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PDAT4 > 36/37/38 - Asthma > Flashcards

36/37/38 - Asthma Flashcards

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1
Q

Asthma
Classification & Presentation

A

Chronic R_eactive + Obstructive_ airway disease
Characterized by:
airway INFLAMMATION** & **HYPERresponsiveness

Presentation:
Wheezing / SOB / chest Tightness
Cough
+/- Increased mucus Production

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2
Q

Asthma
DIAGNOSIS

A

Requires a combination of:
Medical History**+**Spirometry

Reduced FEV1/FVC ratio = airway obstruction

  • *INCREASE in FEV1 > 12%**
  • *AFTER BRONCHODIALATOR = Reversibility**
  • or bronchoconstriction / HYPERresponsiveness on challenge test*
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3
Q

Phenotype Asthma

A

Clinical Characteristics
based upon:
Genetic makeup / Bio Mechanisms / Environmental Exposures

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4
Q

Endotype Asthma

A

Specific Biologic/Immunologic MECHANISM
that drives the
pathophysiologic cause of Asthma presentation

Eosinophilic Endotypes
HIGH /low TH2

NON-eosinophilic Endotypes
HIGH & low TH1

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5
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-1 / IL-8 / IL-17 / TNF-a / TRL4

Source Cell Types:
TH17 cells - Macrophages - NK/NKT Cells - CD8 TCells

End Result:
↑Neutrophil release of pro-inflammatory chemokines

A
  • *low TH1**
  • *NON-eosinophylic Endotypes**
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6
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-12 / INF-y / 15-Lipooxygenase

Source Cell Types:
TH1 - Goblet Cells

End Result:
↑Neutrophil release of Pro-inflammatory chemokines

A
  • *HIGH TH1**
  • *NON-eosinophilic Endotype**
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7
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-25 / IL-33 / IL-5 / IL-13 / TSLP

Source Cell Types:
TH2 - Mast Cells

End Result:
↑Eosinophil Differentiation & Maturation
↑NO production / ↑Periostin
↑ Mast Cell Degranulation

A

LOW TH2
Eosinophilic Endotype

just different Cytokines and No B-cell Involvement

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8
Q

Which Endotype of Asthma?

Dominant Cytokines:
IL-4 / IL-5 / IL-13 / TSLP

Source Cell Types:
TH2 - B Lymphocytes - Mast Cells

End Result:
↑Eosinophil Differentiation & Maturation
↑NO production / ↑Periostin
↑ Mast Cell Degranulation

A

HIGH TH2
EOSINOPHILIC Endytype

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9
Q

Goals of Asthma Therapy

A

Reduce Impairment

  • *<** 2 Daytime Symptoms / WEEK & ↓Reliever meds
  • *<** Nightime awakenings / MONTH from asthma

Reduce RISK of future exacerbations / airflow limitation / ADR
Prevent exacerbations
↓ED Visits or Hospitilzations
↓Loss of lung functions / lung growth
↓Drug ADR

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10
Q

What questions do we ask to

ASSESS ASTHMA SEVERITY & CONTROL?

A

OVER THE PAST 2-4 WEEKS
How much is Asthma Impairing Patient’s Life?

Daytime Asthma Symptoms?

Nighttime Awekenings?

Rescue Medication use?

Lung Function?

PERCEPTION of Limitation

Validated Questionaires
ACT / ATAQ / ACQ

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11
Q

Monitoring & Follow-Up

When to RE-EVALUATE?

A

Recommend to RE-Evaluate:
Within 1 WEEK after an EXACERBATION

  • *1-3 Months after STARTING treatment**
  • full benefit may take ~3 MONTHS+*

Every 3-12 Months once stable​

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12
Q

WHO SHOULD USE CONTROLLER MEDICATION?

A

RULE OF 2

  • *Daytime Symptoms** or Reliever use
  • *>** 2 days per WEEK
  • *Nightime Awakening from Asthma**
  • *>** 2 days per MONTH
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13
Q

When would consider

STEPPING DOWN?

