Week 1: Asthma/Allergic Rhinitis Flashcards
Guidelines used for Asthma
Global Initiative for Asthma (GINA)
NAtional Asthma Education and Prevention Program: Expert Panel Report (NAEPP EPR-3)
What is asthma
disease characterized by eiither INTERMITTENT OR PERSISTENT presence of highly variable degrees of airflow obsturction from airway wall inflammation and bronchial smooth muscle contriction and in some pts, persistent changes in airway structure occur
Etiology of Asthma
Race (black and puerto ricans highest prevalence)
60-80% of susceptibility due to genetic factors
genetic predisposition to atopy(genetic to develop allergic diseases) increases risk for asthma significantly, but not all asthmatics have atopy
environmental factors
*soscioeconomicstatus
*exposure to seocnd hand tobacco smoke
*allergen exposure
*urbanization
*RSV infection
*decreased family size(less exposure to pathogens)
*decreased exposure to common childhood infectious agents
Asthma triggers
Resp. infections(RSV, rhinovirus, parainfuenza, myobacterium pneumonia, chlamydia
*VIRAL resp. nfections single most significant trigger in children
allergens(airborne pollen, house dust mites, animal dander, cockroaches, fungal spores)
environment(cold air, fog, ozone, sulfur dioxide, nitrogen dioxide, tobacco smoke, wood smoke
exercise, particularly in cold, dry climate
drugs/perservatives: ASA, NSAIDS (COX-inhibitors), sulfites, benzalkalonium chloride, nonselective beta blockers
occupational stimuli: bakers,farmers, spice and enzyme workers, printers, chemical workers, plastics/rubber/wood workers
Clinical Presentation of Asthma
patient may have NO SS at time of exam
SYMPTOMS VARY IN INTENSITY AND TIME
Symptoms:
*dyspnea
*chest tightness
*coughing
*wheezing or whistling sound when breathing
*may occur in association w. exercise, laughter, cold air, allergen exposure, or spontaneously
Signs:
expiratory wheezing on auscultation
cry, hackign cough
signs of atopy(Allergic Rhinitis or eczema)
reduced O2 sat.
as far as SS, mor elikely to be asthma if…
> 1 type of symptoms (wheeze, sob, COUGH, CHEST TIGHTNESS)
symptoms often worse at night or in th eearly morning
symptoms vary over time and in intensity
symptoms have identifyable triggers
as far as SS, less likely to be asthma if…
chornic production of sputum
isolated ocugh with non other respiratory symptoms
sob associated w. dizziness, lightheadedness or peripheral tingling
exercise induced dyspnea w. stridor (high pitched whistle sound most often heard when taking in a breath)
Dx of asthma
no single dx test…
2 defining features: patient hx
*respiratory symptoms
*evidence of varibale airflow limitation
physical exam
*often normal, wheezing on fofrced expiration but not unique to asthma
confirm airflow limitation (FEV1/FVC is reduced atleast once)
confirm variation in lung function is greater than in healthy individuals,
ex: excessive bronchdilator reversibility
significant increase in FEV1 or PEF after 4 weeks of controller treatment
excessive diurinal variability from 1-2 weeks of twice daily PEF moinitoring
7 main classess used for management of asthma
short acting beta agonists (SABA)
inhaled corticosteroids (ICS)
long-acting beta agonists (LABA)
Long acting muscarnic antogonist (LAMA) aka antiAch
leukotriene modifiers
theophylline
biologics
short acting beta 2 agonists (SABAs)
mao: relaxes airway smooth muscles by stimulating beta 2 adrenergic receptors, increases cAMP and antagonizes bronchoconstriction-> bronchdilation
types:
*short acting: onset: 5-15 min
duration: 4-6h
recommended prn > atc
ADR: tachycardia, tremor, shakiness, lightheadedness, cough, palpitations hypokalemia, tachyphylaxis, hyperglycemia
SABAs
ex: Albuterol
dosage forms:
dosing:
SABAs
ex: Albuterol
dosage forms:
1.Pressurized inhalation suspension (MDI)
*proair HFA, Proventil hFA, ventolin HFA, authorized generics
2. Inhalation poweder(DPI)
prair respiclick
3.nebulizers (accuneb,albuerol sulfate solution 0.021%,0.042%0.083%, 0.5%)
4. oral syrup, tablet
dosing:
SOB/rescue: inhale 2 puffs q4-6h prn (mdd 12 puffs/day adults
exercise induces bronchsopasm (EIB): inhale 2 puffs 5-20 min prior to exercise
SABAs
ex: Levalbuterol (R-isomer of albuterol)
dosage forms:
dosing:
SABAs
ex: Levalbuterol
dosage forms:
Pressurized inhalation suspension
*Xopenex HFA, GENERICS
2.nebulizer solution
8xopenex solutoin, Levalbuterol HCl sol.
dosing: SOB resuce-inhale 2 puffs q4-6h prn (MDD 12 PUFFS/DAY adults
EIB: 2 puffs 10-30 min before exercise
Inhaled Corticosteroids examples
Maintenance Medication!!!!
