Asthma Flashcards
1
Q
How is asthma categorized?
A
Asthma is categorized by a predisposition to chronic airway inflammation and bronchoconstriction (narrow airways)
2
Q
What is the mechanism of the classic symptoms of asthma?
A
The inflammation and bronchoconstriction cause airflow obstruction, which results in expiratory airflow limitation (difficulty with exhalation). This results in recurrent episodes of wheezing, breathlessness, chest tightness and coughing, which as the classic symptoms of asthma
3
Q
What is the most common complication of asthma?
A
The most common complication is exacerbations, which can range from mild to severe, in some cases, can be fatal
4
Q
What are the different factors that can contribute to disease severity?
A
A detailed history and physical examination can help define the type, along with triggers, environmental factors and comorbid conditions that can contribute to disease severity
5
Q
With most types of asthma, what can contribute to the disease process?
A
Most types of asthma have activation of inflammatory mediators and an increase in inflammatory cells contributing to the disease process
6
Q
What types of asthma can required specialized treatments?
A
Some patients have a genetic predisposition to the development of severe allergic asthma or severe eosinophilic asthma
7
Q
How is asthma diagnosed?
A
An asthma diagnosis is confirmed with spirometry and pulmonary function tests. These should be measured at the patient’s baseline and after use of a short-acting bronchodilator to test for reversibility
8
Q
What is FEV1?
A
How much air can be forcefully exhaled in one second
9
Q
What is FVC?
A
After taking a deep breath, the maximum volume of air that is exhaled (how much air is exhaled)
10
Q
What is FEV1/FVC?
A
The percentage of total air capacity (“vital capacity”) that can be forcefully exhaled in one second (the speed of the exhale)
11
Q
What are other tests that may be involved in diagnosing asthma?
A
Fractional exhaled nitric oxide (FeNO) and the peak expiratory flow rate (PEFR)
12
Q
What does FeNO measure?
A
FeNO measures nitric oxide in exhaled breath and can indicate the level of airway inflammation. It can be used as an additional test to diagnose asthma or for ongoing monitoring in difficult cases
13
Q
How is PEFR measured?
A
PEFR is measured using a peak flow meter. This is typically used for monitoring control as part of the asthma action plan, but it can be used at initial diagnosis to test for variability in expiratory airflow limitation.
14
Q
What are some common triggers of asthma attacks?
A
Genetics, pollution, cigarettes, cold air/changes in weather, pets, dust, pollen, cockroaches, perfume, cosmetics and drugs (e.g. aspirin, NSAIDs, non-selective beta-blockers)
15
Q
What are some common comorbid conditions that can trigger an attack?
A
Infections (colds and viruses), allergic rhinitis, GERD, obesity, obstructive sleep apnea, anxiety, stress and depression
16
Q
What guides initial treatment of asthma?
A
Classification of asthma severity guides the intensity of initial treatment
17
Q
What are key components that are assessed at diagnosis and at each follow up visit?
A
Daytime symptoms, nighttime awakenings, frequency of SAVA rescue inhaler use and activity limitations, along with lung function and exacerbation frequency
18
Q
What is the classification of intermittent, step 1 severity?
A
- Daytime symptoms: < 2 days/week
- Nighttime awakenings: <2x/month
- SABA rescue inhaler use: <2 days/week
- Activity limitations: None
- FEV1 (% predicted): > 80%
- FEV1/FVC: Normal
- Exacerbations requiring oral systemic steroids: 0-1/year
19
Q
What is the classification of mild, step 2 severity?
A
- Daytime symptoms: > 2 days/week but not daily
- Nighttime awakenings: 3-4x/month
- SABA rescue inhaler use: >2 days/week, but not daily or >1x/day
- Activity limitations: Minor limitation
- FEV1 (% predicted): > 80%
- FEV1/FVC: Normal
- Exacerbations requiring oral systemic steroids: > 2/year
20
Q
What is the classification of moderate, step 3 severity?
A
- Daytime symptoms: Daily
- Nighttime awakenings: > 1x/week but not nightly
- SABA rescue inhaler use: Daily
- Activity limitations: Some limitation
- FEV1 (% predicted): 60-80%
- FEV1/FVC: Reduced 5%
- Exacerbations requiring oral systemic steroids: > 2/year
21
Q
What is the classification of severe, step 4/5 severity?
A
- Daytime symptoms: Throughout the day
- Nighttime awakenings: Often (7x/week)
- SABA rescue inhaler use: Several times per day
- Activity limitations: Extremely limited
- FEV1 (% predicted): < 60%
- FEV1/FVC: Reduced 5%
- Exacerbations requiring oral systemic steroids: > 2/year
22
Q
What is the goals of therapy of long-term asthma management?
A
Long-term asthma management should focus on reducing impairment (e.g. symptoms, frequency of rescue inhaler use, limitations to normal activity) and reducing risk (exacerbations, hospitalizations and medication adverse events)
23
Q
What are the two major guidelines used for treating asthma?
A
NHLBI’s Expert Panel Report (EPR) and the Global Initiative for Asthma (GINA)
24
Q
What is the general approach to treating asthma?