A

STABLE FOR 3+ MONTHS

Aims of stepping down:
Minimum effective treatment Dose
Continue encouraging controller dose

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14
Q

ASTHMA ACTION PLAN

Includes WHAT?

A

Daily Medications

List of TRIGGERS** + **ACTIONS to control

How to RECOGNIZE worsening asthma
based on SYMPTOMS or PEF (peak-flow)

How to RESPOND to worsening asthma
Bronchodilator use & when to INCREASE intnsity of treatment

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15
Q

What Medications

can WORSEN or TRIGGER Asthma?

A

ASPIRIN

NSAIDs

  • *BETA-BLOCKERS**
  • OLOLs
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16
Q

What can WORSEN or TRIGGER Asthma?​

A
  • *VIRAL** illnesses
  • *Exercise / Sport / Exertion**

ALLERGIES
mold / dust / animals / pollen / sulfides / cockroaches

  • *Exposure to Irritants**
  • *smoke** / air pollutants / perfumes

Stress / Emotions

Endocrine / Hormonal Changes
pregnancy / thyroid disorders / menses

Environmental Factors
vacuuming / open windows / weather / humidity

Medications
ASPIRIN / NSAIDS / BETA LOCKERS

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17
Q

What COMORBID CONDITIONS

may WORSEN ASTHMA?

A

Atopic Triad
Rhinitis / Sinusitis / Nasal Polypts

GERD

ALLERGIES
food or domestic / allergic bronchopulmonary Aspergillosis

Obesity / Anxiety / Stress

OSA
Obstructive sleep apnea

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18
Q

Role in Therapy:
Reliever / Rescue - Asthma Medications

Inhaled/Oral SABA = Albuterol / Levalbuterol

Inhaled SAMA = Ipratroprium Bromide

A

ALL PATIENTS NEED QUICK RELIEF MEDICATION

As NEEDED for:
Intermittent / Persistant Asthma - Step 1 +

PREVENTATIVE for:
Exercise Induced Bronchospasm = EIB

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19
Q

Albuterol / Levalbuterol

Drug Class / Onset of Action / ADR

A
  • *SAMA =** Quick Onset:
  • *MDI > DPI > Neb > oral**
  • oral is NOT preferred*

ADR:

  • *Tachycardia / Tremor / Excitement / Nervousness**
    rare: Pharyngitis / Rhinitis / Bronchospasm

Precautions:
CV Disease / Arrythmia
HyperThyroidism / Diabetes / Seizures

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20
Q

Ipratropium Bromide
MDI / Neb

Drug Class / Indication / ADR

A

SAMA
NOT appropriate rescue medication ALONE in ASTHMA
used in COMBO + SABA (albuterol) in patients not responding in ER/hospital
less effective bronchodialator than SABA, NOT anti-inflammatory

ADR:
Well tolerated –> HA / Cough / Eye irritation (neb)

Precautions:
AntiCholinergic Precautions: Glaucoma / BPH

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21
Q

What is the:
PREFERRED INITIAL & BACKBONE CONTROLLER MED
for
PERSISTANT ASTHMA
Step 2+

A
  • *INHALED CORTICOSTEROIDS**
  • *-SONE / -NIDE**

Most Effective MONOTHERAPY
only therapy shown to reduce risk of DEATH from ASTHMA

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22
Q

What is the PREFERRED
INHALED CORTICOSTEROID (ICS)
in PREGNANCY?