Ciclesonide
*alvesco-MDI
Fluticasone
*proprionate- (FLovent Diskus/HFA, Advair Diskus/HFA, Wixela Inhub (generic)(combo))-DPI/MDI
*proprionate-(Airduo respiclick and authorized geenric)-DPI (combo)
*furoate-(arnuity Ellipta, Breo Ellipta (combo))-DPI
BEclomethasone
*QVAR-MDI
Mometasone
*Asmanex Twishaler-dpi
*ASMANEX hfa-mdi
Bedesonide
*pulmicort flexhaler-DPI
*pulmicort respules-nebulizer
ICS ROLE IN asthma therapy
most effecive anti-inflammatory medications for persistent asthma… 1st line
- reduce chornic airway inflammation
reduce risk of exacerbations
improve lung funciton
reduce symptoms
improve QOL
ICS adverse effects
ICS AE diminished due to decreased systemic absorpption buttt…
Most common side effect: oral candidiasis (thrush) and dysphonia (horse voice).
*occurs in 30% ofpts. councel to rinse mouth and spit after use. can use spacer/chamber for MDIs.
hyperglycemia, increased risk of factures at higher doses
growth concerns in young children (reduce growth on average cm/year @higher doses
use lowest effective dose: step down dose when asthma is well controlled
ICS considerations
ics monotherapy used as controller therapy
avoid use in acute bronchspasm and status asthmaticus
General ICS product considerations
avoid dpi IN children <4 Y.O
MDI’s should usuallybe shaken
DPIs should never be shaken
DPI’s should be avoided in those w. milk protein allergeis (budesonide dpi IS AN EXCEPTION)
CPI’d may contain lactose
ICS products
name: Ciclesonide (Alvesco)
available dose:
frequency:
total daily dose intensity category:
Low:
medium:
high:
considerations:
ICS products
name: CICLESONIDE (alvesco)
available dose: 8- mcg, 160 mcg
frequency: BID dosing
total daily dose intensity category:
Low: 80-160 mcg
medium: 160-320 mcg
high: >320 mcg
considerations:
activated in lung. good alternative for pts who experience frequent trhush/horsness from other ICS.
ICS products
name: Fluticasone Products
available dose:
frequency:
total daily dose intensity category:
Low:
medium:
high:
considerations:
ICS products
name: Fluticasone (Flovent, Arnutiy, Armon Air)
available dose(mcg):
Fluticasone Propionate(Flovent Discus or HFA)
HFA: 44, 110, 220
Diskus: 50,100,250
Fluticasone Proprionate (Armon Air respiclick)
available dosing(mcg): 55,113,232
Fluticasone Furoate (Arnuity Ellipta)
available dosing: 100 mcg, 200mcg
frequency:
Flovent: BID
Armonair:BID
Arnuity Ellipta: QD
total daily dose intensity category:
Proprinonate:
Low:100-250
medium:>250-500
high:>500
furoate:
low:100
medium;100
high:200
considerations:
*proprionate vs furoate; furoate has higher affinity to glucocorticoid receptors
*fluticasone products have higher risk of sore throat/horseness compared to other ICS products
ICS products
name: Beclomethasone
available dose:
frequency:
total daily dose intensity category:
Low:
medium:
high:
considerations:
ICS products
name: Beclomethasone (QVAR Rdihaler)
available dose:
MDI:40,80mcg
frequency: BID
total daily dose intensity category:
Low: 100-200
medium:>200-400
high:>400
considerations:
*smaller inhaled particles lead to better lung penetration when compared to other ics
ICS products
name: Mometasone (Asmanex)
available dose:
frequency:
total daily dose intensity category:
Low:
medium:
high:
considerations:
ICS products
name: Mometasone (Asmanex)
available dose:
MDI (HFA): 100,200
DPI (Twisthaler): 110, 220
frequency: QD-BID
total daily dose intensity category:
DPI: depends on dpi devide, see product info
MDI..
