphylaxis
Omalizumab precautions
anaphylaxis = black box
parasitic infection
Fever/Rash
Mepolizumab (Nucala) MOA
Humanized IgG1 monoclonal antibody against IL-5 preventing it from binding to its receptor on eosinophils thereby reducing blood, tissue, and sputum eosinophils
What to monitor Mepolizumab
improvements in symptoms
Patient education Mepolizumab
Side effects = hypersensitivity
What to monitor Dupilumab
Improvement in symptoms
exacerbations
FEV1
side effects
Patient education Dupilumab
Store in fridge
SQ injection training, sharps disposal
Advise to d/c and seek treatment if hypersensitivity
TSLP mechanism of Action
Reduces TSLP impact in lungs
can use on a variety of different asthma types
Adverse Drug Reactions with Dupilumab
injection site reactions
conjunctivitis
HSV infection
Tezspire monitoring
asthma control
Tezspire pt education
role in therapy
side effects
avoiding live vaccinations
Tezspire precaution
avoid use of live attenuated vaccines
may put patients at risk of parasite infection
Adverse drug reactions Tezspire
Helminth infection Hypersensitivity back pain pharyngitis Arthralgia (joint stiffness)
ACT
Asthma Control Test
20-25 = well controlled 16-19 = not well controlled 5-15 = very poorly controlled
GINA guidelines for Difficult-to-treat Asthma
- Confirm diagnosis
- Look for factors contributing symptoms/exacerbations
- Optimize therapy
- Review in 3-6 months
- Asses severe asthma phenotypes
- Consider other treatments
- Review response
- Continue to optimize therapy
Before considering Adjusting therapy, consider…..
Adherence Inhaler Technique Comorbid conditions Persistent Allergan exposure Incorrect diagnosis
In patients <5 years, before stepping up therapy GINA recommends to…
try something different
3 ways to adjust therapy
Day-to-Day = based on symptoms
Short Term = 1-2 weeks - when exposed to seasonal allergen or illness
Sustained = >2-3 months - when symptoms uncontrolled
How to step-down therapy
if pt has good control for > 3 months
reduce ICS by 25-50%
close supervision of those with risk factors or exacerbation or persistent airflow limitation
Mild asthma
well controlled on step 1/2 treatment
Moderate asthma
well controlled on step 3/4 treatment
Severe asthma
asthma remains uncontrolled despite high dose ICS/LABA or requires high dose ICS/LABA to maintain control
Vaccinations for Asthma
Flu
Covid-19
Pneumococcal depends on reference
Other therapies for Asthma
SCIT and SLIT (Subcu and Sublingual immunotherapy)
NHLBI SCIT recommended as…
adjunct in those 5+ w/ mild/moderate allergic asthma
GINA SLIT recommended in….
adults with Allergic Rhinitis and sensitization to house dust mite w/ suboptimally controlled asthma despite low dose ICS
only if FEV1 > 70%
Bronchial Thermoplasty (BT)
procedure which uses heat to remove muscle tissues from the airways
not recommended by GINA
**Modifiable Risk Factors for Asthma**
> 1 Risk Factor of Exacerbations > 1 Severe Exacerbations in the past year Exposure to irritants (Tobacco, food allergies, allergens) FEV1 < 60% predicted Obesity Psychological Conditions Socioeconomic Problems Sputum Eosinophilia
Possible Non-pharmacolgical Therapy for Asthma
Avoidance of irritants and triggers Physical Activity Healthy Diet Weight Reduction Education Others
Comorbid Asthma Conditions
Allergic Rhinitis Pregnancy GERD Obesity Obstructive Sleep Apnea Depression/Anxiety Food Allergies
Asthma Action Plans should have 2 aspects
Daily management
How to recognize and handle worsening asthma
Patient Education for Asthma
- Facts about Asthma
- Medication therapy (SE, Proper technique, Role of med)
- Self monitoring
Two ways to do Asthma Action plan
Symptom or Peak Flow based
Peak Flow based action plan
- Find patients best peak flow
2. zones are determined by % of best peak flow
Picking Peak Flow vs Symptomatic based plan
If bad perception of symptoms then peak flow might be easier to use.
Asthma Exacerbations (Flare ups)
Acute or sub-acute episodes of progressively worsening SOB, cough, wheezing or chest tightness
Signs and Symptoms of Asthma Exacerbations
Inc RR, HR prolonged expiratory phase pronounced accessory muscle use diaphoresis difficulty lying supine, speaking lethargy or reduced exercise tolerance nasal flailing in your children
Triggers for Asthma Exacerbations
Respiratory infections allergens Seasonal changes environment emotions exercise drugs/preservatives poor adherence to therapy occupational stimuli
ER/Hospital Management of Exacerbation
Supplemental O2 ( 93-95% children >12, 94-98% children <11
Ipratropium = reduce hospitalizations
add steroids
How to handle asthma exacerbations at home?
Follow asthma action plan w/ close follow up
ER/Hospital management drugs for exacerbation
Albuterol + Ipratropium
Prednisone
Magnesium
Atropy
a genetic predisposition for the development of IgE-mediated response to common aeroallergens
Bronchial Hyperresponsiveness (BHR)
Increased sensitivity of the airways to narrow in response to various stimuli
Exercise Induced Bronchospasm (EIB)
Exercise-induced bronchospasm which can be pre-treated with certain bronchodilators