A

BUDESONIDE
Pulmicort Flexhaler DPI
Pulmicort Respules Nebulizer (only Neb ICS available)

  • *Ok to add LABA**
  • if not well controlled*
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23
Q
  • *Inhaled Corticosteroids**
  • *-SONE / -NIDE**

BENEFITS / USES

Study These Flashcards
A
  • only therapy shown to* REDUCE RISK OF DEATH from ASTHMA
  • *MOST effective MONOTHERAPY - Controller**
  • *Symptom Improvement**
  • *starts @1-2 Days** –> MAX in 4-8 Weeks
  • *BHR/Inflammation Improvement**
  • *starts @1-2 days** –> progressive up to 1 year

LUNG FUNCTION IMPROVEMENT
begins in 3-6 weeks

  • does NOT reduce AIRWAY REMODELING
  • -> discontinuation can cause HIGH RISK for EXACERBATION*
24
Q
  • *Inhaled Corticosteroids
  • SONE / -NIDE**

ADR / DI

Study These Flashcards
A

Local: Thrush / Dysphonia / Cough / reflex bronchospasm

Rare: systemic effects / stunted growth / bruising / cataracts

CYP3A4 INHIBITORS
–> increase SYSTEMIC exposure
DI Risk:
Fluticasone-Budesonide >
Ciclesonide,Flunisolide,Mometasone > Beclomethasone

