Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
65 Cards in this Set
- Front
- Back
|
Chronic often reversible inflammatory disorder of the airways
•Infiltration of mast cells, eosinophils, and lymphocytes, and many other inflammatory mediators •Recurrent episodes of wheezing, coughing, chest tightness, and shortness of breath •Airway hyperresponsiveness |
Asthma
|
|
|
What makes it difficult to breathe in asthma?
|
Airway inflammation and tightening of smooth muscle in the passages.
|
|
|
What things are seen in the initial assessment of asthma?
|
Recurrent episodes of wheezing, coughing, chest tightness, and shortness of breath
•Airflow obstruction that is at least partially reversible • AFTER TX FEV1 of >200 mL and •12% increase from baseline measure after SABA •Increased bronchial hyperresponsiveness •Presence of other risk factors •Atopic conditions (i.e. eczema, allergic rhinitis, etc) |
|
|
What is a test that is used and what related conditions can show up with asthma?
|
Have spirometry performed at baseline and in testing at regular intervals, usually yearly
Atopic conditions show up in patients with asthma IgE-eczema, rhinitis etc. |
|
|
What are examples of inhaled allergens that can cause asthma?
|
Pollen
•Cockroaches •Animal dander •House dust mites •Damp rooms –mold |
|
|
What are examples of inhaled irritants that can cause asthma by release of acetylcholine causing tightness in airways?
|
Perfumes
•Tobacco smoke •Cleaning agents •Airborne chemicals •Wood burning stoves |
|
|
What are some asthma triggers/exacerbating factors?
|
•GERD
•Obesity •Rhinitis •Occupational exposures •Viral respiratory infection •Exercise •ASA/NSAIDs •Strong emotion •Menstrual cycles •Sulfite sensitivity •Beta -blockers (including eye drops) |
|
|
What impairment issues do you look at when staging asthma severity?
|
•Frequency & intensity of symptoms
•Functional limitations •Effect on quality of life |
|
|
What risk issues do you look at when staging asthma severity?
|
•Future exacerbations
•Loss of pulmonary function •Risk of adverse effects from medication |
|
|
What are the goals for treating asthma?
|
•Reduce Impairment
•Prevent asthma symptoms •Require infrequent use (<2 days a week) of inhaled SABA •Maintain (near) normal pulmonary function. •Maintain normal activity levels •Meet the patient’s expectations with asthma care •Reduce Risk •Prevent recurrent asthma exacerbations •Prevent loss of lung function •Provide optimal pharmacotherapy |
|
|
What are good questions to ask a patient who comes in with asthma like complaints?
|
1. How often are you taking your meds (if an asthmatic patient).
2. What were you doing, where were you when the attack happened? 3. What triggers your asthma? |
|
|
•Provides objective data to assist clinician
–Guides medication changes •Documents “Personal Best” •Detects impending exacerbation –BEFOREsymptoms arise •Helps identify triggers |
8The Role of Home Peak Flow Monitoring
|
|
|
What is involved with peak flow meters and establishing a personal best?
|
•Establish when asthma is under “good control”
•Establish over a 2-3 week period •Measure at least twice daily (i.e. morning & afternoon) •Record the highest valueobtained during this 2-3 week period |
|
|
What is involved with peak flow meters After a “Personal Best” is Established?
|
•Use at least every morning upon awakening
•Use before taking any asthma medication •Use after taking a rescue medication to determine impact •Use as directed by PCP*** (i.e. action plan) |
|
|
Asthma Action Plans Three Zone Management
•Once the “PB” is established…Youset their 3 zones What are these three zones? |
•80-100% of Personal Best = GreenZone
–Continue with regular activities –Follow your maintenance medication plan •50-80% of Personal Best=YellowZone –May require medication adjustment –Contact health care provider •<50% of Personal Best = RedZone –Emergency –Dial 911 –Contact Health Care Provider Note: If peak flow reading 20% or more after using a SABA consider adjusting controller therapy |
|
|
A patient presents to you with a personal best of 400L/min. Please calculate the values for each zone based on this information.
