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79 Cards in this Set
- Front
- Back
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Asthma attacks can consist of what two phases?
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1. immediate-phase response
(occurs on exposure to stimulus, mainly bronchospasm) 2. late-phase response (bronchospasm, vasodilation, edema, mucous, anti-inflammatories needed) |
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ID some drugs that may trigger asthma attacks.
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- beta blockers, Caclium antagonists, dipyridamole, NSAIDs, sulfites, ASA
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Achieving and maintaining clinical control for asthma includes what components?
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- minimal or no chronic symptoms and symptoms day or night
- minimal or no exacerbations - no limitations on activities, no school missed - maintain (near) normal pulmonary function |
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agents used for long term control of asthma include:
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- corticosteroids
- LABAs - Leukotriene modifiers - methylxanthines - Cromolyn - Anti- IgE |
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Quick relief agents for asthma include:
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- SABAs
- Anticholinergics - systemic corticosteroids |
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What is the major advantages of inhaled therapy for asthma?
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- deliver drugs directly to the airways
- deliver higher concentrations locally - minimize systemic side effects |
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Which is more efficient: inhalers or nebulizers?
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nebulizers (deliver higher doses of drug to lungs)
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use of nebulizers is limited due to:
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- cost
- convenience - over reliance by pt |
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Describe the MOA of inhaled corticosteroids
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- depress inflammatory response and edema in the respiratory tract and diminish bronchial hyperresponsiveness.
(reduced mucous, decreased local generation of prostaglandins and leukotrienes, adrenoceptor upregulation, long-term reduced eosinophils and mast cells) |
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What is the most effective long-term control therapy for persistent asthma?
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Inhaled corticosteroids (only therapy shown to reduce risk of death from asthma)
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Response to therapy with inhaled corticosteroids should be expected in what time frame?
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- symptoms improve 1-2 weeks with max effect 4-8 wks
- FEV1 and peak exp. flow max improvement in 3-6 wks - BHR improvement in 2-3 wks with max at 1-3 mos |
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When are ICS contraindicated?
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- use caution in kids, may stall growth potential
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ADRs associated with Inhaled corticosteroids include:
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- Local: thrush, dysphonia, reflex cough, bronchospasm
- Systemic: hypothalamic-pituitary-adrenal suppression, impaired growth in kids, dermal thinning (dose dependent) |
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True or false: Low-to medium doses of ICS in kids may result in problems with bone density, subscapular cataracts, glaucoma, and significant effects on hypothalamic-pituitary-adrenal axis.
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FALSE
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Adverse effects of ICS in adults include:
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- decreased bone density
- occular effects (high lifetime exposure may increase risk for cataracts, may increase risk of glaucoma with familial hx of disease) |
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How can you reduce the potential for ADR with ICSs?
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- use a holding chamber
- rinse mouth after use - use lowest possible dose - use in combination with LABAs |
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Give some examples of inhaled corticosteroids.
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-fluticasone (flovent)
- beclomethasone (Qvar) - mometasone (asmanex) - triamcinolone (azmacort) - triamcinolone (azmacort) - budesonide (pulmicort) - fluinisolide (aerobid) - ciclesonide (new!) - alvesco |
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Name some common combinations of ICS and LABA combination medications.
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- Fluticasone/salmeterol (advair)
- budesonide/ formeterol (symbicort) |
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Name common LAB2Agonists used in tx of asthma.
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- salmeterol
- formoterol - fluticasone/salmeterol - budesonide/formeterol - arformeterol (neb) - formoterol fumarate (neb) |
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True or false: you can use LABAs alone to manage asthma.
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FALSE. they are beneficial when ADDED to inhaled corticosteroids for prevention of exacerbation
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What is the average onset of effects when administering LABAs (salmeterol)
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- 20 minutes
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Why must you use caution and always prescribe an ICS with a LABA?
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- may lose protection against methacholine, histamines, and exericise (more likely to have asthma attack).
- decreased responsiveness to SABAs (work just as well, but take longer) |
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What is the black box warning on LAB2 agonists?
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- may increase the chance of severe asthma episodes, and death when those episodes occur.
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Drug interactions with LABAs (salmeterol) include:
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- concommitant use of CYP3A4 inhibitors (ketoconazole, ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, telithromycin
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If LABAs are administered with other CYP3A4 inhibitors, what symptoms could result?
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- prolonged CTc
- palpitations - tachycardia |
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A patient presents with asthma that is not controlled by ICS alone. What is your next tx options?
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- Increase ICS (not recommneded)
- add LABA to ICS (salmeterol up to 100mcg/day, Formoterol up to 24mcg/day) |
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Name some Leukotriene Receptor Antagonists.
