Therapeutics I Exam VII (Asthma) Flashcards
Adult and Pediatric Asthma Guidelines (NEAPP and GINA)
Define asthma.
Asthma is a common, heterozygous, chronic inflammatory disorder characterized by episodic airflow limitation, bronchial hypersensitivity, and underlying inflammation.
T or F: Wheezing is both a sign and symptom of asthma.
True. They patient and the provider should be able to notice wheezing.
What is the genetic/atopic triad?
This is a possible aspect behind the pathophysiology of asthma. It includes allergic rhinitis, asthma, and atopic dermatitis (eczema). It is not uncommon for those with asthma to present with the other two conditions as well.
What is the Samter’s triad?
This is another possible aspect behind the pathophysiology of asthma. it includes aspirin sensitivity, asthma, and nasal polyps.
Why can aspirin exacerbate asthma in some individuals?
Aspirin caused COX inhibition which shunts all the arachidonic acid into the LOX pathway which increases leukotriene production which induces inflammation and bronchoconstriction.
If a person presents with asthma and nasal polyps, they have an increased risk for what?
Increased risk for asthma sensitivity due to the Samter’s triad.
What are the two types of asthma?
T-helper 2 cell HIGH asthma and T-helper cell 2 LOW asthma.
What role do T-helper 2 cells play in asthma?
T-helper 2 cells interact with dendritic cells which causes the T-helper 2 cells to secrete IL-4 and IL-5 which are inflammatory markers elevated in asthma.
Those with T-helper 2 cell LOW asthma, may not respond as well to what type of drug treatment?
Inhaled Corticosteroids
Those with T-helper 2 cell HIGH asthma tend to repsond well to what type of treatment for their asthma?
Corticosteroids
What is a peak flow meter?
A peak flow meter is a portable, inexpensive, hand-held device that measures your ability to push air out of your lungs. Air flow is measured by the amount of air that you can blow out in one “fast blast.”
What is spirometry?
Spirometry is a common test used to check how well your lungs work. It measures how much air you breathe in, how much you breathe out and how quickly you breathe out.
What are 3 factors that impact peak flow meter and spirometry and how?
Age, gender, and height influence these the outcomes on these tests. Lung function peaks in your 20s and decreases after that, males have greater lung volume and size, and taller people have greater lung function as well.
What is fractional exhaled nitric oxide (FeNO)?
This is an inflammatory marker that will be high in T-helper 2 cell HIGH asthma and may be high in T-helper 2 cell LOW asthma.
Through which test is asthma diagnosed with?
Spirometry. Peak flow rate is not used as it is much too variable, no graphic representation, and limited calibration.
What 4 things are found from spirometry testing?
- pre and post-bronchodilator assessment
- determines baseline and severity of airflow limitation
- determines reversibility
- FEV1, FVC, and FEV1/FVC
What is FEV1?
This is the forced volume of air exhaled in 1 second found via spirometry testing.
How is reversibility of obstruction determined from FEV1?
Via the FEV1, reversibility is determined by an increased FEV1 by 200mL or more AND a 12% or greater increase from baseline after 2-4 puffs of a SABA like albuterol.
Reversibility of obstruction is determined by a FEV1 increase of _______mL or greater AND a _______% or greater increase from baseline after 2-4 puffs of a SABA.
200mL
12%
What is FVC?
FVC stands from forced vital capacity. It is the full volume of air that can be forcibly expelled from the lungs after the fullest possible inspiration.
What is FEV1/FVC?
This is the fraction of total lung volume that can be exhaled in 1 second. Anything less than 70% is indicated as obstructive disease (just can’t determine which type of lung obstructive disease)
Less than ________% fraction of total lung volume determined by FEV1/FVC indicated obstructive disease in spirometry.
70%
A patient undergoes spirometry testing. Their pre-bronchodilator FEV1 was 4L (goal 4.8) and their post-bronchodilator FEV1 was 4.4L (goal 4.8). What is the total change and % change in FEV1?
Total change is 4400mL- 4000mL= 400mL. This value is greater than 200mL which indicates reversibility
% change is (4400-4000)/4400= 10% change. This does not meet the 12% criteria for reversibility.
Since both numbers need to be hit to indicate reversibility, this patient likely has a lack of reversibility.
What does “reversibility of obstruction” mean?
This means that if a person is given a SABA from spirometry testing, there is a good chance the issues are reversible if a 200mL minimum increase and 12% minimum increase in FEV1 is shown.
A patient presents for spirometry testing. Their pre-bronchodilator FEV1 was 4L (goal 4.8) and their post-bronchodilator FEV1 was 4.4L (goal 4.8). Their pre-bronchodilator FVC was 4.6L (goal 5.4) and their post-bronchodilator FVC was 4.8L. Is their fraction of total lung volume that can be expelled in 1 second less than or greater than 70%?
To calculate fraction of total lung volume that can be expelled in 1 second, divide FEV1/FVC= 4.4/4.8= 91.7%. This value is greater than 70% which indicates no obstructive disease.
What are the signs and symptoms of asthma?
Chest tightness, wheezing (on expiration mostly), dyspnea, dry and hacking cough (especially at night)
T or F: GERD can be a trigger for asthma.
True.
What are two medications that may trigger asthma?
NSAIDs (same reason as the aspirin) and beta blockers
T or F: Obesity plays no role in the development or triggering of asthma.
False. Obesity is a trigger for asthma. A 5-10% weight loss can help symptoms.
What are the two guidelines used for asthma in those 12 years and older?
- National Asthma Education and Prevention Program (NAEPP)
- Global Initiative for Asthma (GINA)
What are the goals of treatment when it comes to asthma?
In the moment, we want to reduce symptoms, maintain normal activity, and achieve a normal pulmonary function test. In the future, we want to prevent asthma exacerbations and medication adverse events.
What are some non-pharm ways to prevent asthma exacerbations and triggers?