|
80-100% (320-400L/min)
50-80% (200-320L/min) <50% (<200L/min) |
|
|
What are the principles of the stepwise approach to asthma management?
|
STEP DOWN
Review treatment every 1 to 6 months Gradually decrease to the least medication necessary to maintain control STEP UP If inadequate control, (as seen by increased use of short-acting beta-2 agonist) …Consider step up. Before stepping up, review patient inhaler technique, compliance, environmental control Refer to asthma specialist if necessary |
|
|
What types of drugs are involved with the asthma maintenance regimens?
|
•Inhaled corticosteroids
•Long acting B2-agonists •Leukotriene antagonists •Mast cell stabilizers •Theophylline |
|
|
What type of drugs are involved with the asthma rescue regimens?
|
•Short acting B2-agonists
•***Anticholinergics |
|
|
Beta 2 Agonists
Agent B1Activity B2Activity B2Poteny Dilation (hours) Isoproterenol ++++ ++++ 1 0.5-2 Metaproterenol +++ +++ 15 3-4 Albuterol + ++++ 2 4-8 Pirbuterol + ++++ 5 4-8 Terbutaline + ++++ 4 4-8 Formoterol + ++++ 0.24 12 Salmeterol + ++++ 0.5 12 |
Beta 2 Agonists
Agent B1Activity B2Activity B2Poteny Dilation (hours) Isoproterenol ++++ ++++ 1 0.5-2 Metaproterenol +++ +++ 15 3-4 Albuterol + ++++ 2 4-8 Pirbuterol + ++++ 5 4-8 Terbutaline + ++++ 4 4-8 Formoterol + ++++ 0.24 12 Salmeterol + ++++ 0.5 12 |
|
|
•Relief of acute symptoms; quick-relief medication.
•Drugs of choice for acute bronchospasm and for exercise-induced bronchospasm. •Inhaled route: •Faster onset than oral route. •More effective than systemic routes. •Fewer adverse effects. •MOA: Adenyl cyclase - CAMP which activates PKA - CA++ leaves the cell - smooth muscle relaxes |
Short Acting Beta2Agonists
|
|
|
The lower the # of B2 potency the higher the what?
|
Potency
|
|
|
What is something you are trying to avoid in beta2agonist asthma meds?
|
The beta2agonist meds that have a very high B1 activity - Isoproterenol, and metaproterenol.
|
|
|
All inhalers should be cleaned how often?
|
Weekly
|
|
|
These are the agents of choice for exercise induced bronchospasm?
|
Short Acting Beta2Agonists
|
|
|
•Relief of acute symptoms; quick-relief medication.
•Drugs of choice for acute bronchospasm and for exercise-induced bronchospasm. •Inhaled route: •Faster onset than oral route. •More effective than systemic routes. •Fewer adverse effects. •MOA: Adenyl cyclase - CAMP which activates PKA - CA++ leaves the cell - smooth muscle relaxes |
Short acting beta2agonists
|
|
|
RescueInhaler - Proventil HFA
1. FDA Approved Age 2. # of Metered Doses 3. Dose 4. Prime 5. Cost |
1. 4-years+
2. 200 3. 90mcg 4. 1st use & 2 weeks 5. $45.74 |
|
|
RescueInhaler - Maxair Autohaler
1. FDA Approved Age 2. # of Metered Doses 3. Dose 4. Prime 5. Cost |
1. 12-years +
2. 400 3. 200mcg 4. 1st use & after 48hrs 5. $119.27 |
|
|
RescueInhaler - ProAir HFA
1. FDA Approved Age 2. # of Metered Doses 3. Dose 4. Prime 5. Cost |
1. 4-years+
2. 200 3. 90mcg 4. 1stuse & 2 weeks 5. $40.98 |
|
|
RescueInhaler - Xopenex HFA
1. FDA Approved Age 2. # of Metered Doses 3. Dose 4. Prime 5. Cost |
1. 4-years+
2. 200 3. 45mcg 4. 1st use & after 3days 5. $52.49 |
|
|
RescueInhaler - Ventolin HFA
1. FDA Approved Age 2. # of Metered Doses 3. Dose 4. Prime 5. Cost |
1. 4-years+
2. 64 or 204 3. 90mcg 4. 1st use & 2 weeks 5. $36.12 |
|
|
Of the rescue inhalers, which three are albuterol inhalers?