Low:200-400
medium:200-400
high:>400
considerations:
qd dosing, administer in evening
ICS products
name: Budesonide
available dose:
frequency:
total daily dose intensity category:
Low:
medium:
high:
considerations:
ICS products
name: Budesonide (pulmicort)
available dose:
DPI(flexhaler): 90, 180
Nebulizer: 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml
frequency: QD-BID dosing
total daily dose intensity category:
Low:200-400
medium:>400-800
high:>800
considerations:
*only ICS available as a nebulizer
*nebulizer prefferedin in children <4
Long acting Beta 2 agonists (LABAs)
MOA:
EXAMPLES:
inhalation kinetics:
duration:
considertions
moa: same as SABAs
FDA approved for asthma:
Salmeterol (Serevent)
Formoterol (not available as single agent)
Vilanterol (not availableas single agent)
inhalation kinetics:
onset of bronchdilation
salmeterol: 15-30 min
formoterol (as symbicort): w.in 5 min
duration: drug dependent
LABAs role in asthma therapy
considerations:
*LABAS not to be used as monotherapay in asthma
*Formoterol/ICS combos now recommended as PRN/reliever per GINA guide for asthma prevention as early as step 1 and management
*other ICS/LABA combos recommnded as step up therapy beginning w. step 3 (GINA)
LABA black box warning
increased risk for asthma related death when used as monotherapy
LABAS should only be used in asthmatics as adjuntive therpay when in combo w. inhaled corticosteroid
monotherapy w. LABA may cause respiratory related death
effect not seen in monotherpay in copd
BBW does not apply to LABA combo therapies.
ICS/LABA combo Products
Budesonide/Formoterol (Symbicort)
MDI:1-2 PUFFS BID
dosage: 160/4.5, 80/4.5
considerations:
discard 3 mo. after removal from foil pouch
also labeled for COPD
may be used as rescue therapy/PRN due to short onset
othersss
Fluticasone Proprionate/salmeterol (Advair/Wixela[generic])
Fluticasone proprionate/ salmeterol (Airduo respiclick)
Fluticasone furoate/ Vilanterol (Breo Ellipta)
Mometasone/ Formoterol (Dulera)
*even tho this is an ics/formoterol combo mentioned in GINA guidelines, budesonide is the on that has been studied, and is preffered
LONG acting muscarinic antagonists (LAMAs)
MAINTENANCE therapy
moa: inhibit action of Ach @m3 muscarinic receptors in bronchial smooth muscle-> bronchdilation
fdafda labeled for asthma: Tiotropium(spiriva)
inhalation kinetics
onset bronchodilation: w.in 30 min
duration >/24 hrs
Tiotropium (Spirive Respimat)
LAMA
strengths: 1.25 mcg
2 inhalations once daily
higher dose for COPD
*may be beneficial to add on for still uncontrolled asthma in pts ona medium-high dose ICS+LABA (step 4 gina)
Oral therapies
Leaukotreine Receptor Antagonists (LTRAs)
maintenance medications for persistent asthma
MOA: block proinflammatory leukotreins at receptor sites to reduce airay constriction and mucous secretion
ex: Leukotrein D4 antagonists
*montelukast (singulair)
*zafirlukast (accolate) only indicated for asthma
5-Lipooxygenase inhibitor
*decrease leukotreine production
*zileuton (zyflo): only indicated for asthma
LRTAs role i therapy
non preffered therapy
alternative theray in step 2 GINA guidelines
ass on in steps 3 and 4 GINA guidelines
Montekulast (singulair)
dosed based on age: >/15 y.o 10mg QPM
allergic rhinitis: same
EIB: 10 mgtaken 2 hrs before exercise, no more than once q24hr
ae: headahce, uppeR RESPIRATORY INFECTIONS, gi n/v/d,
PSYchiatric changes: aggressive behavior, altered mood/mental status, suicidal thoughts.
