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Pharmacology > Week 6 Respiratory Part 2 > Flashcards

Week 6 Respiratory Part 2 Flashcards

1
Q

What is characterized by variable airflow obstruction-often reversible (esp with meds)?

A

asthma

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2
Q

What causes the airflow obstruction in asthma?

A

bronchial hyper-responsiveness (BHR)- various triggers causing chronic airway inflammation-airway remodeling

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3
Q

What is the most common chronic disease of children?

A

asthma (7%)

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4
Q

How many deaths are there a year from asthma?

A

5,000 deaths/year

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5
Q

What percentages of asthma deaths are preventable?

A

80-90%

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6
Q

Where do most of the asthma deaths occur?

A

Out of the hospital

inadequate therapy

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7
Q

Asthma is caused by infiltration of what?

A

eosinophils & mast cells

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8
Q

What are some of the mediators in asthma? (3)

A

prostaglandins
thrombaxanes
leukotrienes

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9
Q

What are the prostaglandins that cause bronchicontriction in asthma?

A

D2 and F2 alpha

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10
Q

What is the effect of thrombaxanes in asthma?

A

bronchiconstriction/inflammation

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11
Q

What are the leukotrienes involved in asthma?

A

C4, D4, E4= SRS-A

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12
Q

What are the bronchodilators for asthma?

A

beta 2 agonists
anticholinergics
theophylline

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13
Q

What are the anti-inflammatory agents for asthma?

A

inhaled glucocorticosteroids (ICS)

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14
Q

What are the pharmacotherapy targets for asthma?

A

bronchodilators
anti-inflammatory agents
leukotriene receptor antagonists (LTRAs)
Anti-Interleukin 5 antibodies (IL-5)

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15
Q

How is asthma severity classified?

A

frequency of symptoms

severity of symptoms

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16
Q

How is asthma diagnosed?

A

abnormal PFTs that improve by 15% or more after bronchodilator therapy

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17
Q

What is the cornerstone of asthma treatment?

A

pharmacotherapy

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18
Q

What are the 2 main therapeutic options for asthma?

A

bronchodilators and inhaled corticosteroids

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19
Q

What are the bronchodilators used for asthma?

A

beta agonists: rescue inhalers for acute exacerbations

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20
Q

When are anticholinergics mostly used as bronchidilators?

A

less with asthma and more with COPD

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21
Q

What medication suppresses the underling inflammation caused by asthma?

A

imahuled corticosteroids

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22
Q

What is an example of a leukotriene receptor antagonist?

A

montelukast

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23
Q

What is the goal of step 1-intermittent treatment?

A

long term control: none

Quick relief: short acting bronchodilator (SABA PRN)

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24
Q

What is the treatment regimen for step 2-mild persistent?

A

long term control:
preferred: low dose ICS
alternativeL an LTRA (montelulast)
quick reliefL SABA

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25
Q

What is the treatment regimen for step 3-moderate persistent?

A

long term:
low dose ICS+ LABA (preferred)
alternative: medium dose ICS OR low dose ICS+ LTRA
Quick relief: SABA

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26
Q

What is the treatment regimen for step 4- severe persistent?

A

long term:
medium or high dose ICS + LABA (preferred)
Alternative:
medium or high dose ICS+ LAMA OR high dose ICS +LTRA or theophylline
Quick relief: SABA

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27
Q

What are the most effective bronchodilators that are indicated for intermittent bronchospasm, of asthma?

A

beta 2 agonists

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28
Q

What are the drugs of choice for acute asthma and exercise induced bronchospasm (EIB)?

A

beta 2 agonists

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29
Q

How is bronchoselectivity increased with beta 2 agonists?

A

increased by inhalation

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30
Q

What are the 2 categories of beta 2 agonists?

A 
short acting (SABA)
long acting (LABA)
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31
Q

What are the short acting (rescue) beta 2 agonists?

A 
albuterol
levalbuterol
metaproterenol
terbutaline
pirbuterol
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32
Q

What is the onset and duration of short acting beta 2 agonists?

A

onset: 1-5 minutes
duration: 2-6 hours

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33
Q

What are the long acting (maintenance/control/prophylactic) beta 2 agonists?

A

salmeterol
formoterol
indacatrol

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34
Q

What is the onset and duration of long acting beta 2 agonists?

A

onset: 5-15 minutes
duration: >12 hours

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35
Q

What medication resulted in increased asthma related deaths?

