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
Assessing symptom control
ACT — most used
Daytime symptoms
Nighttime wakenings
Symptoms
assess, adjust and review
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
Asthma vs COPD
