Treatment of COPD and Asthma Flashcards
What is the pathophys of asthma?
Airway inflammation-airway hyperresponsiveness-respiratory symptoms-airflow obstruction, bronchial hyperresponsiveness, underlying inflammation.
Goals of asthma therapy:
prevent symptoms.
Require infrequent use of SABA
Prevent recurrence, loss of lung function
Intermittent Asthma classification: for Ages 0-11
Treatment step
Symptoms: < 2x/month (0 for 01-4)
SABA use: 4yo) FEV1 >80%, FEV1/FVC >85%
Exacerbations: 0-1/year
Treatment step 1
Mild Persistent asthma classification
Treatment step
Symptoms: >2days/week but not daily
Nighttime awakenings: 1-2x/month ( 0-4) 3-4x/month (5-11)
SABA use: >ddays/week but not daily
Normal activity interference: Minor limitation
Lung Function: (>4yo) Fev1: >80%, FEV2/FVC >80%
Treatment step 2
Moderate persistent asthma classification for children
Treatment step
Symptoms: Daily
Nighttime awakenings: 3-4x/mo (0-4), >1x/week but not nightly (5-11)
SABA use: Daily
Normal activity interference: Some limitation
Lung function: (>4yo) Fev1 60-80%, FEV1/FVC 75-80%
0-4: Step 3 consider short course of oral systemic corticosteroids
5-11: Step 3 Medium dose ICS,consider short course of oral systemic coricosteroids
Severe persistent asthma classification for children
Treatment step
Symptoms: Throughout the day Nighttime awakenings:(0-4) >1x/week, (5-11) Often 7x/week SABA Use: Several times/day Activity: extremely limited Lung Function (>4yo): FEV1 <75%
0-4: Step 3 and consider short course of oral systemic corticosteroids
5-11: Step 3 Medium dose ICS option OR step 4 and consider short course of oral systemic corticosteroids
Tx for Step 1 asthma in Children 0-4 year
SABA PRN
Tx for Step 2 asthma in children 0-4 years
SABA + Low dose ICS, alternative Montelukast or cromolyn
Tx for Step 3 asthma in children 0-4 years
SABA + Medium dose ICS (if you have done Montelukast as step 2 alternative then try low dose ICS before up to medium dose)
Tx for Step 4 asthma in children 0-4 years
SABA + Medium dose ICS AND either Montelucast or LABA
Tx for Step 5 asthma in children 0-4 years
SABA + High-dose ICS AND either montelukast or LABA
Tx for Step 6 asthma in children 0-4 years
SABA + High-dose ICS AND either Montelukast or LABA AND oral corticosteroids
Tx for Step 1 asthma in children 5-11 years
SABA PRN
Tx for Step 2 asthma in children 5-11 years
SABA + Low Dose ICS alternative: LTRA cromolyn, nedocromil
Tx for Step 3 asthma in children 5-11 years
SABA + Medium-dose ICS OR low-dose ICS + either LABA, LTRA, or theophylline
Tx for step 4 asthma in children 5-11 years
SABA + Medium-dose ICS + LABA, alternative Medium-dose ICS + either LTRA or theophylline
Tx for Step 5 asthma in children 5-11 years
SABA + High-dose ICS + LABA alternative medium-dose ICS + either LTRA or theophylline
Tx for Step 6 asthma in children 5-11 years
SABA + High-dose ICS + LABA + oral corticosteroid Alternative High-dose ICS + either LTRA or theophylline + oral corticosteroid
Asthma classification adult: Intermittent
Tx step
Symptoms: < 2x/mo
SABA Use: < 2days/week
Activity interference: None
Lung function: Normal FEV1 between episodes; FEV1 >80%, FEV1/FVC normal
Tx step 1
Asthma classification adult: Persistent Mild
Tx step
Symptoms: >2days/week Nighttime awakenings: 3-4/mo SABA use: >2days/week Activity interference: Minor Lung function: FEV1>80%, FEV1/FVC normal
Step: 2
Asthma classification adult: Persistent Moderate
Tx step
Symptoms: daily Nighttime awakenings: >1x/week SABA use: Daily Activity interference: some limitation Lung function: FEV1>60-<80%, FEV1/FVC: reduced 5%
Step 3
Asthma classification adult Persistent Severe:
Tx step
Symptoms: throughout the day Nighttime awakenings: Often 7x/week SABA use: Several times/day Activity interference: extremely limited Lung function: FEV1< 60, FEV1/FVC: reduced 5%
Step 4 or 5
Step 1 asthma tx adults
SABA PRN
Step 2 asthma tx adults
Low-dose ICS, alternative cromolyn, nedocromil, LTRA or theophylline
Step 3 asthma tx adults
Medium dose ICS OR Low-dose ICS + LABA alternative Low-dose ICS + either LTRA, Theophylline or zileuton
Step 4 asthma tx adults
Medium-dose ICS + LABA alternative Medium-dose ICS + either LTRA, Theophylline, or zileuton
Step 5 asthma tx for adults
High-dose ICS + LABA AND consider omalizumab for patients who have allergies.