|
Preventil HFA, Pro Air HFA, Ventolin HFA.
Ventolin is the only one with a dose counter. |
|
|
Short Acting Beta2Agonists
•Breath activated inhaler •Delivers 200mcg/actuation •Contains 400 metered actuations/inhaler •Must be primed prior to use and if not used >48hrs •Usual Adult Dose: 1-2 puffs inh Q 4-6 H prn |
Maxair Autohaler(Pirbuterol)
|
|
|
Short Acting Beta2Agonists
Delivers 45mcg/actuation •Contains 200 metered actuations/inhaler •This is the R-enantiomer of racemic albuterol •Must be primed prior to use and if not used >72hrs •Usual Adult Dose: 2 puffs inh Q 4-6 H prn |
Xopenex(levalbuterol)
|
|
|
What are the three short acting beta2 agonists, and their dosings, via nebulizer?
|
Albuterol(Adults)
•Albuterol Sulfate 0.5% solution 5mg/ml (concentrated) •Albuterol Sulfate 2.5mg/3ml (0.083%) (Pre-mixed) •Dose: 1.25mg-5mg inhaled 3-4 times/day •Albuterol(Children 2-12 yrs) •AccuNeb0.63mg/3ml or 1.25mg/3ml •Dose: 0.63mg-1.25mg inhaled 3-4 times/day •Xopenex(Levalbuterol) •How Supplied: 0.31 mg, 0.63 mg, and 1.25 mg/3 ml •Adult Dose: 0.63-1.25 mg inh 3-4x/day •Pediatric Dose (6-11 yrs): 0.31-0.63 mg inh 3-4x/day |
|
|
What are the oral beta2agonist? (3 of them)
|
•Albuterol Immediate Release Tablets
•How supplied: 2mg and 4mg tablets •2-6 years of age: 0.1-0.2mg/kg three times daily (Max: 12mg/day) •6-12 years of age: 2mg 3-4 times daily •(Max: 24mg/day) •≥12 years of age: 2-4mg 3-4 times daily •Vospire ER® •How supplied: 4mg and 8mg Extended Release Tablets •6-11 years of age:Initially, 4mg every 12 hours; If needed, may increase step-wise up to 12 mg every 12 hours (Max: 24mg/day) •≥12 years of age: 4-8 mg every 12 hours; •(Max: 32 mg/day) •Proventil Repetabs® •How supplied: 4mg Extended Release Tablets •6-12 years of age:4mg every 12 hours •≥ 12 years of age: 4mg-8mg every 12 hours (Max: 32mg/day) |
|
|
•Most effective long-term therapy available for mild, moderate, or severe persistent asthma
•Can be used alone or in combination with other agents •Improves lung function and reduced need for quick relief medications •MOA: Anti-inflammatory effects result from decreased formation, release and activity of the mediators of inflammation. |
Corticosteroids
|
|
|
What are the adverse effects of corticosteroids?
|
Oral candidiasis (thrush): Up to 34%
•Reduced by:Spacer, rinse mouth, dose/freq (if possible) •Dysphonia: 5%-50% •Reduced by: Spacer, rinse mouth, dose/freq(if possible) •Reflex cough and bronchospasm •Reduced by: Spacer, rate of inspiration, pre-treat with albuterol •Growth rates are highly variable in children •No significant effects on: •Bone mineral density in children •Incidence of cataracts or glaucoma •HPA axis function |
|
|
•Requires less coordination to use
•Improves drug deposition into lungs •Decreases oropharyngeal deposition •Consider a face mask in children < 4-years •Use one actuation per inhalation!!!!! |
Spacers
|
|
|
What are the corticosteroids?