- avoid allergens
- avoid environmental tobacco smoke
- avoid eye and systemic beta blockers
- avoid sulfite-containing foods
- avoid NSAIDS in hypersensitivity or nasal polyps
What 4 questions are asked to determine symptom control and exacerbation risk factors in asthma via GINA?
In the past 4 weeks, has the patient had…
1. Daytime symptoms more than twice per week?
2. Any night waking due to asthma?
3. SABA reliever needed more than twice per week?
4. Any activity limitation due to asthma
Only used for patients using SABA reliever (not an ICS-formoterol reliever).
The tool/questions used to evaluation symptom control and exacerbation risk factors can only be used in what asthma population?
Those using a SABA as a reliever (NOT for those using ICS-formoterol)
15 year old male was diagnosed with asthma 4 months ago. In the past month, he thinks he asthma is under control. He states that he does not wake up at night from the asthma and he is able to play basketball with his friends with zero issues. He used his albuterol inhaler 3 days last week and the week before for shortness of breath. All albuterol use was during the day. What level of asthma control does he have?
Partly controlled. He has daytime symptoms more than twice per week (SOB) and he needed his SABA more than twice per week (3 times). However, he has no activity limitations or night waking due to asthma.
What are 8 risk factor for asthma exacerbations?
- Over-use of SABA
- inadequate use of ICS
- medical conditions like pregnancy, obesity, GERD
- allergen exposre
- major psych or socioeconomic problems
- poor lung function
- type 2 inflammatory marker
- severe exacerbation in past year or lifetime history of intubation or ICU admin for asthma
Over-use of a SABA can cause ____________.
Hypokalemia
How is asthma classified for those NOT taking long-term controllers via the NAEPP guidelines?
Classified based on symptoms per week, nocturnal awakenings per month, SABA use per week, interference with normal activity, and lung function.
How is intermittent asthma classified based on the NAEPP guidelines?
Symptoms: 2 or less days per week
NA: 2 or less times per month
SABA use: 2 or less days per week
Interference: None
Lung function: FEV1/FVC= normal
If a person is classified with intermittent asthma, what step of therapy is initiated?
Step 1
How is mild-persistent asthma classified based on the NAEPP guidelines?
Symptoms: more than 2 days per week but not daily
NA: 3-4 times per month
SABA use: more than 2 days per week but not daily
Interference: Minor
Lung function: FEV1/FVC= normal
If a person is classified with mild-persistent asthma, what step of therapy is initiated?
Step 2
How is moderate-persistent asthma classified based on the NAEPP guidelines?
Symptoms: Daily
NA: more than 1 time per week but not nightly
SABA use: Daily
Interference: Some
Lung function: FEV1/FVC= down 5%
If a person is classified with moderate-persistent asthma, what step of therapy is initiated?
Step 3 +/- oral steroids
How is severe-persistent asthma classified based on the NAEPP guidelines?
Symptoms: Throughout the day
NA: Several times per week
SABA use: Several times per day
Interference: Extreme
Lung function: FEV1/FVC= greater than 5% decrease
If a person is classified with severe-persistent asthma, what step of therapy is initiated?
Step 4 or 5 + oral steriods
What is a normal FEV1/FVC ratio for those between the ages of 8-19 without asthma?
85%
What is a normal FEV1/FVC ratio for those between the ages of 20-39 without asthma?
80%
What is a normal FEV1/FVC ratio for those between the ages of 40-59 without asthma?
75%
What is a normal FEV1/FVC ratio for those between the ages of 60-80 without asthma?
70%
A 15 year old patient is diagnosed with asthma. He was prescribed albuterol (SABA) previously for an upper respiratory tract infection and has been using it 5 days a week during the day for SOB and wheezing. What asthma classification does he have?
Mild-persistent asthma as he as symptoms more than 2 days per week but not daily and uses the SABA more than 2 times per week but not daily.
A 48 year old patient newly diagnosed with asthma states that she is waking up every other night with asthma symptoms. She has symptoms during the day 4-5 times per week. What asthma classification does she have?
Moderate-persistent asthma as is waking up more than 1 time per week but not nightly.
Which asthma classification do you pick for a patient who falls into multiple categories?
Pick the classification that is considered ‘worse’. If they are both mild-persistent and moderate-persistent, you would classify them as moderate-persistent since that is ‘worse’.
A 48 year old patient newly diagnosed with asthma states that she is waking up every other night with asthma symptoms. She has symptoms during the day 4-5 times per week. She is classified as moderate-persistent asthma. What step of therapy should she be initiated on?
Step 3 +/- oral steroids
What diagnostic method can be used for asthma is spirometry testing is inconclusive?
Fractional exhaled Nitric Oxide (FeNO)
FeNO greater than _________ ppb support an asthma diagnosis.
50 ppb
T or F: Those with obesity and asthma may have lower FeNO levels compared to those how have asthma but are not obese.
True.
What 3 things can influence FeNO levels?
Allergic rhinitis, atopy, and smoking
What is step 2 treatment via NAEPP?
Step 2 treatment includes 2 choices that can be selected:
- Low dose ICS + PRN SABA
OR
- PRN ICS + PRN SABA use together only for symptoms
What is step 3 and 4 treatment via NAEPP?
The SMART approach is step 3 and 4 treatment. It includes single maintenance and reliever therapy approach. ICS-formoterol single inhaler will be used for maintenance control and reliever therapy.
Dosing for maintenace is 1-2 puffs once daily or twice daily
Dosing for reliever PRN is 1-2 puffs every 4 hours for symptoms (max 12 per day)
What is the regular daily use/maintenance dosing for ICS-formoterol for step 3 and 4 SMART therapy via the NAEPP?
1-2 puffs once per day or twice per day
What is the reliever/PRN dosing for ICS-formoterol for step 3 and 4 SMART therapy via the NAEPP?
1-2 puffs Q4H PRN for symptoms
What is the maximum amount of puff per day for ICS-formoterol?
12 puffs per day
T or F: SMART therapy (step 3/4 via NAEPP) is FDA approved for use as it is recommended by the guidelines.