BBW: risk for depression and suicidal thoughts
MEthylxanthines-Theophylline
moa: blocks PDE, increasing levels of cAMP, causing releas of epinephrine form adrenal medulla cells, resulting bronchodilation, cns and cardiac stimulation, diuresis, gastric acid secretion
caution in pts w. cvd, hyperthyroidism, PUD, and seizures
active metabolits: caffeine, 3-methylcanthine
AE: Nnausea, loose stools, ehadache, tachycardia, insomnia, tremor, nervousness O(like caffeine)
considerations:
narrow TI
concentraitons need ot be monitored
target conc: 5-15 mcg/mL
Biologic therpapies for asthma
add on therapy for pts w. severe alergiic or eosinophillic asthma
targets : IGE: inihibt ige
inhibit IL-4 , IL3
mostly administered in health care setting
ex: omalizumab
Mepoliumab
Reslizumab
Bnralizumab
Dupilumab
Miscellaneous agents for asthma
cromolyn-mast cellstabilizers
Asthmanefrin: OTC epinephrine
*nonselective beta and alpha agonists. AVOID. can cause bronchconstriction and CV AE
systemic corticosteroids: used in seevre asthma. can cause systemic side effects such as hyperglycemiz, increased appetite, insomnia/nervousness, osteoporosis, growth retardation, immunosupression, HPA axis supression
counseling points in general for respiratory devices
wash hands w. soap and water befoe use
take a deep breath and exhale completely before accutating the inhaler
after dose inhaled, hold breath for 10 seconds or as long as comfortable, then rbeath out slowly
if more than one inhalantion is required. wait 1-2 min btw doses
if inhaler ocntaines ICS, rinse out mouth or brush teeth immediately after administration to prevent oral candidiasis (thrush)
MDI
aerosolized drug delivered by actuating in haler
requires coordination of breath and actuation
hand-breath coordination can be difficult in children, and even some adults. can be overcome by using a spacer/holding chamber
MDI counseling
usually require shaking and priming
prime w. 1-2 sprays upon first use or if it has been a while since last use
spacer/holding champer
reduced need for hand-breath coordination
best for oyung children
can reduce risk of oral candidiasis when used with ICS
Take home points for different inhalers
MDI:
*required hand-breath coordination
*use spcare for small childrem
*requires priming and shaking
DPI:
*no need tocoordinate breath
*requirs forceful inspiration (avoid in children <4)
DO NOT SHAKE
Soft mist inhalers
*Less hand-breath cooridnation vs mdi
less forceful inspiration vs dpi
REQUIRE PRIMING
Nebulizer
*no need to coordinate breath
*must sit and breath through device until medication is gone
Assessing Asthma Severity
Mild: controlled by Step 1 or 2 trtment strategy
Moderate: controlled by step 3 or step 4 treatment strategy
severe: controlled by step 5
assessed retrospectively fromlevel of treatment required to control treatment and exacerbations
only assessed after pt has been on controller treatment for several months (2-3 months)
PTS ASTHMA MUST BE CONTROLLED W. THERAPY BEFORE ASSESSING ASTHMA SEVERITY
chronic asthma control assessment 2 domains
- symptom control
2.risk factors for exacerbations and poor outcomes
chronic asthma symptom control assessment
in the past 4 weeks, has the pt had….
1.daytime asthma symptoms more than twice/week
yes. no.
- any night waking due to asthma
yes. no - relieve SABA symptoms more than twice/week not related to EIB use
yes.no
4.any activity limitation due to asthma(missing things like work and school)
yes. no
well controlled:none of these
partly controlled:1-2 of these
uncontrolled: 3-4 of these
risk for exacerbations
medicaitons: ics not prescribed, poor adherance,incorrect inhaler technique, high SABA use
comborbidites, obesity, chornic rhinosinitis, GERD, cofirmed food allergy, anxiety, depression, pregnancy
exposures: smoking, allergen exposure if sensitzed, air pollution
setting: major socioeconomic problems
lung function: low FEV1 esp, ifless than <60% predicted, higher reersibility
other: sputum, blood eosinophils, elevated feno IN ALLERGIC ADULTS ON ICS
EVER BEING intubated in an ICU FOR ASTHMA
having 1 or mroe exacerbatio inlast 12 months
goals of long term asthma management
symptom control
risk reduction
ASTHMA MANAGEMENT Therapy Selection
2 tracks
- Controller and Preffered Reliever Track
(ICS-formoterol as reliever) aka MART track (maintenance and reliever therapy)
PRN ICS-FORMOTEROL IS THE RELIEVER IN TRACK1*
A)Step1-2: PRN dose ICS-formoterol
B)STEP3:low dose maintenance ICS-formoterol
C)STEP4: Medium dose maintenance ICS-formoterol
D)STEP 5: Add on LAMA(refer to phenotype assessment).Consider high dose ICS-formoterol
PRN ICS-FORMOTEROL IS THE RELIEVER IN TRACK1*
- Controller and alternative reliever track
PRN SABA IS THIS RELIEVER IN THIS TRACK*
A)Step1: take ICS whenever SABA taken
B)Step 2: Low dose maintenance ICS
C) Step3: Low dose maintenance ICS-LABA
D) Step 4: medium/high dose maintenance ICS-LABA
E)Step 5: Add on LAMA (refer to phenotype assessment). consider high dose ICS-LABA
why isnt SABA monotherpy recommended in asthma treatment?