  • Reduce risk of LOCAL side effects*
  • *RINSE MOUTH / SPACER**
  • Reduce ALL ADRs*
  • *Step down therapy / lowest effective dose**
25
**Which ICS Drugs have the** **HIGHEST DRUG INTERACTION RISK?**
**Strong CYP3A4 Inhibitors** **_Fluticasone & Budesonide_** \>\>\> **Ciclesonide / FLunisolide / Mometasome** \>\> **Beclomethasone** *least drug ineracton risk* | (Ritonavir / Ketoconazole / Protease Inhibitors)
26
**LABA = -TEROL** **Uses in Asthma Therapy**
* *Preferred ADJUNCT to ICS therapy = Step 3+** * superior to LTRA / LAMA / cromolyn / theo when ADDED to ICS* * **_NEVER use LABA ALONE in ASTHMA_*** * *ALWAYS COMBINED WITH ICS** * not an ALTERNATIVE to ALBUTEROL/ICS* * *Formoterol = FASTEST onset of Action (Minutes)** * *Vilanterol = *slowest (hours)*** --\> but **long duration (22hours)**
27
**What Asthma drug has a _BLACK BOX WARNING_**?
* *_LABA**_ _**= -terol_** * *ON ITS OWN** --\> **INCREASE in ASTHMA RELATED DEATHS** ## Footnote **LABA should ALWAYS be in COMBO with ICS**
28
**_LAMA = -IUMs_** ## Footnote **Asthma Therapy / ADR**
**_ADD-ON_** to **Med/High dose ICS + LABA** = **Step 4 or 5** Cause **bronchodilation** + ***reduce mucus secretion*** by: * inhibiting* **muscarinic cholinergic receptors** * *4-8 Week benefit** ADR: **Dry Mouth / Metallic Taste / AUR** Caution: **NAG / Bladder Obstruction**
29
**Which Phenotypic Guided Asthma Therapy?** **Can be administered AT HOME?**
* *_DUPILUMAB = Dupixent_** * *IL-4R / IL-13** Target * *SUBQ every other week** **\>12 y/o** Requires: **Blood EOS _\>_ 300 cells/uL**
30
**Which Phenotypic Guided Asthma Therapy?** **Is indicated for** **_ALLERGIES**_ & _**HIGH IgE Levels?_**
* *_OMALIZUMAB_** = **Xolair** * *IgE target** **// \>6 y/o** **_IgE has to be 30-700 IU/mL_** & **_ALLERGIES_** * *SUBQ every 2-4 weeks** * *DOSED BY WEIGHT & BASELINE IgE**
31
**Which Phenotypic Guided Asthma Therapy?** **ONLY IV DRUG**
* *_RESLIZUMAB_** = Cinqair * *IL-5** Also **_18 y/o+_** (*others are \>12yo)* Requires **_BLOOD EOS \> 400 cells/uL_**
32
**Which Phenotypic Guided Asthma Therapy?** **Biomarker targets are** **_IL-5_** & **what are their INDICATIONS?**
_**MEPOLIZUMAB** = Nucala_ 12yo // Blood EOS **\>150** (90 days) // **\>300** (1year) * *_RESLIZUMAB_** _= Cinqair_ * *\> 18 y/o** // **IV** // **\>400 EOS** * *_BENRALIZUMAB_** _= Fasenra_ * *IL-5R** // 12yo // **\>300**
33
**Which Phenotypic Guided Asthma Therapy?** **_Anti-TSLP Antibody_** good for **BOTH HIGH & LOW TH2**
**_TEZEPULUMAB_** *not yet FDA approved*
34
**Phenotypic Guided Asthma Therapy** **ADR / Requirements**
ADR: * *Nasopharyngitis / HA / Back Pain / Fatigue+Myalgias** * *INJECTION SITE REACTIONS** **Anaphylaxis / Hypersensitivity** VV _ALL PATIENTS MUST HAVE_ **_EPINEPHRINE_** * *All ADMIN in healthcare setting**: * EXCEPT for DUPILUMAB*
35
**Leukotriene Receptor Antagonist = LTRA** **Asthma Uses / ADR / DI**
**Montelukast / Zariflukast / Zileuton ORAL** * **Less effective than ICS*** & ***LABA + ICS*** * *Safer**, but ***no more effective than adding Theophylline*** **Zileuton = Monitor LFTs**
36
**Oral Corticosteroids** **Asthma Uses**
* *_Prednisolone_** \> **Prednisone** * *FOR ORAL SOLUTION, TASTE** * *_Add-On therapy in STEP 6_** * low daily dose* **_Asthma EXACERBATIONS_** Short course = burst
37
**Methylxanthines** **Asthma Uses / ADR**
**Theophylline = IV/PO** ---- **Aminophylline = IV**only * *Only modest Asthma Effects** * not for use in SEVERE asthma* **_NARROW THERAPEUTIC WINDOW_** life-threatening side effects * *_DRUG INERACTIONS_** * *CYP1A2** & **CYP3A4**
38
**Mast Cell Stabilizer = Cromolyn Sodium** **Asthma Use**
**Inhibits early/late Asthma Response**&**EIB** (exercise induced) *not very effective compared to other agents* * *20mg QID** --\> 4 weeks * *2-4 weeks for effectiveness** **_NEEDS DAILY CLEANING_** hard to use **NEBULIZER SOLUTION**
39
**Macrolide Antibiotics** **_ASTHMA USE?_**
**Azithromycin** = AZISAST trial Beneficial for: **_NON-EOSINOPHILIC ASTHMA_** **Blood Eos \< 200 cell/uL**
40