False. SMART therapy is not FDA approved.
T or F: SABA use by itself for asthma can increase the risk for death.
True
ICS with formoterol should not be used as a reliever for patients already on what medication for maintenance therapy?
ICS with salmeterol therapy
Sublingual and SubQ immunotherapy for asthma is typically used as _________ therapy for those with severe asthma.
Adjunct
What is the main adverse effect seen with SubQ immunotherapy for asthma?
Severe allergic reactions which is why these are administered within an office and not during an asthma episode.
When is sublingual immunotherapy indicated for those with severe asthma?
If a severe allergic reaction occurred with the SubQ injectable immunotherapy but only for asthma patients with adequate FEV1.
T or F: The NAEPP 2020 revision of guidelines stated there was zero evidence supporting the use of sublingual immunotherapy in severe asthma patients.
True. But they are still used.
What is bronchial thermoplasty?
It is a tool that heats up and burns away muscle from the away to control and reduce asthma exacerbations. It can acutely cause worsening of asthma symptoms and is not recommended due to that.
What are the 5 adverse effects associated with bronchial thermoplasty for asthma?
Short-term worsening of asthma symptoms, cough, wheezing, chest pain, and infection
What step of treatment is initiated for intermittent asthma?
Step 1. This step includes as needed SABA use.
T or F: Those with severe persistent asthma are started on step 6 therapy via the NAEPP guidelines.
False. No one is started at step 6. Those with severe persistent asthma are started on step 5 and can be escalated up to step 6.
What is step 5 of guideline directed asthma therapy based on NAEPP guidelines?
Once daily medium-high dose ICS-LABA (ICS formoterol possibly) with a LAMA (tiotropium) and a PRN SABA (albuterol)
What is step 6 of guidelines directed asthma therapy based on the NAEPP guidelines?
Daily high dose ICS-LABA (ICS formoterol) with PRN SABA (albuterol) and oral corticosteroid
T or F: Theophylline is recommended in both NAEPP and GINA guidelines for asthma.
False. This medication is not recommended in either guideline.
In order to initiate stepping up or down on treatment guidelines for NAEPP, asthma symptoms need to be controlled for at least _________ months.
3 months
For asthma exacerbations in an ambulatory care setting for those on step 1 and 2 therapy, what is used?
A SABA like albuterol is used for up to 3 treatments at 20 minute intervals.
For asthma exacerbations in an ambulatory care setting for those on step 3 and 4 therapy, what is used?
ICS-formoterol 1-2 puffs up to maximum of 12 rescue puffs.
T or F: FeNO levels can be falsely decreased in patients who are obese and have asthma.
True.
A 14 year old patient presents with asthma symptoms 3 times per week during the day and 3 times a month at night. What level of asthma severity does this patient have?
Mild persistent asthma
A 14 year old patient presents with asthma symptoms 3 times per week during the day and 3 times a month at night. They were found to have mild-persistent asthma. What step of therapy should the patient be started on according to NAEPP?
Step 2 therapy
A 14 year old patient presents with asthma symptoms 3 times per week during the day and 3 times a month at night. They were found to have mild-persistent asthma. The patient was started on step 2 therapy. What medications are used in step 2 therapy via the NAEPP guidelines?
Daily low dose ICS and PRN SABA
OR
PRN ICS and PRN SABA
What signs and symptoms could a patient with asthma have?
SOB, wheezing, cough, chest tightness, etc
A trigger can worsen inflammation which causes the mucosal lining to become more ________ and makes goblet cells secrete more _______.
Swollen
Mucus
Why does wheezing occur?
Airways constrict due to inflammation and air has difficulty passing through causing a wheezing like sound.
What is the maximum daily dose of maintenance and recuse therapy for budesonide-formoterol (ICS-formoterol combo) (Symbicort)?
12 puffs per day maximum no matter the reason
What are the 3 general principles surrounding the treatment of asthma with GINA?
- everyone gets an ICS
- everyone has a reliever inhaler that contain rapid acting bronchodilator (formoterol is preferred, next is SABA like albuterol)
- everyone gets a written action plan
In GINA, all adults (12+) can choose one of two options for their reliever for asthma treatment. What are these two options?
- PREFERRED- prn low dose ICS-formoterol (symbicort)
or
- Reliever is SABA
What is the ‘cycle’ of asthma treatment according to GINA?
Assess, adjust, and review treatment often.
T or F: ICS-formoterol used as a reliever reduces the risk of exacerbations compared to using a SABA as the reliever.
True
In the GINA guidelines, what asthma symptoms would qualify a person for step 1 or 2 therapy?
The person has asthma symptoms less than 3-5 days per week with normal or mildly reduced lung function.
Where does sublingual immunotherapy play a role in asthma treatment?
It is an option as adjunct therapy in track 2 treatment via the GINA guidelines.
What is step 1 and 2 therapy via the GINA guidelines?
PRN low dose ICS-formoterol therapy
In the GINA guidelines, what symptoms would classify a patient into step 3 therapy?
Symptoms present on most days (more than 5), or waking at night at least once per week, or low lung function (FEV1 60% or less).
What is step 3 therapy per the GINA guidelines?
Maintenance low dose ICS-formoterol
In the GINA guidelines, what symptoms would classify a person into step 4 therapy?
Daily symptoms, waking at night once per week or more, and low lung function or recent exacerbation.
What is step 4 therapy per the GINA guidelines?
Maintenance medium dose ICS-formoterol
Per the GINA guidelines, what symptoms would classify a person into step 5 therapy?
No one would be initiated into step 5 therapy in the GINA guidelines. They would be started on step 4 and eventually moved up to step 5.
What is included in step 5 therapy per the GINA guidelines?
Addition of a LAMA like tiotropium (spiriva) to the medium-dose maintenance ICS-formoterol.
How does LAMAs like tiotropium aid in asthma?
LAMAs like tiotropium do not decrease symptoms of asthma but improve lung function and decrease exacerbations.