*increases risk for severe exacerbations
*prn SABA trains pt to regard it as primary therapy and can leas to adherance issues when a controller inaler is added
ics should be started ASAP after dx because…
it prevents exacerbations and reduces hospitalization and death
*increases pt. long term lung function if on an ICS
Asthma management algorithm INITIAL THERAPY
First confirm dx, sympto control and modifiable risk factors, comorbidities, inhaler techinque and adherance, pt preferences and goals
INITIAL THERPAPY: Determine based on symptoms
Controller and Preferred reliever track (PREFERRED TRACK)
A. if symptoms occur <4-5 days/ week
STEP1-2
B. If symptoms occur most days or waking w. asthma >/once a week.
STEP 3
C)Daily symptoms or waking w. asthma >/ once a week, and lowlung function
STEP4
D) short course OCS may also be needed for pts presenting w. severly uncontrolled asthma
Controller and alternate relieve track
A) symptoms <2x a month
STEP 1
b)symptoms >/ 2x/month, but <4-5 days a week
STEP2
c) If symptoms occur most days or waking w. asthma >/once a week.
STEP 3
D)Daily symptoms or waking w. asthma >/ once a week, and lowlung function
STEP4
E) short course OCS may also be needed for pts presenting w. severly uncontrolled asthma
!!!!1THEN FLLOW UP IN 1-3 MONTHS!!!!!
Asthma Management algorithm adjusting therapy
assess symptom controll
A) if well controlled
*maintain therapy; may step down if well controlled 3 months
*may retrospectively assess severity once controlled for several months
B)if partially or uncontrolled
*always check adherance,inhaler technique
*step up 1 step (if the above are not issues
*review trigger management
Stepping down asthma therapy
asthma control: good controlled maintained for >/3 months
reduce ICS dose by 25-50% at 2-3 months intervals
if current therapy is low dose ICS or LTRA, PRN ICS/formoterol is a step down option
do not completely stop ICS unless needed temporarily to confirm dx
Document plan
Non pharm ASthma Interventions
avoid tobacco smoke and other triggers if possible
physical activity; encourage while also providing mangement for Exercise induced bronchsopasm (EIB)
avoid meds that worsen asthma such as NSAIDS, BB
remediation o dampness or mold in homes
Sublingual immunotherpay (SLIT)
ASthma preventative therapy
influenza vaccine and other vaccinations to prevent resp. diseases
covid vaccination
Exercise induced bronchospasm
drop i FEV1 of >/15% form baseline (pre-exercise)
pretreatment w. SABA or ics-formoterol
warmup b4 exercise,
cover mouth w. scarf/mask in cold weather
pre-exercise reliever should not be ocunted when assessing overall asthma control
defin asthma exacerbation
progressive increase in SOB, cough, wheezing, or chest tightness and progressive decrease in lung function
asthma exacerbation triggers
viral respiratory infections
allergens (pollen, fungal)
food allergy
air pollution
seasonal changes (return to school)
poor adherance to ICS
factors that increase asthma related death
hx of asthmarequiring intubation and mechanical ventilation
hospitalization or ED visit whitin 1 year
curently using oral corticosteroids
not currently using ICS
SABA overuse: >1 albuterol/month
PHM/SH: psychiatric or psychosocial problems, food allergies
poor adherance w. ics ASTHMA MEDICATIONS OR WRITTEN ASTHMA ACTION PLAN
comorbidities: pneumonia, diabetes, arrhythmias after hospitalization
tratment goal for exacerbations
correct hypoxemia if present
reverse obstruction
reduce relapse
Treatment setting for exacerbations
self management
primary care: mild exacerbations
ED/ inpt. admission
assessment of exacerbations
hx:
onset and cause
severity of SS
all medication use
PE:
*vvitals: including techypnea, tachycardia, BP, dry cough and temp. ability to complete sentences, level of conciousness
respiratory xam: use of accessor muscles
resp exams: use of accessory muscles, wheezing, diminished breath sounds, others: cyanosis, hypoxic seizure
need to assess for other conditions and complications.
