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129 Cards in this Set
- Front
- Back
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Are corticosteroids long term or short term medications?
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long-term medications
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Should you use corticosteroids as a rescue medication(during an emergency)?
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NO--it is a long term therapy
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What is the most potent and effective anti-inflammatory medication?
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inhaled Corticosteroids
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beclomethasone HFA (QVAR)
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inhaled corticosteroid (one of the most used)
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triamcinolone acetonide (axmacort)
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inhaled corticosteroid
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fluticasone propionate (Flovent HFA)
(Flovent Diskus-DPI) |
inhaled corticosteroid (one of the most used)
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flunisolide MDI (Aerobid)
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inhaled corticosteroid (not often used)
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flunisolide HFA (Aerospan HFA)
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inhaled corticosteroid
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budesonide nebs (pulmicort Respules)
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inhaled corticosteroid
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budesonide DPI (pulmicort flexhaler)
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inhaled corticosteroid (one of the most used)
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mometasone furoate DPI (asmanex twisthaler)
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inhaled corticosteroid
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ciclesonide (alvesco)
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inhaled corticosteroid (new drug)
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Why is the inhaled form of corticosteroids used in long-term control of asthma?
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because we see long-term prevention of symptoms, suppression of disease and reversal of inflammation
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All of the inhaled corticosteroids are equally effective as long as...
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they are used in equivalent doses
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methylprednisolone (medrol)
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oral corticosteroid
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prednisone
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oral corticosteroid
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prednisolone
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oral corticosteroid
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When would you use an oral corticosteroid?
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These are systemic so only use in a severe case
methylprednisolone (medrol) prednisone prednisolone |
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When are nasal corticosteroid used?
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allergic rhinitis (not asthma)
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What is the activity of an aerosolized anti-inflammatory?
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1. block the late reaction to allergens
2. reduce airway hyper-reponsiveness |
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What type of medication inhibits cytokine production and inflammatory cell migration and activation?
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anti-inflammatories
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When should you not give an inhaled corticosteroid?
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with patients that have:
status asthmaticus persistant fungal infections |
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What might happen with a patient that has a persistant fungal infection that is given a corticosteroid?
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oral candidiasis (thrush)
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What are some adverse reactions of using metered dose inhalers (MDI)?
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throat irritation
hoareness oral candidiasis |
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List some adverse systemic effects caused by corticosteroids.
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*hypothalamic/pituitary/adrenal suppression
infections cataracts glaucoma fluid and electrolyte imbalances peptic ulcers confusion psychoses |
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How can your patient reduce the adverse effects associated with metered dose inhalers (MDI)?
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using a spacer and rinsing mouth after medication is administered
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Cromolyn sodium (Intal)
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mast cell stabilizer
(nebs/MDI) |
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Who uses neb Cromolyn?
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babies
kids under 5y/o pts that can't use inhalers *mast cell stabilizer* |
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Nedrocromil (Tilade)
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mast cell stabilizer
(inhaled nebs or MDI) |
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What is the MOA of mast cell stabilizers?
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-blocks early and late reaction to allergen
-stabilizes mast cell membranes by inhibiting activation and release of mediators from eosinophils and epithelial cells -inhibits acute response to exercise and cold air |
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When would you not give a patient nedrocromil (tilade) or cromolyn (intal)?
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if they are hypersensitive to either one
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what adverse effects are caused by nedrocromil (tilade) or cromolyn(intal)?
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irritated throat
cough nedocromil has an unpleasant taste |
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Are the therapeutic effects of the mast cell stabilizers (nedrocromil or cromolyn) immediate?
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NO
-effects may occur as soon as 2 weeks but 4-6 weeks before maximum benefits |
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What medications are prescribed by pulmonologists and used in the long term control and prevention of symptoms in adults who have moderate to severe persistent allergic asthma that is not controlled by inhaled corticosteriods (ICS)/
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immunomodulators
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omalizumab (xolair)
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immunomodulator (anti-IgE)
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What medication may cause the following adverse effects?
-pain/bruising at injection site -anaphylaxis -neoplasms |
immunodulators
(anti-IgE) omalizumab (xolair) |
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How are immunomodulators (anti-IgE, omalizumab) administered?
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given subcutaneously every 2-4 weeks
*be prepared to treat anaphylaxis* |
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LTRA
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leukotriene receptor antagonist
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ICS
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inhaled corticosteroid
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SABA
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short acting beta 2 agonist
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LABA
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long acting beta 2 agonist
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Which medications are NOT used for acute asthma exacerbation?