The reliever used in the GINA guidelines is always low dose PRN _____-______________.
ICS-formoterol
In the US, what is the dosage form of budesonide-formoterol DPI?
160/4.5
What is the dosing for PRN budesonide-formoterol in step 1 and 2 therapy per GINA guidelines?
Just used as needed but the maximum is still 12 puffs per day.
What is the dosing for budesonide-formoterol in step 3 therapy per GINA guidelines?
Step 3 therapy in GINA is low-dose maintenance and reliever therapy with ICS-formoterol.
1 puff once or twice daily for maintenance and 1 puff as needed for relief.
What is the dosing for budesonide-formoterol in step 4 therapy per GINA guidelines?
Step 4 in GINA is medium-dose maintenance and reliever therapy with ICS-formoterol.
2 puffs twice daily for maintenance and 1 puff as needed for relief.
When can therapy step downs be considered in the GINA guideliens?
After stable and well-controlled asthma for at least 3 months.
When stepping-down a patient for asthma treatment, what should you make sure they are not doing during this time?
Traveling, getting pregnant, have an infection, still have bas asthma
Do not stop a patient on their ________-_________ maintenance treatment therapy in patients with severe asthma.
ICS-LABA (ICS-formoterol)
When thinking about step 4 in the GINA guidelines when someone is on a moderate to high dose of an ICS-formoterol (LABA) maintenance treatment, how is this treatment stepped down?
Continue to ICS-LABA but decrease the ICS portion by 50%. Eventually, the goal is to switch to a lower maintenance dose of the ICS-formoterol.
When thinking about step 4 in the GINA guidelines, when someone is on a medium dose of ICS-formoterol as their maintenance and reliever, how is treatment stepped down?
Just reduce the dose to low-dose and continue with the low-dose ICS-formoterol
When thinking about step 3 therapy in the GINA guidelines, when someone is on low-dose ICS formoterol as their maintenance and reliever, how is treatment stepped down?
Reduce the maintenance ICS-formoterol dose to once daily and continue the as needed us with the low-dose ICS-formoterol.
When thinking about step 2 therapy in the GINA guidelines, how is treatment stepped down?
There is no step down from step 2 as there is no where to go since step 1 and 2 indicate the same therapy.
T or F: Abrupt discontinuation of a LABA like formoterol can cause deterioration in those with asthma.
True.
What is SMART therapy?
This is single maintenance and reliever therapy in the form of ICS-formoterol. ICS is the maintenance and formoterol is the reliever portion. Typically used is budesonide-formoterol which is called symbicort.
What is the ICS-SABA that could technically be used as reliever therapy even though it is not preferred over ICS-formoterol?
Budesonide-albuterol (Airsupra)
What is the dosing for Budesonide-albuterol (Airsupra)?
80mcg of budesonide and 90mcg of albuterol. It is used as a reliever as 2 puffs as needed for a maximum of 12 puffs per day.
What is the enantiomer of albuterol?
Levalbuterol (Xopenex HFA)
What are the 4 different brand names for the SABA, albuterol?
Proventil HFA
Ventolin HFA
ProAir HFA
ProAir RespiClick
What is the brand name for levalbuterol?
Xopenex HFA
What are DPI inhalers?
These are inhalers that have dry powder inside and in general contain lactose so need to be careful in those with allergy to milk proteins.
Those with _________ allergies should not use ProAir RespiClick (albuterol) or any other DPI device due to the lactose content.
Milk allergies
What drug-drug interactions should be evaluated and why in those taking SABAs like albuterol or levalbuterol?
Drug-drug interactions involving hypokalemia and QTc prolongation need to be watched.
What are the two medications or classes of choice for acute asthma symptoms and/or prevention of exercise-induced bronchospasms?
SABAs like albuterol and levoalbuterol
What are the 4 adverse effects associated with SABAs like albuterol (Proventil HFA, Ventolin HFA, ProAir HFA, ProAir RespiClick) and Levalbuterol (Xopenex HFA)?
Tremors, tachycardia, hypokalemia, hyperglycemia
What is the typically dosing for SABAs like albuterol or levalbuterol?
2 puffs every 4-6 hours as needed
OR
2 puffs 5-20 minutes before exercise
What is the maximum number of puffs allowed per day of SABAs like albuterol and levalbuterol?
12 puffs per day
What 2 medications may be used in asthma exacerbations?
Short-acting anticholinergic like ipratropium and/or a short course of prednisone.
T or F: Short-acting anticholinergics like ipratropium are commonly recommended in the treatment of asthma.
False. Ipratropium is only indicated for symptom relief in exacerbation settings for patients not getting adequate relief from SABA therapy.
What are the adverse effects associated with short-acting antimuscarinics like ipratropium?
Bitter and metallic taste in mouth, small increase in cardiovascular events, dry mouth, less respiratory secretions, blurred vision
What is the brand name for the SAMA, ipratropium bromide?
Atrovent
What is the brand name for the SAMA and SABA combo, ipratropium with albuterol?
Combivent Respimat and DuoNeb
When are oral corticosteroids indicated for use in asthma?
Really only indicated for exacerbations
What is the oral corticosteroid dosing for prednisone for exacerbation control?
40-60 mg per day for 3-10 days with food(5 days typically)
What are the many adverse effects associated with oral corticosterooids?
Hypertensions, increased appetite, weight gain, insomnia, skin atrophy, osteoporosis, hyperglycemia, and hypokalemia
What is one of the most serious adverse effect associated with oral corticosteroids?
Hypokalemia. LABAs and SABAs can also cause hypokalemia
T or F: Oral corticosteroid tapering typically does not need to occur if it has been taken for less than 2 weeks.
True
What drug-drug interactions should be looked out for with oral corticosteroids?
Immunosuppressants and vaccines. Oral corticosteroids can blunt the proper immune system response to vaccines.
T or F: All oral corticosteroids have equivalent dosing that can just be changed to a different steroid.