Step 6 asthma tx for adults
High-dose ICS + LABA + Oral corticosteroid AND omalizumab for pts with allergies
MOA for step 1 SABA
Binds to B receptors on several sites-smooth muscle relaxation
Onset approx 5 minutes
ADE SABA
dose-dependent heart palpitations, anxiety, tachycardia, tremor (use of SABA >2days/ week need to change long-term control med)
ex of SABA
“OL” albuterol, Levalbuterol,
MOA anticholinergics
Inhibits cholinergic and muscarinic receptors on bronchial smooth muscle causing bronchodilation. Onset 5-15 minutes.
ADE anticholinergics
Dry mouth and respiratory secretions, Increased wheezing, Less cardiac tim than SABA
Low-dose ICS MOA
- decreased number and activity of inflammatory cells,
- enhances effect of B-adrenergic drugs.
- inhibits bronchoconstrictor mechanism
- direct smooth muscle relaxation
ADE Low-dose ICS
- Cough, dysphonia, Oral thrush (rinse and spit)
- In high doses: adrenal suppression, osteoporosis, skin -thinning, bruising, cataracts
- Low-medium doses: growth suppression in children, velocity may be altered.
Inhaled Corticosteroids examples
“Ones and Ides” Beclomathasone, Budesonide
LTRA definition, ex, MOA
Leuoktriene receptor antagonist: Montelukast, Interfere with pathway of leukotriene mediators, which are released from mast cells, eosinophils and basophils.
-Can be adjunct with ICS (not preferred to LABAs for >12yo)
Mast cell stabilizers ex and MOA
Cromolyn, Stabilizes mast cells, Blockade of chloride changes. may be preventative prior to exercise of unavoidable exposure to allergens
ADE LTRAs
No specific adverse event have been identified
Zileuton MOA
Similar to LTRA’s only blocks the enzyme not the recptor
Zileuton ADE:
Elevation of liver enzymes, not preferred over LTRAs
Zafirlukast interactions
Food-decreases bioavailability, take at lest 1 hour before or 2 hours after meals, CYP 2C9 Substarte and inhibitor, Increase levels of warfarin!
Theophylline MOA
mild to moderate bronchodilator
non-selective phosphodiesterase inhibitor
must monitor serum theophylline conc. adjust dose to achieve 8-15mcg/mL at steady state
ADE theophylline
Usual dose: Insomnia, gastric upset, aggravation of ulcer, increased hyperactivity in children, dysuria.
Toxicities of theophylline
Tachycardia, N/V, Tachyarrhythmia, CNS stim, HA, Seizure, Hematemesis, Hyperglycema, Hypokalemia
DI theophylline
Metabolized by CYP 1A2 and CYP3A4 (also induces these!!)
Many DI’s exist!! This is not a first line medication. A lot of older pt’s may be on it-because they don’t like to switch.