**Vitamin D** **Asthma Use?**
*low VIT D --\>* INCREASED risk of **Asthma Exacerbations** Vitamin D: ***_Inhibits production of IL-17_*** * good for:* * *_NON-EOSINOPHILIC ASTHMA_**
41
**Bronchial Themoplasty** **Asthma Use?**
**_Add-on Therapy_** for select patients with **unconctrolled ASTHMA** **Thermal Energy (150\*F)** * _Reduces:_* * *Bronchial airway smooth muscle MASS** // **Airway Narrowing**
42
**Which ICS is preferred in CHILDREN?**
**_BUDESONIDE_** because it is the **NLY ICS available via NEBULIZER**
43
**When to consider** **REFERRAL to ASTHMA SPECIALIST?**
**_2+ Exacerbations in 1 Year_** that was **TREATED with SHORT COURSE STEROIDS** **_ICU admission**_ or _**Intubation_** Unresponsive to Therapy **_Uncontrolled on STEP 4+_** or **_STEP 3+ for Children_** **Atypical Presentation / difficult diagnosis** **_Phenotypic Guided Therapy_** **Presence of SEVERAL Comorbidities**
44
**SINGLE INHALER THERAPY**?
**_FORMOTEROL**_ + _**ICS_** Used as: **_Maintenance_** **AND** **_RELIEVER_** * reduces EXACERBATIONS* * *cheaper / mixed results** * limited evidence*
45
**Which DOSAGE FORM?** Highly dependent on: **_TIMING of ACTUATION & BREATH_** **Hand-Breath Coordination** * **_SLOW &_* _DEEP BREATH_** * tilt head back to open up airways*
* *_MDI_** * *Metered Dose Inhaler** If coordination is bad: **Use DPI** or **Breath-Activated MDI** or **SPACER** **_MDI + Spacer_** has **EQUAL EFFICACY** to **NEBULIZER**
46
**Which DOSAGE FORM?** Has an **Activation Step** (differs for each one) * *_Breath Activated / Actuated_** * less dependent on hand-breath coordination* **_DEEP / FORCEFUL BREATH_** requires sufficient **inspiratory force**
* *_DPI_** * *DRY POWDER INHALER** ***can NOT use spacer or holding chamber*** Requires: **clean with DRY cloth** when dirty
47
**Spacers & Holding Chambers** **For use with WHICH INHALER?** **Recommended for WHO?**
ONLY (*not breath actuated MDI nor DPI)* * *_MDI_** = **METERED DOSE INHALER** * decreases the need for:* * *Hand-Breath Coordination** Recommended for: * *Young Children \<4y/o + MASK** * **poor MDI technique*** * *Poor Response to SABA MDI** should be cleaned with: **soap + water**
48
**Asthma Exacerbations** **How do we GRADE them?**
_Mild-Moderate_ **Talks in PHRASES** / Prefers **SITTING/LAYING** **RESPIRATORY RATE \< 30bpm PULSE 100-120** **O2 SAT** **PEF \>50%** _SEVERE_ _LIFE THREATENING_
49
**RISK FACTORS** for **_Asthma Exacerbations_** & **Death**
* Uncontrolled Asthma Symptoms* * *_OVER-USE of SABA_** (**\>1 /month**) **_*Inadequate* ICS Use_** **_Low FEV_** (**\<60% predicted** **Psychiatric Disease // Trigger Exposure** **Pregnancy // Uncontrolled Comorbidities** allergies / obesity / GERD **_EOSINOPHILIA**_ or _**Elevated IgE_** blood / sputum **_\>1 Exacerbation in past YEAR_**
50
**Outpatient Management of EXACERBATIONS** **Early +/- Mild Symptoms** **Reduction in PEF/FEV (60-80%)**
_INCREASE_ **FREQUENCY** or **# of ALBUTEROL PUFFS** or **NEBULIZER TREATMENT** or **ADD SPACER** *if MDI*
51
**Outpatient Managment of Exacerbations** **Late / Severe Symptoms** **Reduction in PEF/FEV \<60%**
* *_SYSTEMIC STEROIDS_** * *Prednisone 40-60mg PO 3-7 Days** Continue rescue / maintanence meds
52
**What Dosage forms are considered** * *DPI's** * *Dry Powdered Inhalers** * *Deep & Forceful Breath** * less coordination*
**DISKUS** * *TWIST / FLEX / TURBO / NEO** - **_HALERS_** * EXCEPT for REDIHALER = BREATH ACTIVATED MDI* **Ellipta / Respiclick**
53
**Which drug is considered a** **BREATH ACTIVATED MDI?**
* *_REDIHALE_****_R_** * *Beclamethasone = ICS** ## Footnote *easier to use than MDI*
54
**Which drug types can cause / should be cautioned with:** **BPH / Bladder Neck Obstruction?**
**MUSCARINICS** **SAMA / LAMA** Ipratropium / -iums
55
**Which Drugs should we be cautioned with** **GLAUCOMA ?**
* *_LAMA**_ / _**SAMA_** - iums **_ICS_** / **Oral Corticosteroids**

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