False.
Tiotropium (_________) is a ______-_______ anticholinergic medication used in those ________ years and older.
Spiriva
Long-acting
12
What is the dosing for those 12+ for the LAMA tiotropium (Spiriva)?
1.25 mcg (2 puffs) daily for asthma
Dosing is different for COPD
What are the 3 specific adverse effects associated with the LAMA, tiotropium (Spiriva)?
Dry mouth, upper respiratory infection, and sinusitis
The LAMA, tiotropium (spiriva), should be used with caution in what two patient populations?
Glaucoma and urinary retention
Per the NAEPP guidelines, when is LAMA therapy considered?
LAMA can be considered in step 5 of NAEPP therapy. LABAs are recommended over LAMAs in steps 3 and 4.
Per the GINA guidelines, when is LAMA therapy considered?
Add on therapy in step 5 per the GINA guidelines.
What are some of the different inhaled corticosteroids?
Beclomethasone HFA (Qvar RediHaler), Budesonide (Pulmicort Flexhaler), ciclesonide HFA (Alvesco), Fluticasone Propionate HFA (Flovent HFA), Fluticasone furoate (Arnuity Ellipta), and mometasone twisthaler (Asmanex)
What is the brand name for the ICS, Beclomethasone HFA?
Qvar RediHaler
What is the brand name for the ICS, Budesonide?
Pulmicort Flexhaler
What is the brand name for the ICS, Ciclesonide HFA?
Alvesco
What is the brand name for the ICS, fluticasone propionate HFA?
Flovent HFA
What is the brand name for the ICS, fluticasone furoate?
Arnuity Ellipta
What is the brand name for the ICS, momentasone twisthaler?
Asmanex
What are the 3 general function of inhaled corticosteroids in asthma?
- increase number of symptom free days
- improve lung function
- reduce symptoms
Inhaled corticosteroids take about _____-______ weeks before any benefit can be seen.
1-2 weeks
What are the 5 adverse effects associated with inhaled corticosteroids?
Upper respiratory infection, throat irritation, dysphonia, hoarseness, and candidiasis
To prevent candidiasis with inhaled corticosteroids, what should be counseled on?
Tell patients to use a spacer and/or rinse mouth out after inhalation
If you have fluticasone furoate DPI (Arnuity Ellipta) and want a medium dose, how many puffs would you use and how often if it comes in 100 or 200 mcg per inhalation?
The medium dose for fluticasone furoate is 100 mcg. Since it comes in a 100mcg formulation, it would be dosed as 1 puff per day.
If you have beclomethasone HFA (Qvar RediHaler) and want a high dose, how many puffs would you use and how often if it comes in a 40 mcg and 80 mcg formulation per actuation?
The high dose is anything greater than 400 mcg. Using the 80 mcg formulation, you would need 5 puffs to get to 400mcg. Since this can be dosed twice per day, you would recommend 6 puffs per day in two divided doses.
T or F: LABAs like salmeterol and vilanterol are used for acute bronchospasms.
False. LABAs are not used for acute bronchospasm except ICS-formoterol but it has to be with an ICS.
In order for formoterol to be used for asthma, it has to be in combination with what?
ICS
What are the adverse effects associated with LABAs like salmeterol (Serevent Diskus), formoterol, and vilanterol?
Tremors, tachycardia, hypokalemia, hyperglycemia. The same as the SABAs.
T or F: Formoterol by itself is often recommended for the treatment of asthma.
False. Using formoterol by itself is not allowed, it must be with ICS.
What is the brand name for the LABA, Salmeterol?
Serevent Diskus
What is the black box warning for LABAs without ICSs and LABA containing products?
Increased risk for asthma-related death in those with uncontrolled asthma
There are many scales that can be used to evaluate the risk of QTc prolongation in patients. What two risk evaluation tools were discussed in class?
Tisdale Risk Score and RISQ-PATH
What risk factors for QTc prolongation are shared between the Tisdale risk score and RISQ-PATH?
Female, older age (65 for RISQ and 68 for Tisdale), hypokalemia (3.5 or less with RISQ), QTc (greater than 450ms for Tisdale and RISQ for men and greater than 470ms for RISQ female), MI (ischemic cardiomyopathy per RISQ), on 1 or more QTc prolonging drug already
What molecule does theophylline look very similar to?
Caffeine
What is the target serum range for theophylline?
5-15 mcg/mL
Theophylline (Theo-24/ Theo-Dur) is a ______________ substrate.
CYP1A2
What are the two brand names associated with theophylline?
Theo-24 and Theo-Dur
What is the significance of theophylline being a substrate for CYP1A2?
Those who smoke on theophylline may have lower therapeutic levels as smoking induces CYP1A2. If smoking is stopped, theophylline serum levels may increase.
What are the adverse effects of theophylline at therapeutic levels (5-15mcg/mL)?
Insomnia and GI upset
What are the adverse effects of theophylline at supratherapeutic levels?
Nausea, vomiting, CNS stimulation, tachycardia, arrhythmias, seizures, hyperglycemia, and hypokalemia
T or F: Theophylline has a wide therapeutic index.
False. Theophylline is a narrow therapeutic index drug.
What are the two adverse effects associated with the leukotriene receptor antagonists zafirlukast (Accolate) and montelukast (Singulair)?
Rare hepatitis and Churg-strauss syndrome
What is Churg-Strauss Syndrome?
This is blood vessel inflammation that may be due to leukotriene receptor antagonists like montelukast or due to lack of tapering from oral corticosteroids when it tapering was needed.
T or F: LFT monitoring is crucial when patients are on the leukotriene receptor antagonist, montelukast.
False. This medication was a good improvement from the leukotriene synthesis inhibitor as LFTs do not need to be monitored.
What is the dosing for the Leukotriene synthesis inhibitor, Zileuton (Zyflo)?
4 times per day
What is the main adverse effect associated with Zileuton (Zyflo)?