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LABA-long acting beta 2 agonist
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salmeterol xinofoate (serevent diskus)
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long-acting beta 2 agonist (LABA)
(most widely used) |
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formoterol (foradil aerolizer)
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long acting beta2 agonist (LABA)
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arformoterol nebulizer solution (Brovana)
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long acting beta2 agonist (LABA)
tx for COPD Not FDA approved for asthma |
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formoterol nebulizer solution (Perforomist)
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long acting beta2 agonist (LABA)
tx for COPD Not FDA approved for asthma |
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Which two LABA-long acting beta2 agonist drugs are used for COPD but have not been approved for asthma?
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arformoterol nebulizer (Brovana)
formoterol nebulizer (Perforomist) |
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What class of drug basically is an antagonist of bronchospasm?
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LABA-long acting beta2 agonist
-has the MOA of bronchodilation due to smooth muscle relaxation following adenylate cyclase activation and increase in cyclic AMP |
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Who should not use LABA-long acting beta2 agonist inhalers?
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patients with cardiac arrhythmias associated with tachycardia or heart block
pts with narrow angle glaucoma |
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should people with narrow angle glaucoma use LABA drugs?
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NO neither should ppl w/ cardiac arrhythmias associated with tachycardia or heart block
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If your pt presents with the following symptoms: tachycardia, skeletal muscle tremor, hypokalemia, prolonged QT interval in overdose, dizziness, N/V, pharyngitis...what medication might you suspect is causing these adverse reactions???
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LABA-long acting beta2 agonists
salmeterol xinofoate (serevent diskus) formoterol (foradil aerolizer) aformoterol nebulizer (Brovana) formoterol nebulizer (perforomist) |
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What drug interactions will LABA's have with beta blockers?
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-beta blocker effect may be decreased or completely reversed
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What medication is sometimes used to prevent preterm labor?
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LABA's long acting beta2 agonist may inhibit uterine contraction
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What medications have a "black box" warning??
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LABA's- they control symptoms but do not treat the underlying cause of inflammation, making the pt a "ticking time bomb"
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Are LABA's a monotherapy?
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NO! they must be used with an ICS (inhaled corticosteroid)
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Can LABA's with continued use provide shorter duration of protection against EIB (exercise induced bronchospasm)?
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Yes :(
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what products seem to be more effective than two agents alone due to the delivery systems?
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Combination products although they are more expensive.
corticosteroid+LABA Fluticasone propionate + salmeterol xiafoate = Advair HFA/diskus budesonide+formoterol= symbicort |
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How old should your patient be before they can use a combination product?
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12y/o or older
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Why might you use Methylxanthines?
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1. adjunctive therapy to inhaled corticosteriods to prevent nocturnal asthma sx
2. prevention of reversible bronchospasm associated with chronic bronchitis and emphysema 3.possible anti-inflammatory effects |
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Theophylline
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mehtylxanthine (COPD)
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Slo-Phyllin
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methylxanthine (COPD)
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Slo-Bid
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Methylxanthine (COPD)
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Theo-Dur
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Methylxanthine (COPD)
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Aminophylline
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Methylxanthine (COPD)
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What is the MOA for Methylxanthine?
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-smooth muscle relaxation (bronchodilation) from phosphodiesterase inhibition
-increases diaphragm contractility and mucociliary clearance |
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List some Methylxanthines:
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Theophylline
Slo-Phylline Slo-Bid Theo-Dur Aminophylline (COPD) |
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Theophylline
Slo-Phyllin Slo-Bid Theo-Dur Aminphylline These drugs belong to what class? |
Methylxanthines for COPD
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Should you give a patient with an underlying seizure disorder Methylxanthine?
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NO --unless they are taking an anticonvulsant
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What is the relationship between Methylxanthine and adverse effects?
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the adverse effects are dose related
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Methylxanthine is not well tolerated, what are some adverse effects that you should warn your patient of?
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tachycardia, restlessness, convulsions, insomnia
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Should you increase or decrease theophylline levels if your patients is:
-on rifampin -a smoker - on beta agonists - on phenytoin |
decrease theophylline (methylxanthine)
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should you increase or decrease theopylline levels if your pt is:
-taking cimetidine -taking quinolones -on macrolides -using oral contraceptives -using allopurinol |
increase theophylline (methylxanthine)
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What leukotriene modifier would you use for a 1 year and older?
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montelukast (long term control and prevention of mild persistant asthma)
*singular* |
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Which leukotriene modifier is used for patients 7 and older?
