W15 Asthma Flashcards
Asthma learning objectives
understand the goals of asthma
treatment
assess patient specific factors to
determine an appropriate initial
medication regimen for a patient
presenting with asthma
identify barriers to appropriate
asthma management
identify general approaches to
step-up and step-down
management
counsel patients on inhaler
technique and use
Pathogenesis FYI
Asthma, background FYI
Asthma, what are the treatment goals?
achieve good symptom control minimize future risk of:
● exacerbations
● asthma-related mortality
● persistent airflow limitation
minimize treatment side effects
don’t forget: what are the patient’s goals?
Asthma: what are the pharm treatment options
Preferred (3) and adjunct? (4)
Preferred
inhaled corticosteroids (ICS)
long-acting beta-agonists (LABA)
short-acting beta agonists (SABA)
Adjunct
long acting muscarinic antagonist (LAMA)
leukotriene receptor antagonist (LTRA)
oral corticosteroids (OCS)
immunotherapy (injectable)
ICS MOA FYI
ASTHMA
inhaled corticosteroids (ICS)
MOA
Place in therapy
ADRs
Pearls
Examples
controller & reliever
MOA
—inhibits inflammatory response in numerous ways (see prev slide)
—goals: reduce symptoms, increase lung function, improve quality of life
place in therapy
—preferred first line treatment for all patients
—controller and/or reliever
adverse effects
—oral candidiasis (thrush) - to prevent, advise patients to…
rinse and spit
—difficulty speaking (dysphonia)
—cough, headache, hoarseness
—possible growth impairment with long term use in children
pearls
—low-medium doses are sufficient for most patients, rarely need high-dose ICS
examples
beclomethasone (Qvar Redihaler);
budesonide (Pulmicort);
fluticasone (Flovent HFA);
mometasone (Asmanex HFA);
ciclesonide (Alvesco)
long-acting beta-agonists (LABA)
MOA
—agonizes β2 receptors → bronchodilation
place in therapy
—controller and/or reliever
—ONLY use in combination with an ICS (never on its own)
adverse effects
—nervousness, tremor
—tachycardia, palpitations
—hyperglycemia, hypokalemia
pearls
—formoterol onset of action is 2-3min, can use (w/ ICS) as reliever
🔺 BBW: ↑ risk of asthma-related death when used alone
🔺 BBW: ↑ risk of asthma-related hospitalizations in pediatrics
examples
—salmeterol (Serevent™),
nebulized formoterol (Perforomist™) — formoterol is fast, acts in 2-3 mins, therefore preferred.
—ultra-long-acting (in combination w/ ICS): olodaterol, vilanterol, etc.
Common ICS + LABA combo inhalers
Asthma
short-acting beta-agonists (SABA)
MOA
Examples 2
MOA
—agonizes β2 receptors → bronchodilation
Place in therapy
—PRN, in addition to ICS-containing regimen used to be a mainstay of relieve therapy (we’ll continue seeing this for some time)
Adverse effects
—nervousness, tremor
—tachycardia, palpitations
—mild: hyperglycemia, hypokalemia
Pearls
—if taking at the same time as other inhaled agents, use SABA first (to open airways)
🔺caution in CVD, hyperthyroidism, seizures, diabetes, narrow-angle glaucoma
Examples
—albuterol (ProAir™, Proventil™, Ventolin™);
—levalbuterol (Xopenex™)
leukotriene receptor antagonists (LRTA)
Common use?
🔺BBW
Which agent?
MOA
—inhibit activity leukotrienes (mediators of airway inflammation)
—reduce airway edema, constriction and inflammation
place in therapy
—add on therapy, when preferred treatment is not adequate
adverse effects
—headache, dizziness
—↑ liver function tests
—upper respiratory tract infections
pearls
—🔺BBW: neuropsychiatric events!
—zafirlukast & zileuton are contraindicated in hepatic impairment
—montelukast for exercise-induced bronchospasm: take 2hr prior to exercise
examples
—⭐️montelukast (Singulair™);
—zafirlukast (Accolate™); zileuton (Zyflo™)
long-acting muscarinic antagonists (LAMA)
Last line
Maybe if COPD, smoked in the past
MOA
anticholinergic, blocks the bronchoconstrictive effect of parasympathetic nervous
system
place in therapy
add on therapy, when preferred treatment is not adequate or has failed
adverse effects
dry mouth, nausea, metallic taste
pearls
avoid in patients with narrow-angle glaucoma
avoid in patients with urinary obstruction, such as BPH
examples
tiotropium (Spiriva Respimat)
oral corticosteroids (OCS)
Short term exacerbation mngt
OCS increases risk of __________ over the lifetime?
Examples
MOA
—inhibits inflammatory response in numerous ways (see previous diagrams)
place in therapy
—add-on therapy, mostly for rescue purposes
—this is a last-line options for long-term control
adverse effects
—short term: weight gain, emotional instability, insomnia, fluid retention, ↑ BP & BG
—long term: psychiatric, glaucoma, acne, striae, fat deposits, muscle wasting, GI
—bleed/esophagitis , impaired wound healing, hirsutism, poor bone health
pearls
—just 4–5 lifetime OCS courses increases risk of osteoporosis, diabetes, and cataracts
examples
—prednisone; prednisolone; dexamethasone
immunotherapy - omalizumab (Xolair™)
typically requires referral to allergy specialist
BBW
MOA
—inhibits IgE binding to IgE receptors on mast cells and basophils
place in therapy
—moderate-severe persistent allergic asthma
—chronic (not acute) management
adverse effects
—injection site reaction, headache, dizziness, fatigue, arthralgia
pearls BBW:
—anaphylaxis - initiation must occur in a healthcare setting (most ab therapies have this BBW)
—↑ risk of cerebrovascular events
—route: subcutaneous injection
also approved for
—rhinosinusitis (chronic) with nasal polyps
—urticaria (chronic spontaneous)
GINA guidelines
Starting treatment for asthma based on symptoms and night time wakenings
What are steps 1-5?