Hepatotoxicity which is why LFTs are monitored every month for the first 3 months and then every 2-3 months for the next 9 months.
Zileuton (Zyflo), a leukotriene synthesis inhibitor, is a CYP _______ inhibitor.
3A4
What is the dosing for Montelukast (Singulair)?
10 mg before bed
How often do LFTs need to be monitored for patients on Zafirlukast (Accolate)?
Every 2-3 months
What is the boxed warning associated with Montelukast (Singulair)?
Serious neuropsychiatric event including suicidality
According to GINA, what 3 patient populations may be considered for biologic asthma therapy?
It may be appropriate to consider biologic therapy according to GINA in those with uncontrolled asthma with frequent symptoms and exacerbations, uncontrolled asthma despite high dose of preventative treatment, and severe asthma despite maximized therapy.
Which patients on biologics for asthma absolutely need an epi pen?
Those on Omalizumab (Xolair) or Reslizumab (Cinqair)
Those on biologics for asthma will likely have elevated ___________ counts.
Eosinophil
The suggested eosinophil count before initiation of Benralizumab (Fazenra) is _________ cell/uL.
150
What is the dosing for Benralizumab (Fazenra)?
30 mg SubQ Q4weeks for 3 doses
THEN
30 mg SubQ Q8weeks
For all the biologics used in asthma, what are the 3 general changes seen with these medications?
- decreased exacerbations
- decreased symptoms
- improvement or no change in lung function
Dupilumab (Dupixent) should only be initiated if a patient has an eosinophil count above ____________ and/or an FeNO greater than _______ ppb.
150 cell/uL and/or 20 ppb
What is the dosing for Dupilumab (Dupixent)?
400-600 mg SubQ
THEN
200-300 mg SubQ every other week
Mepolizumab (Nucala) should not be given unless eosinophil counts are above _______-_______ cell/uL.
150-300
What is the dosing for Mepolizumab (Nucala)?
100 mg SubQ Q4weeks
Omalizumab (Xolair) targets IgE. What range should serum IgE be before this medication is considered?
30-700 IU/mL
What is the dosing for Omalizumab (Xolair)?
225-375 mg SubQ Q2weeks
OR
150-300 mg SubQ Q4weeks
Frequency and dosing depends on body weight and serum IgE levels
What two biologics would never be allowed to be given at home due to their increased risk for an anaphylactic reaction?
Omalizumab (Xolair) and Reslizumab (Cinqair)
Reslizumab (Cinqair) should not be given unless eosinophil counts are above _______ cells/uL.
400
What is the dosing for Reslizumab (Cinqair)?
3 mg/kg IV Q4weeks
Which biologic in asthma is the only one given IV and not SubQ?
Reslizumab (Cinqair)
Before initiating biologic therapy for asthma, treatment of pre-existing _________ infections should be done.
Helminth (roundworm). Biologics themselves will decrease the effectiveness of anti-worm therapy.
Some biologic therapy, especially those targeting IL-5 like Benralizumab, Mepolizumab, and Reslizumab, may lead to an increased risk for ___________.
Malignancies
What are the 2 adverse effects associated with Benralizumab (Fazenra)?
Headache and fever
What are the 3 adverse effects associated with Mepolizumab (Nucala)?
Headache, injection site reaction, and reactivation of shingles
What vaccine should be given in older people with asthma being started on the biologic, Mepolizumab (Nucala)?
Zoster vaccination to prevent reactivation of shingles
What are the 2 adverse reactions associated with dupilumab (Dupixent)?
Transient increase in eosinophils and injection site reaction
What is unique about the injection site for Omalizumab (Xolair)?
The maximum amount of drug allowed per injection site is 150 mg so there may need to be more than one site based on the dose for the patient.
What are the 2 adverse effects associated with Omalizumab (Xolair)?
Injection site reaction and thromboembolic disease
Thinking about biologics in general, what are the two most concerning things that can occur?
Anaphylaxis and the risk for malignancies
What is the drug Tezepelumab (Tezspire)?
This is a monoclonal antibody that is a thymic stromal lymphoprotein blocker that results in reduced inflammatory cytokines. It is used in addition to other therapies in severe asthma.
What is the brand name for the drug Tezepelumab?
Tezspire
What is the dosing for the drug Tezepelumab (Tezspire)?
210 mg SubQ Q4weeks
What are the 3 adverse reactions associated with Tezepelumab (Tezspire)?
Arthralgia, back pain, and injection site reactions
Tezepelumab (Tezspire) has not been evaluated in what group of patients?
Those with CrCl less than 30 mL/min
________ medications are preferred in pregnancy for asthma.
Inhaled
What two inhaled medications are recommended for asthma during pregnancy?
Albuterol inhaler and Budesonide inhaler
What is the ASTHMA mnemonic?
A- A rescue inhaler for everyone (ICS-formoterol or SABA)
S- Steroid adherence with ICS + signs and symptoms of asthma
T- Technique for each inhaler + triggers for asthma
H- Health maintenance (vaccines, smoking)
M- MOA for each inhaler + medication appropriateness
A- allergen avoidance + allergen immunotherapy
What vaccines are recommended for those with asthma?
Flu, COVID, pneumococcal, and RSV (GINA only for RSV)
What is an asthma exacerbation?
This is an increase in frequency and severity of symptoms that may or may not be managed by medications.
There are 3 different asthma action plans based on symptoms, green, yellow, and red. What is included in the green asthma action plan?
Green means good which means there are no asthma symptoms, peak flow is at or above 80%, and medications are used as directed.
If peak flow drops by _______%, a doctor should be called no matter what.
20%
What is included in the yellow asthma action plan?
Symptoms are getting worse and peak flow is between 50-79%. Directions here state to use 2-4 puffs of SABA and repeat in 20 minutes if needed. Reassess exacerbation in an hour. It the lungs respond, all is good. If they do not respond, repeat the SABA, call MD, and add on oral corticosteroid.
ICS-formoterol use and not SABA has a separate action plan.
