Airways Disease Flashcards
(22 cards)
A 35-old patient with IgE-mediated asthma is poorly controlled on maximal dose inhaled therapy and has required 5 courses of oral steroids in the last year.
Which of the following medications would be indicated?
A Benralizumab (Fasenra)
B Dupilumab (Dupixent)
C Mepolizumab (Nucala)
D Omalizumab (Xolair)
E Resulizumab (Cinqaero)
D Omalizumab (Xolair)
Licensed for IgE mediated asthma. The others are licensed for eosinophilic asthma with the exception of dupilumab (Dupixent) which is licensed for allergic asthma with eosinophils >0.15 and no IgE indication.
A 35-old patient with asthma which is poorly controlled on maximal dose inhaled therapy and has required 4 courses of oral steroids in the last year.
Eosinophil count 0.34
Which of the following medications should be commenced?
A Benralizumab (Fasenra)
B Mepolizumab (Nucala)
C Montelukast
D Omalizumab (Xolair)
E Theophylline
A Benralizumab (Fasenra)
Both benralizumab and mepolizumab could be offered here but benralizumab is more cost-effective.
A patient with severe asthma is commenced on Omalizumab (Xolair).
Which best describes the mechanism of action of this drug?
A Anti IL-5 monoclonal antibody which reduces circulating eosinophils
B Binds to subunit of IL-4 receptor blocking IL-4 and IL-13 signalling
C Monoclonal antibody that binds to IgE
D Monoclonal antibody targeting IL-6 receptors
E Tumor necrosis factor (TNF)-alpha inhibitor
C Monoclonal antibody that binds to IgE
Anti IL-5 monoclonal antibody which reduces circulating eosinophils describes the action of mepolizumab, resulizumab and benralizumab
Binds to subunit of IL-4 receptor blocking IL-4 and IL-13 signalling describes the action of dupilumab.
Monoclonal antibody targeting IL-6 receptors describes the action of tocilizumab and sarulimab in treatment of COVID-19.
Tumor necrosis factor (TNF)-alpha inhibitors e.g. infliximab, etanercept and adalimumab are used in autoimmune conditions.
Indication for Omalizumab (Xolair)
Severe persistent allergic IgE mediated asthma
Clinical criteria for Omalizumab (Xolair)
IgE 30-1500
Positive skin test or in vitro reactivity to a perennial aeroallergen
FEV1 <80%
Frequent day symptoms or night waking
Frequent exacerbations despite daily high dose ICS+LABA
More than 4 courses of oral steroids in a year
Mechanism of action of Mepolizumab (Nucala)
Anti IL-5 monoclonal antibody which reduces circulating eosinophils
Clinical criteria for Mepolizumab (Nucala)
Blood eosinophils >0.30 in last 12 months
Optimised asthma management
4 or more exacerbations requiring systemic steroids in last 12 months or equivalent 5mg pred per day for 6 months
Indication for Mepolizumab (Nucala)
Severe refractory eosinophilic asthma in adults
A 25 year-old presents with intermittent shortness of breath and wheeze
She has a history of eczema and hayfever.
What is the most likely diagnosis?
A Allergic asthma
B Eosinophilic asthma
C Eosinophilic granulomatosis with polyangiitis
D Exercise-induced asthma
E Intermittent laryngeal obstruction
Indication for Benralizumab (Fasenra)
Severe eosinophilic asthma inadequately controlled despite high dose maintenance ICS-LABA
Mechanism of action of Benralizumab (Fasenra)
Anti IL-5 receptor monoclonal antibody which reduces circulating eosinophils
Side effects of mAbs targeting eosinophils
Hypersensitivity reactions inc. anaphylaxis, skin reactions, fever, headache, nasal congestion, abdominal pain, back pain, eczema
How to assess response to mAbs
Adequate response is clinically meaningful reduction in severe exacerbations needed OCS (~50% fewer) or
Clinically significant reduction in maintenance OCS use while maintaining or improving asthma control
Assess yearly and if no adequate response to treatment - stop, can continue if adequate response
Mechanism of action of Dupilumab (Dupixent)
Severe asthma not controlled by high dose ICS plus another drug due to type 2 inflammation
Clinical criteria for Dupilumab (Dupixent)
Blood eosinophil count of >0.15
FeNO of >20 parts
Sputum eosinophils of 2% or more
Asthma that is clinically allergen driven
The need for maintenance oral corticosteroids
(nb. also licensed for moderate to severe atopic dermatitis)
A patient with severe asthma is commenced on Benralizumab (Fasenra).
Which best describes the mechanism of action of this drug?
A Anti IL-5 monoclonal antibody which reduces circulating eosinophils
B Binds to subunit of IL-4 receptor blocking IL-4 and IL-13 signalling
C Monoclonal antibody that binds to IgE
D Monoclonal antibody targeting IL-6 receptors
E Tumor necrosis factor (TNF)-alpha inhibitor
A Anti IL-5 monoclonal antibody which reduces circulating eosinophils. NB this is also the mechanism of action of mepolizumab and resilumumab.