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- Montelukast (singulair)
- zafirlukast (accolate) - zileuton (zyflo) |
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What is the MOA of leukotriene receptor anatgonists?
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- competetively antagonizes leukotriene receptors in the brionchiolar muscle, antagonizing endogenous leukotrienes causing bronchodilation.
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How does Zileuton work?
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- inhibits 5-lipoxygenase - an enzyme necessary for leukotriene synthesis
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Leukotriene receptor antagonists are contraindicated in who?
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- OB
- elderly (caution) - pts with acute liver dz |
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ADRs associated with Leukotriene receptor antagonists are:
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- GI disturbances
- HA - Liver toxicity (Zileuton and Zafirlukast) - Increase respiratory infections in elderly (zafirlukast and montelukast) |
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What are drug interactions with Zafirlukast?
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- Warfarin (increase PTT)
- food can reduce bioavailability - take 1 hour before or 2 hrs after meals. |
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What are drug interactions with Zileuton?
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- theophylline (doubles concentration)
- warfarin (increases PTT) - Propranolol (doubles propranolol AUC) |
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A warning on leukotriene receptors that is curently being evaluated by FDA.
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Possible association between montelukast and behavior/mood changes, suicidality, and suicide.
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Identify some methylxanthines.
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Theophylline and aminophylline
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Describe the MOA for methylxanthines.
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(theophylline and aminophylline)
Appear to increase cAMP levels in bronchial smooth muscle cells by inhibiting phosphodiesterase and preventing transformation of cAMP to AMP. Increased cAMP relaxes smooth muscle and causes bronchodilation |
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When are methylxanthines indicated?
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- refractory pts
- used as monotherapy and in combination with ICS. |
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Methylxanthines are contraindicated in:
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- children <4 yrs
- cardiac disease - HTN - hepatic impairment |
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Use of methylxanthines is limited due to what?
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- very narrow therapeutic window and multiple drug-drug ineteractions.
- safer options are available. |
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What drug/drug interactions do methylxanthines have.
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- cimetidine, macrolides, quinolones, etc.
- CYP1A2 and 3A4 substrate |
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Adverse effects of methylxanthines include:
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- nausea, irritibility, insomnia, vomiting, HA
- tachyarrhythmia @20-30mcg/mL - sz, ventricular arrhythmias @ 40+mcg/mL |
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Cromolyn sodium and nedocromil are types of _____.
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mast cell stabilizers
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Describe the MOA for mast-cell stabilizers.
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- stabilize mast cells preventing the release of inflammatory mediators
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In what pts are mast cell stabilizers indicated/useful?
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- <20 yrs old with severe allergic disease and moderate asthma
- pregnancy |
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ADRs associated with mast cell stabilizers include:
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- cough
- transient bronchospasm - throat irritation - bad taste (necromil) |
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True or false: mast cell stabilizers are used during allergy season as tx for acute asthma.
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FALSE: must be utilized regularly for several weeks before effects are noted. it is NOT indicated for acute asthma
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___ is an immunomodulator used to treat persistent and severe asthma that won't respond to other therapies.
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Omalizumab
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Omalizumab has a black box warning for what?
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- anaphylaxis
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How do systemic corticosteroids help to treat asthma? (MOA)
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- decrease inflammation by suppression of migration of leukocytes and reversal of increased capillary permeability.
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What is a typical short-course of systemic corticosteroid for tx of asthma?
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- prednisolone daily (40-50mg) for 5-10 days with taper
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How to B2 agonists work to treat asthma?
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- stimulate adrenoceptors leading to rise in intracellular cAMP levels and subsequent smooth muscle relaxation and bronchodilation
- prevent activation of mast cells as minor effect - potent bronchodilator without significant B1 stimulation |
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Indications for prescribing a B2 adrenergic agonist include:
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- relief of bronchospasm during acute exacerbation
- pre-treatment for exercise induced bronchoconstriction - tx symptoms of asthma (but not underlying disease) - adjunct to corticosteroids or alone in very mild asthma |
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ADRs associated with B2 agonists include:
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- fine tremor
- tachycardia - hypokalemia in very high doses - some pts experience increased risk of exacerbation or decreased lung volume (esp if using very often) |
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What is the ONLY inhaled agent indicated for acute asthma attacks?
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Short Acting Beta Agonists.
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___ is an anticholinergic indicated for relief of acute bronchospasm.
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- Ipratropium
- Tiotropium |
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What is the treatment of choice for bronchospasm due to B-blockers?