|
(QVAR®) Beclomethasone MDI
40 or 80 mcg/inh (Pulmicort Flexhaler™) Budesonide DPI 90, 180, mcg/inh (Pulmicort®Respules) Budesonide Neb 0.25mg, 0.5mg, & 1mg/2ml (Aerobid®) Flunisolide MDI 250 mcg/inh (Flovent HFA®) Fluticasone HFA 44, 110, 220 mcg/inh (Asmanex®Twisthaler) Mometasone DPI 220 mcg/inh (Azmacort®) TriamcinoloneMDI 75 mcg/inh(MFR-d/c) |
|
|
One of the best inhaled corticosteroids
•Approved: 12+ years of age •Available: 80mcg/inh & 160mcg/inh (both 60 act) •Dosing: –80mcg-160mcg BID (Max 320mcg BID) •Features/Notes –Dosing window on top of the canister –Inhaler does notneed to be shaken prior to use –Do not wash any partof the inhaler in water •“Claims to Fame” –Small particle size >50% dose reaches the lung –Converted to its active form by esterases in the lung –Only 1% is available for systemic exposure |
treatmentAlvesco® (Ciclesonide) MDI
|
|
|
Oral Corticosteroids include what three?
|
Methylprednisolone
Prednisolone Prednisone |
|
|
Oral Corticosteroid
Strength: 1, 2.5, 5, 10, 20, 50mg tablets 5mg/5ml 5mg/ml Adult Dose: “Short Burst” 40-60mg/day single or 2 divided doses for 3-10 days Child Dose: “Short Burst” 1-2mg/kg/day Max 60mg/day for 3-10 days |
Prednisone
|
|
|
Oral Corticosteroid
Strength: 5mg tablets 5mg/5ml 15mg/5ml Adult Dose: “Short Burst” 40-60mg/day single or 2 divided doses for 3-10 days Child Dose: “Short Burst” 1-2mg/kg/day Max 60mg/day for 3-10 days |
Prednisolone
|
|
|
Oral Corticosteroid
Strength: 2, 4, 8, 16, 32mg tablets Adult Dose:7.5-60mg daily; either QD or QOD Child Dose: 0.25mg-2mg/kg daily; either QD or QOD |
Methylprednisolone
|
|
|
These two drugs are what?
•Serevent Diskus®(salmeterol) 50mcg •Onset 30 minutes •Dose (>4yrs age): 50mcg inh BID •Expires 6 weeks from opening foil pouch •Foradil®(formoterol) 12mcg •Onset 5 minutes •Dose (>5yrs age): 12mcg via device Q12 h •Keep formoterol capsules in the refrigerator prior to dispensing •Expires in 4 months when stored at room temperature •Side Effects •Tremor, tachycardia, and nervousness •**Black Box Warning for LABA** |
Long Acting B2-Agonists
|
|
|
You never want to give a long acting bronchodilator without giving a?
|
steroid
|
|
|
•MUST BE used concomitantly with anti-inflammatory medications for long-term control of asthma symptoms
•Can be used to prevent exercise-induced bronchospasm •These agents do noteliminate the need for an anti-inflammatory agent when used for asthma •Not to be used to treat acute symptoms or exacerbations |
Long acting beta agonists (long acting bronchodilator)
|
|
|
What is the only Long acting beta agonists (long acting bronchodilator) that can be used to prevent exercise induce bronchospasm?
|
Seravant
|
|
|
What are three combination products for the TX of asthma?