Monoclonal antibody that binds to IgE describes the action of omalizumab.
Binds to subunit of IL-4 receptor blocking IL-4 and IL-13 signalling describes the action of dupilumab.
Monoclonal antibody targeting IL-6 receptors describes the action of tocilizumab and sarulimab in treatment of COVID-19.
Tumor necrosis factor (TNF)-alpha inhibitors e.g. infliximab, etanercept and adalimumab are used in autoimmune conditions.
A patient with severe asthma is commenced on dupilumab (Dupixent).
Which best describes the mechanism of action of this drug?
A Anti IL-5 monoclonal antibody which reduces circulating eosinophils
B Binds to subunit of IL-4 receptor blocking IL-4 and IL-13 signalling
C Monoclonal antibody that binds to IgE
D Monoclonal antibody targeting IL-6 receptors
E Tumor necrosis factor (TNF)-alpha inhibitor
B Binds to subunit of IL-4 receptor blocking IL-4 and IL-13 signalling
A 22-year-old with asthma complains of intermittent breathlessness. She has persistent nasal discharge and frequent bouts of sinusitis.
Eosinophils are 0.44. IgE is normal.
What is the most likely diagnosis?
A Allergic asthma
B Eosinophilic asthma
C Eosinophilic granulomatosis with polyangiitis
D Exercise-induced asthma
E Intermittent laryngeal obstruction
B Eosinophilic asthma
A 38-year-old male presents with worsening asthma not controlled on high-dose inhaled steroids. It was diagnosed aged 30 and he also has a history of rhinitis and nasal polyps.
Eosinophils are 1.25. pANCA is negative.
What is the most likely diagnosis?
A Allergic asthma
B Eosinophilic asthma
C Eosinophilic granulomatosis with polyangiitis
D Exercise-induced asthma
E Intermittent laryngeal obstruction
C Eosinophilic granulomatosis with polyangiitis
NB pANCA is only positive in 35-75% of cases. Clinical features here are typical. Blood eosinophils >10%.
A 24-year-old student presents with frequent bouts of sudden onset wheeze following a suspected chest infection a few weeks prior.
Bloods are normal.
What is the most likely diagnosis?
A Allergic asthma
B Eosinophilic asthma
C Exercise-induced asthma
D Intermittent laryngeal obstruction
E Viral-induced wheeze
D Intermittent laryngeal obstruction
A 54 year old man attends your clinic with a 6-month history of dry cough and worsening exertional dyspnoea. He is a smoker with a history of longstanding rheumatoid arthritis (RA), not currently on treatment. Pulmonary function testing demonstrates forced expiratory volume in 1 second (FEV 1) 40% predicted, forced vital capacity (FVC) 35% predicted, FEV 1:FVC ratio 75%, total lung capacity (TLC) 42% predicted, and transfer factor corrected for alveolar volume (KCO) 15% predicted.
Which of the following would be consistent with these findings?
A Caplan’s syndrome
B Pulmonary arterial hypertension
C Rheumatoid arthritis-associated interstitial lung disease (RA-ILD)
D Rheumatoid arthritis-associated pleural effusion
E Shrinking lung syndrome
C RA-ILD
The combination of restrictive spirometry with reduced lung volumes and transfer factor suggest a pulmonary parenchymal pathology. In this scenario, RA-ILD is the most likely diagnosis. ILD is the most common pulmonary manifestation of RA and may onset before joint symptoms.
Prevalence is up to 40 % with peak age 50–60 years, males > females. RA-associated lung disease may also manifest as rheumatoid nodules (solitary or multiple, can cavitate), pleural effusions (exudative, pH <7.2, glucose <1.6, LDH > 700, raised cholesterol), pneumothoraces, and rarely
bronchiectasis and bronchiolitis obliterans. RA-ILD may mimic IPF (UIP) or NSIP. Treatment with anti-infl ammatory agents (prednisone) and immunomodulators (azathioprine/cyclophosphamide) is recommended. Avoid anti-TNF agents (cause accelerated death from ILD) and methotrexate. Caplan’s syndrome, the combination of pneumoconiosis with rheumatoid factor positivity, is associated with exposure to mining dust. Shrinking lung syndrome is associated with SLE, the features being reduced lung volumes due to diaphragmatic weakness but preserved KCO. Pulmonary arterial hypertension typically manifests as an isolated reduction in TLCO/KCO.
A 53 year old woman presents with an 8-week history of cough, fever, and sweats. Her blood eosinophil count is 1.0 ×10 9 /L (normal range 0.0–0.4 × 10 9 /L), immunoglobulin E (IgE) is normal. CXR shows bilateral peripheral dense opacifi cation with an inverse pulmonary oedema appearance. Sputum eosinophil count is mildly elevated.
What is the most likely diagnosis?
A Acute eosinophilic pneumonia
B Chronic eosinophilic pneumonia
C Churg–Strauss syndrome
D Hypereosinophilic syndrome
E Loeffler’s syndrome (simple pulmonary eosinophilia)