A person is experiencing a ‘yellow’ level asthma exacerbation and they administer 4 puffs of their albuterol SABA. 20 minutes later there is still no change in her symptoms so she takes another 4 puffs. At this point, what should she do?
Repeat SABA 1 more time, call MD or 911, and take at-home oral steroid.
If a SABA like albuterol does not help with recurrent exacerbations, typically these patients will be sent home with __________ to take during a severe exacerbation.
Prednisone
What is included in a red asthma action plan?
Peak flow is less than 50% and presents with marked coughing, wheezing, and/or dyspnea, inability to speak more than short phrases or words, use of accessory breathing muscles, and drowsiness are all present. With this, treatment needs to start right away and it is 4-6 puffs of a SABA repeated after 20 minutes and basically 911 and adding on an oral steroid.
What are the 4 keys steps for treating an asthma exacerbation?
- increase SABA therapy
- add on SAMA therapy where appropriate
- prednisone 1mg/kg/day for adults for 5-10 days
- oxygen therapy where appropriate
What are the 3 life-threatening symptoms of an asthma exacerbation?
Drowsiness, confusion, and silent chest
What is silent chest?
This is a life-threatening sign of an asthma exacerbation. It means there is no much inflammation that zero air exchange is occurring at the levels of the alveoli and capillaires.
If a person presents to a clinic with life threatening asthma exacerbation signs, what medications should be given as they are transferred to an acute care center?
Inhaled SABA, inhaled SAMA (ipratropium bromide), oxygen, and systemic corticosteroid
If a person presents to a clinic with mild or moderate asthma exacerbation signs, what treatment should be started?
4-10 puffs of a SABA repeated every 20 minutes, oral steroid like prednisolone, and given oxygen. Reassess in an hour and if worsening, transfer to an acute care facility.
After an asthma exacerbation, what 4 things should be arranged at discharge assuming they were treated at a hosptial?
- make sure they continue their reliever as needed
- start or set up a control/maintenance inhaler
- continue prednisolone for 5-7 days after
- follow up in 2-7 days (at follow up, try to switch to GINA track 1 treatment with ICS-formoterol)
If a person presents to the hosptial with a severe asthma exacerbation, what medications are given?
Inhaled SABA, Inhaled SAMA like ipratropium bromide, oxygen to maintain o2 between 93-95%, oral or IV steroids, and can consider IV magnesium and high dose ICS.
When is IV magnesium given for severe asthma exacerbations in a hosptial setting?
Typically used in the pediatric population to reduce hospitalizations for asthma.
What are the signs of a mild or moderate asthma exacerbation?
Talks in phrases, prefers sitting to lying down, not agitated, increased respiratory rate, no accessory muscles used, pulse rate elevated, and oxygen sats between 90-95%.
What is the role of ipratropium in asthma treatment?
Add on therapy for bronchodilation to maximize SABA therapy in the emergency department.
Thrush or oral candidiasis with an ICS can be minimized by using a _________ or __________.
Spacer or rinsing out mouth
What is the black box warning on LABAs in asthma and how does that influence treatment combinations?
The warning is an increased risk for asthma-related deaths and because of this, LABAs are never used as monotherapy and always have to be in combination with an ICS.
What are the signs and symptoms of an asthma exacerbation that can be considered life-threatening?
Drowsiness, confusion, and silent chest
Dosing for albuterol (ProAir HFA or Ventolin HFA) according to the TOP 200 is what?
2 puffs Q4-6H PRN
What are the 3 dosing formulations for Fluticasone (Flovent) HFA for the TOP 200?
44, 110, and 220 mcg/actuation
What is the dosing per the TOP 200 for fluticasone (Flovent) HFA?
88-440 mcg BID
What are the 3 dosing formulations for Fluticasone (Flovent) Diskus for the TOP 200?
50, 100, and 250 mcg/actuation
What is the dosing per the TOP 200 for fluticasone (Flovent) Diskus?
50-1,000 mcg BID
What are the two dosing formulation for the combination product fluticasone and vilanterol (Breo Ellipta)?
100/25 mcg and 200/25 mcg
What is the dosing per the TOP 200 for Fluticasone/Vilanterol (Breo Ellipta)?
100/25 mcg and 200/25 mcg
1 puff daily
What is the dosing formulation for fluticasone/salmeterol diskus combination (Advair/ Wixela)?
100/50mcg, 250/50mcg, and 500/50 mcg
What is the dosing per the TOP 200 for Fluticasone/salmeterol diskus combination (Advair/ Wixela)?
100/50mcg, 250/50mcg, and 500/50 mcg
1 puff BID
What is the dosing formulation for fluticasone/salmeterol HFA combination (Advair/ Wixela)?
45/21mcg, 115/21mcg, and 230/21 mcg
What is the dosing per the TOP 200 for Fluticasone/salmeterol HFA combination (Advair/ Wixela)?
45/21mcg, 115/21mcg, and 230/21 mcg
2 puffs BID
What is the brand name for Prednisone?
Deltasone
Do males or females have a higher rate of asthma?
Females
Bronchoconstriction seen with asthma can be due to what 3 things?
- Allergens activating IgE dependent release of cytokines
- Aspirin and NSAIDs causing non-IgE release of cytokines
- irritants
What are the 5 histological changes that can occur from chronic bronchoconstriction?
Hyperinflation, marker hypertrophy and hyperplasia, increased wall thickness with inflammatory reaction, desquamation, and edema, mucus gland hypertrophy and hypersecretion, and airway remodeling. The airway remodeling can lead to fibrosis and increased ration of goblet to ciliated cells.
What is the primary inflammatory molecule elevated in asthma?
Eosinophils
What is not included in the determination of the classification of asthma severity in those 0-4 years old?
Lung function testing like FEV1 and FVC are not used as this age range can not do the testing.
In terms of pediatrics age 0-4 and 5-11, intermittent asthma classification correlates to what step of treatment?