|
•Advair Diskus(fluticasone/salmeterol)
•One inhalation BID •How supplied: 100/50, 250/50, 500mcg/50mcg •Discard after 1 month of opening foil wrapper even if all the doses are not used •Advair HFA(fluticasone/salmeterol) •Two inhalations BID •How supplied: 45/21, 115/21, 230mcg/21mcg •Discard when empty or according to expiration date on package •Symbicort(budesonide/formoterol) •Two inhalations BID •80mcg/4.5mcg (For pts not controlled on low-med doses of ICS) •160mcg/4.5mcg (For pts not controlled on med-high doses of ICS) •Discard after 3 months of opening foil wrapper even if all the doses are not used |
|
|
Long-term control and prevention of symptoms, especially nocturnal symptoms
•Dose-related acute toxicities: •Tachyarrhythmias •Central nervous system stimulation •Seizures •Hyperglycemia and hypokalemia. •MOA: Bronchodilation. Smooth muscle relaxation from phosphodiesterase inhibition and possibly adenosine antagonism. |
Theophylline
|
|
|
Cigarettes can increase clearance of this med?
|
Theophylline
|
|
|
What is the dosing for theophylline in asthma that comes in the immediate-release tablets and elixir?
|
–Initial: 300 mg/day PO in divided doses over 6 to 8 hours
–May increase total daily dose by 100mg after 3 days if tolerated (Max = 800 mg/day) |
|
|
What is the dosing for theophylline in asthma that comes in the extended release 12 hour formulation?
|
–Initial: 300 mg/day PO in divided doses every 12 hours
–May increase total daily dose by 100mg after 3 days if tolerated (Max = 800 mg/day) |
|
|
What is the dosing for theophylline in asthma that comes in the extended release 24 hour formulation?
|
–Once stable on theophylline: 400mg-600mg/day
–Note: Dose should be same mg as previous immediate-or controlled-release dosing |
|
|
In giving any type of theophylline it is important to do what?
|
•In any scenario, maintain steady-state serum = 5-15 mcg/mL
|
|
|
What are the inhibitors of theophylline?
|
•ETOH (Theo 30%)
•Zileuton (Theo 73%) •Cimetidine (Theo 70%) •Zafirlukast (Theo 120%) •Propranolol (Theo 100%) •Ciprofloxacin (Theo 40%) |
|
|
What are the inducers of theophylline?
|
•Smoking (Theo 50%-80%)
•Rifampin (Theo 20%-40%) •Phenytoin (bothby 40%) •Omeprazole (Theo ?? %) •Phenobarbital (Theo 25%) •Carbamazepine (Theo 30%) |
|
|
•Produced and released from multiple sources
•Contract smooth muscle •Increase vascular permeability and mucus secretions |
Leukotrienes
|
|
|
•May be considered an alternative therapy to low doses of inhaled corticosteroids or cromolyn or nedocromil in patients with mild persistent asthma
•Three Agents –each work differently! |
Leukotriene inhibitors
|
|
|
What are the three leukotriene inhibitors?
|
Accolate, Singulair, and Zyflo CR
|
|
|
Which of the leukotriene inhibitors can cause an increase in warfarin levels due to CYP2C9 inhibition?
|
Accolate
|
|
|
This leukotriene inhibitor is popular, once daily dosing, can be used as early as 1 year of age, not alot of DDIs?
|
Singulair
|
|
|
•MOA -inhibits the binding of IgE to the high-affinity IgE receptor on the surface of mast cells and basophils
•Intended Use: Allergic Asthma •Candidates: •12 years + •Moderate-severe persistent asthma •+ Skin test to perennial aeroallergen •Inadequately controlled with inhaled corticosteroids •Dose is based on body weight (kg) and serum IgE levels (measured before start of treatment). |
Anti-IgE Antibody Medications
•Xolair®(Omalizumab) |
|
|
What three vaccinations should asthmatics have?
|
2009 Seasonal Influenza
Trivalent inactivated influenza vaccine (TIV) annually 2009 (H1N1) Influenza Intramuscular formulation Pneumococcal: 23-valent PPV Persons aged 19-64 years who have asthma should receive a single dose of PPSV23 |