LABA MOA
- Tail binds to B receoptor at exosite-prevents molecule from dissociating from receptor.
- Head attaches to same spot as SABA’s.
- Causes bronchodilation
- do not use as mono therapy!!
- Every 12 hour dosing is crucial to maintaining proper control!
ADE LABA
Tachycardia
tremor
hypokalemia
Unexpected bronchospasm & hyperresponsiveness
Black box warning LABA
-Increased risk of severe asthma exacerbation and asthma related death with regular use of LABA
Omalizumab MoA
Recombinant DNA antibody (IgE), Binds to portion of IgE antibody preventing binding to its high-affinity receptor on mast cells and basophils,
-decrease in release of mediators in response to allergen exposure.
Approved for >12yo
ADE Omalizumab
Urticaria, anaphylaxis (0.1%) , injection site pain and bruising
DI oral systemic corticosteroids
Herpes infection varicella TB HTN peptic ulcer dz DM Osteoporosis
What time frame tx requires a tapered dose when taking pt off of oral corticosteroids?
5days
Healthier younger pt’s > 3-5 days
Non-pharm tx for asthma
Avoid triggers, Remove carpets Encase mattress pillows vacuum close windows air filters allergen-free zone
First line for exercise-induces bronchospasm (EIB)
SABA (albuterol)
Second line for EIB
LTRA’s
Last line for EIB
Cromolyn
Non-Phare techniques for EIB
Warm-up
Mask or scarf over mouth in cold weather.
Inflammatory mediator of Asthma
Eosinophils
Inflammatory mediator of COPD
neutrophils
Pink puffers
Emphysema
Blue Bloaters
Chronic bronchitis
R/f for COPD
cigarette smoking, Genetics (a1 antitrypsin rare)
symptoms of COPD
Dyspnea, Chronic smokers cough, Sputum, spirometry
FEV1
FEV1/FVC
Mild stage 1 COPD
FEV1: >80%
FEV1/FVC: <70%
Mild airflow limit, chronic cough and sputum not always present.
FEV1
FEV1/FVC
Moderate stage 2 COPD
FEV1: <70%
SOB on exertion, and cough sputum sometimes present *typical stage where pt presents
FEV1
FEV1/FVC
Severe stage 3 COPD
FEV1: >30% <50%
FEV1/FVC: Greater SOB reduced exercise capacity.
FEV1
FEV1/FVC
Very severe stage 4 COPD
FEV1: <50% plus presence of chronic respiratory failure
FEV1/FVC: 70%
Mild COPD tx
SABA
Step 2 Moderate COPD tx
SABA + Long acting bronchodilators and ADD rehab
Step 3 Severe COPD tx
SABA + Long acting bronchodilators and rehab, ADD Inhaled glucocorticoids if repeated exacerbations
Step 4 Very Severe COPD Tx
SaBA + Long acting bronchodilators and rehab ADD inhaled glucocorticoids and ADD long term O2 consider surgical tx.
goal of tx for COPD
Relieve symptoms. Prevent dz progression
Ex; of SABA
“OL’s” Albuterol, levalbuterol
Ex of anticholinergics
“IUM” Iptratropium, iptratropium albuterl
What has a longer duration of action SABA or Ipratropium
Ipratropium (anticholinergic) has longer duration of action.
Black box warning for LABAs Arcapta, Brovana, Presimat, Valanterol,
may not apply to patients with COPD
Oxygen initiation requirement
Stage IV COPD
Non-pharm tx for COPD
Stop smoking, Avoid triggers, filter air, Adjust ADL’s
tx for Exacerbations of COPD
Oxygen first (>90%)!!! SABA. 2nd line is short acting anticholinergic, systemic glucocorticosteroids, FEV1<50%
ABX for exacerbations of COPD when 3 cardinal symptoms present
Increase dyspnea
sputum volume
sputum purulence OR
if 2/3 if sputum and is one of the symptoms