You’re using ICS-formoterol for BOTH control and relief! Better for worry about poor adherence because it’s just ONE inhaler
Alternative pathway includes albuterol, but it’s not preferred
Even if patient uses albuterol, they should STILL use an ICS
NHLBI guidelines — this is a focused up date, from 10years ago
US guidelines here do not incorporate ICS into their treatment….
Whereas GINA has.
US guidelines do not think ICS has sufficient evidence
Keep in my GINA is global, looks at underserved populations
Jeanine and Pance prep pearls has SABA PRN
What are the most up to date guidelines for asthma relief?
before 2019 and for the last 50 years: SABA reliever monotherapy, including in patients w/ ‘mild’ asthma
now: all adults and adolescents w/ ‘mild’ asthma should be on ICS-containing controller treatment, as either:
● PRN low-dose ICS-formoterol, or
● regular low-dose ICS, plus PRN SABA
formoterol onset of action is 2-3min, faster than the other LABA, salmeterol
your options for ICS-formoterol
● ⭐️budesonide-formoterol (Symbicort™) ⭐️
● mometasone-formoterol (Dulera™)
● any ICS + nebulized formoterol (Perforomist™)
What is the argument against PRN SABA only?
regular use, even for 1–2 weeks, is associated with:
● increased airway hyperresponsiveness
● reduced bronchodilator effect
● increased allergic response
● increased eosinophils
overuse of SABAs is…
● associated w/ ↑exacerbations,↑mortality
● encouraged/reinforced by rapid effects and low cost
especially for those w/ ‘mild’ asthma…
● PRN use of SABA does not protect against severe exacerbations (esp since exacerbation triggers are
unpredictable) - up to 30% asthma deaths are in patients with infrequent symptoms
● starting treatment with SABA trains the patient to regard it as their primary asthma treatment
Albuterol-budesonide
approved Jan 2023!
approved in Jan 2023
indication:
—intermittent symptom relief in adults (the first ICS-containing product approved for this indication)
findings from the MANDALA trial
● randomized, double
—blind, multi
—center study
● patients: adults with moderate
—severe asthma, on ICS controller therapy
● treatment arms:
—albuterol
—budesonide or albuterol,
—PRN asthma symptoms
● treatment duration: at least 24 weeks
● results: compared to albuterol, albuterol-budesonide
showed a 28% reduction in the risk of severe asthma
attack (based on time to first severe asthma attack)
Assessing symptom control
ACT — most used
Daytime symptoms
Nighttime wakenings
Symptoms
assess, adjust and review
investigating potential causes of poor asthma control
confirm the diagnosis assess…
● inhaler technique - ask patient to demonstrate!
● medication adherence, and barriers to adherence (may be psychological or socioeconomic)
address modifiable risk factors for exacerbation
● inadequate or no ICS
● high SABA use (eg, ≥3 x 200-dose canisters per year)
● comorbidities - GERD, sinus disease, OSA, obesity
● allergens - smoking, e-cigarettes, air pollution, etc.
● and others
presence of the above risk factors increase risk of exacerbation, even if patient has few
asthma symptoms
using HFA devices
shake for 5 seconds
prime - release spray away from face
● before first use
● if >7-14 days since last use (time cutoff depends on product)
● if inhaler is dropped
clean weekly
● remove metal canister
● rinse mouth piece under warm water
● air dry
if technique is an issue, consider using a spacer
using inhalers w/ spacers
Less coordination required
Adult can prime for kid
spacers work by…
● trapping the medication in the chamber
● facilitating delivery into the lungs versus the back of the throat
● allowing more time for deep inhalation
requires less hand-breath coordination (great for kids)
only works with MDI’s - HFA or Respimat; NOT feasible with
dry-powder inhalers (DPIs)
as with other inhalers, requires regular cleaning
using dry powder inhalers (DPI)
a dose of powder is activated (pierced) each time the
inhaler is opened or twisted, depending on the device
does not propel drug into the mouth/lungs; requires strong
inspiratory pressure from the patient
“Hold like a hamburger, suck like a milkshake”
asthma triggers are unpredictable
ASA
BB
ACEI
What is Peak Week ?
“Peak Week” = 3rd week of September
● ↑ragweed
● ↑mold due to fallen leaves
● children return to school
● start of flu season
if you haven’t already, read these stories about Laura Levis
● on knowing about Peak Week
● New York Times
● Boston Globe
Stepping UP treatment
When?
How?
Reassess when?
when?
per indicators of poor asthma control
● symptoms
● use of SABA rescue inhaler
● nighttime awakenings
● limitations in activity
● exacerbations
how?
● day-to-day adjustment (e.g. adjust prn ICS-formoterol)
● short term step up: 1-2 weeks (e.g. viral infection)
● sustained step up: 2-3 months
reassess in 2-6 weeks
stepping DOWN treatment
When?
How?
Caution?
when?
controlled for at least 3 months
goals:
● find patient’s minimum effective treatment
● encourage patient to continue controller treatment
how?
approach will be patient specific, but mostly entails going backwards on the step-up schematic (ie, go from step 4 to step 3), including
● fewer control agents
● lower doses of ICS
● less-frequent use of ICS (ie, PRN relief)
caution
● exacerbation risk may increase if treatment is stepped down too quickly
● complete cessation of ICS is associated with a significantly increased risk of exacerbations
Asthma vs COPD