bjective:
chest xray to r/o other ocnditions
PEF or FEV1 (outpt only)
abg(INPT ONLY) only if FEV1<50%
Management of exacerbations in primary care
mild-moderate exacerbation (talks in phrases,prefers sitting to lying, not agitates. RR increased. accessory muscles not used. HR 100-120 bpm. O2 sat. 90-95%, PEF>50%
Treatment:
SABA 4-10 puffs by pMDI+spacer, repeat q20 min for 1 hour
+/-
prenisolone: adults 40-50mg, children 1-2 mg/kg, max. 40 mg
+/- controlled o2 if available: target sat 93-95%
Transfer to acute care facility if…
I. worsening mild or moderate exacerbation after treatment
II. Severe exacerbation (talks inwords, sits hunched forward, agitated, RR>30 bpm, Hr >120 bpm, etc)
III. if exacerbation is life threatening (drowsy,confused, or silent chest)
Acute Care Management of exacerbation
mild-moderate exacerbation (talks in phrases,prefers sitting to lying, not agitates. RR increased. accessory muscles not used. HR 100-120 bpm. O2 sat. 90-95%, PEF>50%
Treatment: (even if pt was treated@ PCP office)
SABA
consider ipratropium bromide
+/- controlled o2 if available: target sat 93-95%
oral corticosteroids
Severe exacerbation(talks inwords, sits hunched forward, agitated, RR>30 bpm, Hr >120 bpm, etc).
SABA
ipratroprium(PREFFERED AGENT in ER)
controlled o2 to maintain sat. 93-95%
oral or IV corticosteroid
consider IV mag
consider high dose ICS
Asthma Exacerbation pharm treatments
Drug: SABA
Dose:
Pearls:
Asthma Exacerbation pharm treatments
Drug: SABA (albuterol)
Dose: MDI 4-8 puffs q30 min up to 4 hours, then 1-4 hrs prn
**Nebulizer: 2.5-5 mg q20minx3 doses, thenq1-4h prn (realistically 2-4 in inpt. setting)
Pearls:SABA>iprotropium
inhaled+spacer=nebulizer
duration: 2-4 hrs.
must keep track of how many prn doses a pt receieved when admitted to see if the doses can be spaced out the next day (4-6 hrs)
Asthma Exacerbation pharm treatments
Drug: Systemic Corticosteroids
Dose:
Pearls:
Asthma Exacerbation pharm treatments
Drug: systemic corticosteroids (prednisone)
Dose: 50 mg po daily for 5-7 days
Pearls: po preffered unless comiting, intubated, somnolence:
onset 4 hrs until improvement
Asthma Exacerbation pharm treatments
Drug: Oxygen
Dose:
Pearls:
Asthma Exacerbation pharm treatments
Drug: Oxygen
Dose: titrate to O2 saturation of 94-98%
Pearls:–
Asthma Exacerbation pharm treatments
Drug: Ipratroprium
Dose:
Pearls:
OPTIONALAsthma Exacerbation pharm treatments
Drug: Ipratropium
Dose: MDI: 8 PUFFS Q20MIN PRN FOR 3 HRS
NEB: 500 mcg q30min x 3 doses, and then 2-4 hrs prn
Pearls:
ED only.in combo w. SABA shoewed fewer hospitalizations and improvement in PEF/FEV1. dose dependent
OPTIONAL Asthma Exacerbation pharm treatments
Drug: Magnesium
Dose:
Pearls:
Asthma Exacerbation pharm treatments
Drug: Magnesium
Dose: 2gm IVx1
Pearls: ED only. failure to respond to initial treatment or have persistent hypoxemia, FEV1<25-30%
Asthma Exacerbation pharm treatments
Drug: ICS
Dose:
Pearls:
Asthma Exacerbation pharm treatments
Drug: ICS
Dose: high dose ICS w.in 1 hr.
Pearls: ED only. can reduce need for admission if systemic steroids not given, if admitted, should be started on or continued. should be given on discharge @ home.