A

long acting beta 2 agonists (paradoxical increase in exacerbations in some)

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36
Q

What are the inhaled steroids that are the most effective anti inflammatories for treating asthma?

A

corticosteroids

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37
Q

When do most pts symptoms improve with corticosteroids?

A

1-2 weeks

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38
Q

What is the advantage of inhaled vs systemic steroids?

A

inhaled avoids systemic side effects

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39
Q

When are high doses of SYSTEMIC corticosteroids used?

A

for severe asthma or severe asthma unresponsiveness to beta 2 agonists

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40
Q

What is the systemic corticosteroid dose for severe asthma?

A

prednisone 1-2mg/kg/daily (max 60mg/day) divided BID or TID x 3-10 days

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41
Q

What is the first line of treatment for persistent asthma?

A

inhaled steroids

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42
Q

What is the toxicity of inhaled steroids?

A

minimal at low-moderate doses

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43
Q

What can reduce systemic absorption and thrush of systemic corticosteroids?

A

mouth ringing reduces absorption

BIF dosing reduced thrush

44
Q

What is the IV corticosteroid given for severe asthma?

A

methylprednisolone

loading dose 2mg/kg then 0.5-1mg/kg every 6 hours

45
Q

What are common inhaled steroids?

A 
Beclomethasone
Triamcinoline (Azmacort)
Flunisolide (aerobid)
Budesonide (pulmicort)
Fluicasone (Flovent)

*all equally effective but doses are NOT interchangeable

46
Q

What medication inhibits constrictive “tone”?

A

anticholinergics

47
Q

Are anticholinergics as potent as beta agonists? Why?

A

No- quaternary NH 4 agents have poor absorption

48
Q

What are cholinergic antagonist agents?

A

ipratropium (atrovent)

tiotropium (spiriva)

49
Q

What is combivent metered dose inhaler (MDI)?

A

atrovent + albuterol

50
Q

What medication for asthma has potency that is limited by a narrow therapeutic index?

A

methylxanthines (MXs)

Theophylline

51
Q

When do toxic effects of methylxanthines (MXs) occur?

A

> 15mg/L

52
Q

What is the therapeutic range of methylxanthines (MXs)?

A

10-20mg/L (OVERLAP with toxic dose effects)

53
Q

What is the MOA of methylxanthines (MXs)?

A

phosphodiesterase (PDE) III & IV inhibition

54
Q

What is an example of a leukotriene modifier? (LTM/ LTRA)?

A

montelukast (singulair)

55
Q

When are leukotriene modifiers best used?

A

as addicts in patients with more severe asthma

56
Q

What 2 LTM/LTRA interact with warfarin and prolong the INR.

A

Zafirlukast & Zileuton

57
Q

What medication increased theophylline (MXs) levels AND need to be cut in half if given together?

A

Zileuton

58
Q

What is the only LTRA with daily dosing?

A

Montelukast (Singulair)

59
Q

What asthma medications have both caused hepatotoxicity?

A

Zafirlukast & Zileuton

60
Q

What is an example of an anti-IgE monoclonal antibody for asthma treatment?

A

Omalizumab (Xolair)

61
Q

What is a complication of Omalizumab (Xolair)?

A

anaphylaxis occurs in 1-2/1000

62
Q

What medication permits reduction in haled-corticosteroid use?

A

Omalizumab (Xolair)

63
Q

What is the greatest draw back of Omalizumab (Xolair)?

A

$10,000-30,000/year

64
Q

What is Omalizumab (Xolair) usually reserved for?

A

severe-persistent asthma

65
Q

What are 2 FDA approved anti-interleukin 5 antibodies (IL-5) for asthma?

A

Mepolizumab (Nucala)
Reslizumab (Cinqair)

$$$$$$

66
Q

What is the benefit of anti-interleukin 5 antibodies (IL-5) for asthma?

A

decreased exacerbations by 50%

67
Q

What is an adverse effect of anti-interleukin 5 antibodies (IL-5) for asthma??

A

possible anaphylaxis

68
Q

COPD is characterized by airflow obstruction due to what?

A

chronic bronchitis or emphysema

69
Q

What COPD is characterized by chronic or recurrent excess mucus secretion into bronchial tree?

A

chronic COPD

70
Q

What are the characteristics of a cough with chronic bronchitis?