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zafirlukast (accolate) for long term control and prevention of mild persistant asthma
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Which leukotriene modifier must you be older than 12 to use?
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zileuton (Zyflo) for long term control and prevention of mild persistant asthma
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When would you combine a leukotriene modifier with an ICS (inhaled corticosteroid)?
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in moderate persistant asthma
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What is the MOA of leukotriene modifier?
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leukotriene receptor antagonist--antagonizes the contractile activity of leukotrienes (sort of like the mast cell stabilizer and works at the cellular level)
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Can you use leukotriene inhibitors and LABA as a substitute for ICS+LABA?
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No
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Which of the leukotriene modifiers has CYP450 enzyme interaction?
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zileuton(zyflo)
zafirlukast(accolate) |
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When would you use a SABA- short acting beta2 agonist?
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for relief of acute symptoms of both asthma and COPD
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Can you use SABA-short acting beta2 agonist for preventive treatment for excercise induced bronchospasm prior to exercise?
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yes
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Albuterol (proventil/ventolin)
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SABA-short acting beta2 agonist
(for relief of acute sx of both asthma and COPD) |
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bitolerol (tornalate)
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SABA-short acting beta2 agonist
(for relief of acute sx of both asthma and COPD) |
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pirbuterol (maxair autohaler)
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SABA-short acting beta2 agonist
(for relief of acute sx of both asthma and COPD) |
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terbutaline (brethine)
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SABA-short acting beta2 agonist
(for relief of acute sx of both asthma and COPD) |
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levalbuterol HFA MDI (xopenex HFA)
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SABA-short acting beta2 agonist (for relief of acute sx of both asthma and COPD)
*pediatrics* |
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levalbuterol nebulizer solution (xopenex)
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SABA-short acting beta2 agonist (for relief of acute sx of both asthma and COPD)
*pediatrics* |
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What is the MOA of SABA's-short acting beta2 agonist?
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binds to beta2 adrenergic receptors
-smooth muscle relaxation -adenylate cyclase activation and increase in cyclic AMP producing antagonism of bronchoconstriction |
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When should you not give your patient SABA's?
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-cardiac arrhythmias associated with tachycardia or heart block
-narrow angle glaucoma |
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What are the adverse reactions associated with the SABA's?
Albuterol (proventil/ventolin) bitolerol (tornalate) pirbuterol (maxair autohaler) terbutaline (brethine) Levelbuterol (xopenex) |
-tachycardia
-skeletal muscle tremor -dizziness -N/V -hypokalemia -increased lactic acid -HA -hyperglycemia |
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What ingredient found in some SABA products may cause anaphylactic symptoms?
Albuterol (proventil/ventolin) bitolerol (tornalate) pirbuterol (maxair autohaler) terbutaline (brethine) Levelbuterol (xopenex) |
sulfites
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Will beta blocker effect be increased or decreased when used with SABA's?
Albuterol (proventil/ventolin) bitolerol (tornalate) pirbuterol (maxair autohaler) terbutaline (brethine) Levelbuterol (xopenex) |
if there is a cross reaction it will most likely decrease the beta blocker effect
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which medications are the drug of choice for acute brochospasm?
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SABA's short acting beta2 agonist
Albuterol (proventil/ventolin) bitolerol (tornalate) pirbuterol (maxair autohaler) terbutaline (brethine) Levelbuterol (xopenex) |
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When taking SABA's, why is inhaled the preferred route?
Albuterol (proventil/ventolin) bitolerol (tornalate) pirbuterol (maxair autohaler) terbutaline (brethine) Levelbuterol (xopenex) |
-inhaled route has faster onset
-fewer ADR's -more effective than systemic route |
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why are beta2 selective agents less preferred than the SABA's?
Albuterol (proventil/ventolin) bitolerol (tornalate) pirbuterol (maxair autohaler) terbutaline (brethine) Levelbuterol (xopenex) |
because beta2 selective agents have the potential for excessive cardiac stimulation
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How do anticholinergics work?
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-competitive inhibition of muscarinic cholinergic receptors
-reduces intrinsic vagal tone of the airways -may block reflex bronchoconstriction secondary to irritants or to reflux esophagitis -may decrease mucous gland secretion |
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ipratropium bromide (Atrovent HFA)
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anticholinergic
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ipratropium nebulizer solution (Atrovent)
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anticholinergic
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ipratropium bromide/albuterol sulf (combivent)
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anticholinergic
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ipratropium/albuterol nebulizer solution (DuoNeb)
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anticholinergic
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The following are anticholinergics:
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-ipratropium bromide (atrovent HFA)
-ipratropium nebulizer solution(Artrovent) -ipratropium bromide/albuterol sulf (combivent) -ipratropium/albuterol neb solution (DuoNeb) |
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Anticholinergics when added to ___________ agonist during severe exacerbations may provide some added benefit.