Treatment of asthma exacerbation on discharge
inhaled ics
Iif not on, add one
if on, step up the dose for 2-4 weeks
ocs
5-7 day total course, reevaulation should occur prior to d/c
reliever:
transition pt back to prn outpt regimen
if iratropium was added in inpt., d/c
follow up w.in 1 week in the outpt setting
MEdications NOT to use in exacerbations
aminophylline/theophylline
leukotreine receptor antagonist
hydration
high dose mucolytics
antihistamines
chest physiotherapy
sedation
abx
covid-19considerations in asthma exacerbations
avoid nebulizers to decrease risk of disseminating virus to othr pts and health care professionals
follow strict infection control procedures
Monitoring in asthma exacerbations
asthma control: PEF, FEV, O2 sat, clinical smtoms, HR
PE: +/- wheezing, accessory muscle use, cyanosis
*clinical pearl: monitor PEF/FEV/HR/O2 qshift. PE daily
maybe more freuently depending on severeity
medication efficacy/toxicity
*control of asthma, as above
steroids: WBC, glucose(monitor daily)
consider short acting insulin if needed
bronchdilators: HR, frequency of use (ATC v. PRN)
Allergic rhinitis definition
IgE mediated inflammatory response of nasal mucous membrane secondary to inhaled allergenic particles
predisposing factors of allergic rhiniits
family hx of allergic rhinitis,atopic dermatitis/eczema, or asthma
allergen exposure
heavy exposure to second hand smoke
allergens of allergic rhinitis
pollen grains(trees, grass, weeds, ragweed)
mold spored
dustmite fecal proteins
animal dander
cockroaches (fecal matter)
clinical presentation of allergic rhiniits
clear rhinorrhea
sneezing
nasal congestion
postnasap drip
itchy eyes, ears, nose, or palate
malaise/fatigue
pale or bluish discoloration and swelling of nasal mucosa
conjunctivitis/watery ocular discharge
classifications of AR
temporal (DO NOT USE)
*seasonalperennial, episodic
8difficultot determine
frequency: intermittent or persistent
severity: mild or moderate to severe.
Frequency
<4 days/wk. >4d/w
<4 wks./yr >4w/y
Severity
no interfere M M
w. QOL I P
interfere w. M-S M-S
QOL I P
allergen avoidance
general: avoidance of smoking, minimize use of wood burning stoves and fireplaces
pollens: keep windows/doors closed during pollen season
avoid using fans to draw outside air in
use AC
miinimize outdoor activities
shower and change after outdoor activities
mold: similar recommendations as above, avoid working w. compost, dry soil and raking leaves. remove moldy surfaces from ome
reduce indoor humidityto <50%
dust mites
animals
cockroches
other non oharm AR interventions
nasal irrigations
adhesive nasal strips
pharm therapy for AR conditions
1.which symptoms are targeted
- prn vs. routine use
- which can be combined fo rbetter effect
AR treatment
ex: intranasal steroids
moa:
pk:
AE:
AR treatment
ex:
moa: reduce inflamation by supressin mediator and cytokine release and recruitment of neutrophils, basophils, eosinophils and mononuclear cells
reduce antigen-induced hyperresponsiveness of the nsasal mucose to subsequent challende by antigen and histamine release
pk:onset 3-5 hrs to 36hrs
AE:headache, dryness, burning, stinging, blood tinged secretions, epistaxis. hpa supression unlikely, hiv pts may have more systemic absorption, growth supression
AR indications for intranasal corticosteroids
Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:
Congestion: Y
Rhinorrhea: Y
Sneezing: Y
Nasal Itching: Y
Ocular Symptoms: Y
AR treatment
ex: antihistamines
moa:
pk:
AE:
AR treatment
ex:
moa: competitively antagonizes histamine (H1 receptors to prevent receptor activation
symptoms controlled based on route of aministration (oral vs. intranasal, opthalmic)
most effective when administered prior to allergen exposure:
pk: 1st gen: lipophyllic, cross bbb
2nd gen more favorable se profile (cetirizine ad levocetirizine most sedating)
AE: 1st gen: lipophilic, cross bbb, ach effects and excessive sedation.