A

most days greater than 3 months/year

for at least 2 consecutive years

71
Q

Bronchitis is denied in _____ .

A

clinical terms

72
Q

What COPD is technically definite by anatomic pathology?

A

emphysema

73
Q

What are the characteristics of emphysema?

A

permanent enlarged air spaces

destruction of alveolar walls

74
Q

What COPD presentation involves impressive history of productive cough and called “blue bloaters” due to CO2 retention?

A

chronic bronchitis

75
Q

With chronic bronchitis, chest percussion is ______.

A

resonant

76
Q

With chronic bronchitis, breath sounds are _______.

A

distant to auscultation

77
Q

What COPD presentation usually has increasing dyspnea with minimal cough, and called “pink puffers” due to tachypnea?

A

emphysema

78
Q

What COPD presents with “pursed lip” which compensates for loss of elastic recoil?

A

emphysema

79
Q

What COPD often uses accessory muscles for breathing?

A

emphysema

80
Q

Chest percussion is ______ in emphysema?

A

hyper resonant

81
Q

What is a major risk factor for both types of COPD?

A

cigarette smoking

82
Q

How does COPD inflammation differ from asthma?

A

asthma: caused by eosinophils & mast cells
COPD: caused by neutrophils, macrophages & CD8 T lymphocytes

83
Q

COPD is characterized by _______.

A

exacerbations

84
Q

What is an acute event characterized by a worsening of the patients respiratory symptoms that is beyond normal day to day variation and leads to a change in mediation?

A

COPD exacerbation

85
Q

How many exacerbations do pts have a year?

A

1-2

86
Q

What percentage of exacerbations will be managed outpatient?

A

more than 80%

87
Q

What severe exacerbations should be admitted to the hospital?

A

accessory muscle use
cyanosis
peripheral edema

88
Q

What are life-threatening exacerbations that should be admitted to the ICU?

A

mental status changes
worsening respiratory status despite ventilator support
hemodynamic instability

89
Q

What are the COPD pharmacotherapies?

A 
cholinergic antagonists (anti muscarinic agents and anticholinergics)
sympathomimetics (beta agonists)
combo anticholingerics/B2 agonists
inhaled corticosteroids
long term low dose oxygen
antibiotics (for exacerbation ONLY)
90
Q

What are the 1st line agents for COPD?

A

inhaled cholinergic antagonists

91
Q

Why are inhales cholinergic antagonists 1st line in COPD

A

fewer side effects with sympathomimetics

92
Q

What is second line treatment after anticholinergics in COPD?

A

sympathomimetics (beta agonists)

93
Q

What is still the drug of choice in acute exacerbations of COPD?

A

sympathomimetics (beta agonists)

due to rapid onset

94
Q

When should a trial of sympathomimetics (beta agonists) be used in COPD?

A

begin a trail if response to ipratropium is unsatisfactory

95
Q

What is significant about ICS in COPD?

A

DO NOT modify lung function decline OR improve mortality

96
Q

When are ICS recommended in COPD?

A

pts with severe COPD or pts with frequent exacerbations

97
Q

What are adverse effects of ICS?

A

oropharyngeal candiasis

hoarse voice

98
Q

What medication is discouraged long term due to adverse effects?

A

SYSTEMIC corticosteroids

99
Q

What has been shown to decrease mortality in COPD?

A

continuous O2 long term

also improves quality of life and decreases time in the hospital

100
Q

How is long term oxygen administered in COPD?

A

nasal canula 2-3L/minute

101
Q

What is the goal of COT? (continuous oxygen therapy)

A

raise PaO2 to >60mmHg

102
Q

What happens in PaO2 is raised too hight?

A

depress respiratory drive-patients may die in their sleep!

103
Q

Why are antibiotics only used in acute exacerbations with COPD?

A

only effective in setting od infection

7-10 days

104
Q

What abx should be used in COPD exacerbation?

A

azithromycin for 3-5 days

105
Q

Combinations of what medications usually work better in COPD compared to alone?

A

anticholinergics and beta 2 agonists

106
Q

What is the controversy when it comes to COPD treatment?

A

over antibiotics and steroids for acute exacerbation of COPD

107
Q

What is the stepwise drug therapy for COPD algorithm,?

A

short acting inhaled bronchodilator for acute symptomatic relief
long acting ICS
combination anticholinergic + beta agonist
consider theophylline
combo ICS + LABA

Pharmacology (17 decks)

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