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beta2 agonist
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What medication can be used as a substitute for patients who do not tolerate beta2 agonists?
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-anticholinergics:
-ipratropium bromide (atrovent HFA) -ipratropium nebulizer solution(Artrovent) -ipratropium bromide/albuterol sulf (combivent) -ipratropium/albuterol neb solution (DuoNeb) |
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Why is using anticholinergics a concern?
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because it only reverses cholinergically mediated bronchospasm
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What are the adverse effects associated with anticholinergics?\
-ipratropium bromide (atrovent HFA) -ipratropium nebulizer solution(Artrovent) -ipratropium bromide/albuterol sulf (combivent) -ipratropium/albuterol neb solution (DuoNeb) |
-dizziness
-dry mouth -constipation -tremor -urinary retention -may worsen narrow angle glaucoma -cause temp blurred vision if sprayed into eyes |
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What medication if added to SABA, short acting beta2 agonist in the emergency department may provide additive effects?
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anticholinergics:
-ipratropium bromide (atrovent HFA) -ipratropium nebulizer solution(Artrovent) -ipratropium bromide/albuterol sulf (combivent) -ipratropium/albuterol neb solution (DuoNeb) |
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what is the treatment of choice for bronchospasm due to beta blocker medication?
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anticholinergics;
-ipratropium bromide (atrovent HFA) -ipratropium nebulizer solution(Artrovent) -ipratropium bromide/albuterol sulf (combivent) -ipratropium/albuterol neb solution (DuoNeb) |
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are anticholinergics proven to be efficacious as long term control therapy for asthma?
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no
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What is the first line of therapy for COPD?
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-anticholinergics:
-ipratropium bromide (atrovent HFA) -ipratropium nebulizer solution(Artrovent) -ipratropium bromide/albuterol sulf (combivent) -ipratropium/albuterol neb solution (DuoNeb) |
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Which medications remain the bronchodilator of choice for acute exacerbations?
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Sympathomimetics (SABA and LABA)
-short acting beta2 agonist -long acting beta2 agonist |
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what combination of medications are most effective in combination rather than monotherapy?
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anticholinergic+sympathomimetic
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After sympathomimetics and anticholinergics, what is the next line of therapy?
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methylxanthines
(debate of risks vs benefits in COPD) |
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when should corticosteroids be initiated?
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during acute exacerbation when the patient is deteriorating despite adequate anticholinergic and/or sympathomimetic therapy as well as possible methylxanthine
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What is the rationale for long term oxygen use?
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-improves survival
-improves quality of life -improves walking distance -decreases hospital time |
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What are the antibiotics of choice for asthma/COPD patients?
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-amoxicillin
-ampicillin -ampicillin/sulbactam -azithromycin |
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Should patients with COPD/asthma get the flu shot?
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yes, every year
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what is the best expectorant?
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water
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what is the rationale for not using expectorants and mucolytics?
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the doses needed to promote expectoration is so large that it leads to unwanted side effects
*mucomyst (acetylcysteine) |
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what are the types of spacers available?
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1. valve holding chambers (VHC)
2. open tube spacer 3. reverse flow spacer |
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When do we use systemic corticosteroids?
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for moderate to severe exacerbations to speed recovery and prevent recurrences of exacerbations
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What is step 1 in asthma management?
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preferred: SABA prn
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What is step 2 in asthma management?
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preferred: low-dose ICS
alternative: cromolyn, LTRA, nedocromil, or theophylline |
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What is step 3 in asthma management?
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preferred: low dose ICS+LABA or med dose of ICS
alternative: low dose ICS+ either LTRA or theophylline |
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What is step 4 in asthma management?
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preferred: medium dose ICS+LABA
alternative: med dose of ICS+either LTRS or theophylline |
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what is step 5 in asthma management?
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preferred: high dose ICS+LABA and consider omalizumab for pt w/ allergies
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what is step 6 in asthma management?
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Preferred: high dose ICS+LABA+oral corticosteroid and consider omalizumab for pts w/ allergies
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What does green zone mean?
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All clear, no asthma symptoms are present.
Continue on same meds |
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What does yellow zone mean?
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Signal caution, may be having episodes that require an increase in medication
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What does red zone mean?
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Medical Alert
Call 911 |