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Anticholinergics (tiotropium, ipratropium)
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Describe the MOA for anticholinergic tx of asthma.
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- parasympathetic vagal fibers provide bronchoconstrictor tone to the smooth muscle of the airways (activated by reflex with stimulation of sensory receptors in the airway wall)
- muscarinic antagonists block receptors that respond to parasympathetic bronchoconstrictor tone. |
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Anticholinergic tx of asthma is contraindicated in ____.
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- Glaucoma
- pregnancy |
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When are systemic corticosteroids important in the tx of asthma?
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Tx of severe acute exacerbations:
- prevent progression of asthma exacerbation - reduce need for referral to ER and hospitalization - prevent early relapse after emergency tx - reduce morbidity of illness. |
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When prescribing more than ____ courses of systemic corticosteroids each year, you should re-evaluate asthma mgmt plan.
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- more than three courses/ year.
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What type of asthma tx should be prescribed to EVERY pt?
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- quick relief - SABA PRN for symptoms
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A pt is prescribed only SABAs. When woudl you consider the need for additional treatment?
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- use of SABA increasing or >2 times/week
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A pt complains that their asthma bothers them a few nights a month ... what should you prescribe?
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- rescue inhaler only, no daily medication needed
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A pt presents complaining that they have asthma symptoms about 4-5 times a month, what do you want to prescribe?
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- Preferred: low dose ICS, PRN beta-2 agonist
- OR: cromolyn or nedocromil, leukotriene modifier, or theophylline |
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A pt with a hx of asthma presents with a daily asthma exacerbation and states that they can't sleep well or take long walks without problems. They are using their rescue inhaler daily. You want to prescribe what?
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- Preferred: low-dose ICS, long-acting inhaled beta-2 agonist, AND rescue inhaler
- Med or high dose ICS or low dose ICS + leukotriene modifier or theophylline |
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A pt experiences persistent asthma problems despite attempted managment that limits physical activity. What should you prescribe?
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- SABA
- Med or high dose ICS, LABA, and if needed glucocorticosteroid |
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Identify risk factors for death from asthma.
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- previous exacerbation requiring intubation
- 2+ hospitalizations or 3+ ED visits in a year - Hospitalization or ED visit in past month - difficulty perceiving asthma severity or severity of worsening asthma - low socioeconomic status - illicit drug use - major psychosocial probs - comorbidities: CV disease, other lung probs, craziness . |
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Treatment goals of acute asthma exacerbation include:
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- correction of significant hypoxia
- rapid reversal of airflow obstruction - reduction of the likelihood of relapse of the exacerbation or future recurrence of severe airflow obstruction by intensifying therapy. |
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A pt presents with an acute asthma exacerbation with activity and with a PF of 76%of normal, what would your course of treatment be?
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-home mgmt
- prompt relief with inhaled SABA - possible short course oral corticosteroids |
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A pt presents with dyspnea and states his asthma is preventing him from normal activities. His PEF is 45% normal. You want to give ___
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- Office or ED mgmt
- Relief from frequent inhaled SABA - Oral corticosteroids, symptoms lasting 1-2 days |
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A pt presents with severe dyspnea and has a hx of asthma. His PEF is 36% of normal. You want to treat how?
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- ED visit and hospital admission.
- Partial relief from inhaled SABA - Oral corticosteroids, symptoms lasting >3d - Adjunctive therapy is helpful |
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A pt is having a severe asthma exacerbation and is unable to speak or complete a PEF test. You want to treat him with ___
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- ICU admission with possible intubation
- minimal relief from SABA - IV corticosteroids - adjunctive therapies are helpful |
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What are the diagnostic criteria for chronic bronchitis?
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- Cough most days during a period of 3+ months for 2+ consecutive years.
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What is the doagnostic criteria for emphysema?
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- abnormal, PERMANENT, enlargement of airspaes distal to the terminal bronchioles, accompanied by destruction of walls without obvious fibrosis
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Oxygen is administered to any pt in respiratory distress except ___
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COPD pts who retain CO2 - too much O2 will depress their respiratory drive
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What is the foundation of therapy for COPD
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- anticholinergic agents and beta-2 agonists. (ipratroprium +albuterol)
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Which COPD pts are indicated for inhaled steroids?
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- pts with moderate to severe reduction in airflow where bronchodilator therapy doesn't work
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____ may be indicated in COPD pts to reduce hospitalizations and provide improved resolution of symptoms in acute exacerbation.
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- Abx
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When are antibiotics used in tx of COPD?
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2 of the 3 present:
- increased dyspnea - increased sputum volume - increased sputum purulence |