Step 1
In terms of pediatrics age 0-4 and 5-11, mild persistent asthma classification correlates to what step of treatment?
Step 2
In terms of pediatrics age 0-4 and 5-11, moderate persistent asthma classification correlates to what step of treatment?
Step 3 or 4
In terms of pediatrics age 0-4 and 5-11, severe persistent asthma classification correlates to what step of treatment?
Step 5 or 6
In terms of pediatrics age 0-4, what is the treatment for asthma in step 1 from the NAEPP?
PRN SABA only
For the start of a respiratory infection, a short course of inhaled corticosteroid can be started.
In terms of pediatrics age 0-4, what is the treatment for asthma in step 2 from the NAEPP?
Daily low-dose ICS and PRN SABA
In terms of pediatrics age 0-4, what is the treatment for asthma in step 6 from the NAEPP?
Daily high-dose ICS-LABA + PRN SABA + oral systemic cortiocsteroids
In terms of pediatrics age 0-4, what is the treatment for asthma in step 3 from the NAEPP?
Daily low-dose ICS-LABA and PRN SABA
OR
Daily low-dose ICS and montelukast
or
daily medium-dose ICS and PRN SABA
In terms of pediatrics age 0-4, what is the treatment for asthma in step 4 from the NAEPP?
Daily medium-dose ICS-LABA and PRN SABA
In terms of pediatrics age 0-4, what is the treatment for asthma in step 5 from the NAEPP?
Daily high-dose ICS-LABA and PRN SABA
Similar to adults, pediatrics must show control for a minimum of ________ months before stepping down treatment steps can be considered.
3 months
For those between the ages of 0-4 years old and 5-11 years old, what is the recommended action plan for treatment if they are considered “well-controlled”?
Maintain the current treatment or consider stepping down if control has been present for at least 3 months. Regular follow-ups every 1-6 months.
For those between the ages of 0-4 years old and 5-11 years old, what is the recommended action plan for treatment if they are considered “not well controlled”?
Step up 1 step and reevaluate treatment in 2-6 weeks. If no clear benefit in 4-6 weeks, consider alternative therapy or diagnosis.
In terms of pediatrics age 5-11, what is the treatment for asthma in step 1 from the NAEPP?
PRN SABA
For those between the ages of 0-4 years old and 5-11 years old, what is the recommended action plan for treatment if they are considered “very poorly controlled”?
Consider short course of an oral systemic corticosteroid and step up 1-2 steps and reevaluate in 2 weeks. If no benefit is seen in 4-6 weeks, consider adjusting therapy or diagnosis.
In terms of pediatrics age 5-11, what is the treatment for asthma in step 2 from the NAEPP?
Daily low-dose ICS and PRN SABA
In terms of pediatrics age 5-11, what is the treatment for asthma in step 3 from the NAEPP?
Daily and PRN combination low-dose ICS-formoterol
In terms of pediatrics age 5-11, what is the treatment for asthma in step 5 from the NAEPP?
Daily high-dose ICS-LABA and PRN SABA
In terms of pediatrics age 5-11, what is the treatment for asthma in step 4 from the NAEPP?
Daily and PRN combination medium-dose ICS-formoterol
In terms of pediatrics age 5-11, what is the treatment for asthma in step 6 from the NAEPP?
Daily high-dose ICS-LABA + PRN SABA + oral systemic corticosteroid
What is the minimum age that SMART (Single Maintenance and Reliever Therapy) can be used?
5 years old
What is the maximum amount of puffs per day allowed of budesonide-formoterol for those between the ages of 5-11?
8 puffs per day maximum
What are the 3 treatment goals when it comes to the management of asthma exacerbations in the pediatric population?
- correct significant hypoxemia
- rapid reversal of airflow obstruction
- reduction of likelihood of recurrence of severe airflow obstruction
In terms of classification of asthma and the level of asthma control, what is different between those ages 0-4 and those ages 5-11?
Those ages 5-11 can do pulmonary function tests like FEV1 and FVC
Why is formoterol used primarily as the main long-acting beta agonist for most asthma?
It has the quickest onset of action (3-5 min) out of all the other long-acting beta agonists
What is the typical set up for an at-home asthma exacerbation in the pediatric population?
- Increase SABA frequency (albuterol)
- Add course of oral systemic corticosteroid (Prednisone or prednisolone)
- Continue taking maintenance medications like the ICSs
- Monitor lung function
What is the typical set up for an in-hospital asthma exacerbation in the pediatric population?
- Oxygen to relieve hypoxia
- Increase SABA frequency (may need to go to continuous albuterol), if not working go to IV SABA terbutaline
- Add IV corticosteroid (methylprednisolone) (not oral)
- Add ipratropium (ED or severe asthma)
- Add magnesium sulfate
Why would magnesium sulfate be given in an in-hospital asthma exacerbation in the pediatric population?
Magnesium displaces the calcium present in smooth muscle and stops the smooth muscle from being able to constrict
The green zone for asthma action plans typically means the patient still has a PEF of ______-_______-%.
80-100%
The yellow zone for asthma action plans typically means the patient has a PEF of ______-_______-%.
60-80%
The red zone for asthma action plans typically means the patient has a PEF of less than ______-%.
60%
Dry powder inhalers can only be used in those _____ years and older.
5 years
What additional device should be used for all meter dose inhalers (MDIs)?
Spacers
Some spacers come with face masks to make administration in the pediatric population easier. What age range would likely wear the small spacer mask?
0-18 months
Some spacers come with face masks to make administration in the pediatric population easier. What age range would likely wear the medium spacer mask?
1-5 years
Some spacers come with face masks to make administration in the pediatric population easier. What age range would likely wear the large spacer mask?
Older than 5 years. At this point though, the child should be able to use the spacer without the mask.
How are inhaled medications given to infants and children?
As young children can’t coordinate deep breathing, we have to administer the puff into the spacer and put it on the infants face for a complete 5-6 breaths before removing the face mask. This must be repeated for the total amount of puffs they need.