Ach AE
changes in appetite and GI discomfort
*caution of use of 1st gen oral antihistamines and anti-ach in elderly pts.can cause urinary retention issues/bph, slowed gi motility, narrow angle glaucoma, combo products
AR indications for oral antihistamines
Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:
AR indications for oral antihistamines
Congestion: minimal
Rhinorrhea: Y
Sneezing:Y
Nasal Itching:Y
Ocular Symptoms: Y
AR treatment
ex: intranasal antihistamines
moa:
pk:
AE:
AR treatment
ex: intransal antihistamines
Azelastine (astepro) OTC, Olopatadine (patanase) RX, Azelastine Fluticasone (Dymista) RX
moa:-same as OAH. equal or superior to OAH. INAH>OAH for nasal congestion
pk: rapid onset:: 15-30 min
AE: bitter taste, epistaxis, headache, somnolense, nasal burning.
taste and BID dosing may limit adherence
AR indications for intranasal antihistamines
Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:
Congestion: Y
Rhinorrhea: Y
Sneezing: Y
Nasal Itching: Y
Ocular Symptoms: N
AR indications for opthalmic antihistamines
ex:
moa:
pk:
AE:
ex: Ketotifen OTC, Azelastine RX, Olopatadine, Alcaftdadine, Emedastine, Epinatine
moa: relieves conjunctivitis, appropriate as monotherpay or in combo w. oral agents
pk:–
AE: headache, blurred vision, burning/stinging of the eyes, discomfort, bitter taste, pharyngitis
AR indications for opthalmic antihistamines
Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:
AR indications for intranasal antihistamines
Congestion: N
Rhinorrhea: N
Sneezing: N
Nasal Itching: N
Ocular Symptoms: Y
AR indications for decongestants
ex:
moa:
pk:
AE:
AR indications for opthalmic antihistamines
ex: Topical (phenylephrine, tetrahydrozoline, Nahazoline, Oxymetazoline).
oral: pseudoephdrine, phenylephrine +combos
moa: sympathomimetic agents that target agrenergic receptors in the nasal mucose to produce vasoconstriction. reduce swollen nasal mucosa and improve ventilation. (systemic and topical
pk:
Topical: applieddirectly to nasal mucosa: rapi onset of action. prolonged use for more than 3-5 days, can cause rebound congestion
Oral: slower onset
AE:topical: rebound congestion
oral: increase BP, use caution in CV pts., avoid use with MAOIs, risk for significant hypertension, cns stimulation, urinary retention
cromolyn in AR
moa: mast cell stablizer
useful for treating and preventing sinus symptoms (runny nose, stuffy nose, sneezing and itching
AE: sneezing and nasal irritation
slow onset of action, frequent dosing
1st line agent in pregnant and breast feeding pts. available as OTC
ipratropium in AR
Treatsrhinorhhea (anti-ach) so drying affects help with rhinorrhea
moa: anti-ach
AE: headache, nosebleeds, and nasal dryness
caution use in narrow angle glaucoma, yasthenia gravis, and bladder neck obstructions/BPH
dosing: 2 sprays in each nostril q2-4 x a day
onset of action 15min
montelukast in AR
symptoms of perineal and seasonal allergic rhinitis
moa: inhibition of the cysteinyl leukotreine receptor
AE: headahce, fatigue, GI upset, nasal congestion, neuropsychiatric events
slower onset, may not achieve full effect until a month after ubse
not a primary therapy for AR
other therapies for AR
OMALIZUMAB-mAB
immunotherapy
AR indications for intranasal cromolyn
Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:
AR indications
Congestion: Y
Rhinorrhea: Y
Sneezing: Y
Nasal Itching: Y
Ocular Symptoms: N
AR indications for IPRATROPIUM
Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:
AR indications for opthalmic antihistamines
Congestion: N
Rhinorrhea: Y
Sneezing: minimal
Nasal Itching: minimal
Ocular Symptoms: N
AR indications for Leukotriene receptor antagonist (Montelukast)
Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:
AR indications for opthalmic antihistamines
Congestion: minimal
Rhinorrhea:minimal
Sneezing:minimal
Nasal Itching: minimal
Ocular Symptoms:no
considerationf for AR treatment
INS have superior efficacy, but OAH may be adequate for some pts w. primary symptoms of sneezing and itchingand those w. intermittent symptoms
ins>oah for nasal symptoms (incl congestion
INS(and prob OAH>LTRA
intranasal antihistamines have more rapid onset than INS
short course of systemic cs not shown superior to INS
common clinical scenarios in AR
if primary symptom is nasal congestion: INS or oral decongestant
INTERMITTENT SNEEZING,nasal itching, and rhinorrhea: (OAH or INAH)
mild symptoms(sneezing and itching intermittent): OAH
moderate severe: INS, INAH, combo therpay
considerations for combo therapyin AR
if one is not effective, can add another of same route (that ive noticied)
for ex: if INS monotherpay not working, can add INAH , if oral antihistamine not working, can add oral decongestant
however, avoid combination with INS and OAH, no evidence of synergistic effect using them together