A
1) Select treatment according to the initial assessment of asthma severity
2) Follow up in 2-6 weeks
3) Follow up visits can decrease to 1-6 months once control is gained and to every three months if a step down in treatment is planned
25
What should be assessed in follow-up visits?
- Assess adherence to medications
- Perform medication counseling (confirm appropriate inhaler technique and understanding of maintenance versus rescue treatment
- Assess control of risk factors, triggers and comorbid conditions
- Review the asthma action plan
- Address patient concerns
- Assess asthma control/severity and step up, maintain or step down treatment. Do not step up therapy until the items above have been addressed; there might be other factors contributing to poor asthma control and increasing doses of medications and/or adding other drugs can increase side effects without providing additional benefit
26
When is asthma considered well-controlled?
Symptoms/use of SABA rescue inhaler < 2 days/week, nighttime awakenings < 2 times/month, no limitations to normal activity
27
When is asthma considered not well-controlled?
Symptoms/used of SABA rescue inhaler > 2 days/week, nighttime awakenings 1-3 times /week, some limitations to normal activity
28
When is asthma considered very poorly controlled?
Symptoms/use of SABA rescue inhaler several times daily, nighttime awakenings > 4 days/week, normal activity extremely limited
29
What specific exposure should be limited in patients with asthma?
Patients with asthma should avoid exposure to tobacco smoke and those who smoke should quit, or be strongly encouraged to quit at each healthcare visit
30
What should not be avoided in patients with asthma?
Physical activity should not be avoided, even in those with exercise-induced bronchospasm
31
Which vaccinations are recommended for patients with asthma?
An annual influenza vaccine is recommended in all patients with asthma > 6 months of age. Patients age 2-64 years should receive one dose of the pneumococcal polysaccharide vaccines (PPSV23, Pneumovax 23)
32
When should sensitivity be assessed?
Any patient with persistent asthma and a clear connection of symptoms with exposure to an allergen should have skin or in vitro testing to assess sensitivity. Treatment with subcutaneous allergen immunotherapy should be used, if indicated, based on the test results
33
What are the different formulations that asthma drugs come in?
Asthma drugs come in oral, inhaled and injectable formulations
34
What is the preferred delivery vehicle for asthma drugs?
Inhaled forms deliver drugs directly into the lungs, have reduced toxicity and are the preferred delivery vehicle
35
What are drugs used to treat asthma long-term classified as?
Drugs used to treat asthma long-term are classified as relievers (rescue inhalers) or controllers (maintenance drugs)
36
What can be used to treat acute symptoms?
Relievers, or rescue inhalers, rapidly open airways within minutes of inhalation to treat acute symptoms
37
What does frequent use of SABA rescue inhalers indicate?
Frequent use of a SABA rescue inhaler (> 2 days per week) indicates worsening asthma control and a need to reassess, and possibly step up, treatment
38
When is worsening asthma control indicated when ICS + formoterol is used as the rescue inhaler?
If an ICS + formoterol is used as the rescue inhaler, worsening asthma control is indicated by the frequency of symptoms (e.g. symptoms > 2 days per week or > 1 nighttime awakenings per week)
39
What is another indication for rescue inhalers other than asthma?
Exercise-induced bronchospasm
40
What are controllers or maintenance inhalers used for in asthma?
Controllers, or maintenance inhalers, are taken on a daily basis to reduce inflammation and maintain asthma control
41
What is the mainstay treatment of asthma?
Inhaled corticosteroids
42
What are examples of relievers for asthma?
Inhaled low dose ICS + formoterol, inhaled short-acting beta-2 agonists (SABAs), systemic steroids, inhaled epinephrine, inhaled short-acting muscarinic antagonists (SAMAs)
43
What are some notes about inhaled low dose ICS + formoterol?
- Used intermittently (as needed) for acute asthma symptoms
- Formoterol is a long-acting beta-2 agonist (LABA) with fast onset; this combination has proven to reduce exacerbations compare to SABA alone
- Max total daily dose of formoterol is 72 mcg
- If ICS-formoterol is also being used as the maintenance drug, the total combined formoterol dose from reliever and controller therapy should not exceed 72 mcg (called maintenance and reliever therapy)
44
What are some notes about inhaled short-acting beta-2 agonists (SABAs)?
- Used intermittently (as needed) for acute asthma symptoms
| - Quickly reverse bronchoconstriction
45
What are some notes about systemic steroids?
- Injections: used during exacerbations
- Oral: used during exacerbations for severe asthma that is difficult to control with other drug combinations
- Use should be limited as much as possible due to risk of adverse effects
46
What are some notes about inhaled epinephrine?
- Available OTC; can be used for acute treatment of mild symptoms in intermittent asthma only
- Not include in asthma guidelines
47
What are some notes about inhaled short-acting muscarinic antagonists?
Can be used in combination with a SABA during exacerbations
48
What are some examples of controllers for asthma?
Inhaled corticosteroids, inhaled long-acting beta-2 agonists, oral leukotriene receptor antagonists, theophylline, inhaled long-acting muscarinic antagonists, injectable monocloncal antibodies
49
What are some notes about inhaled corticosteroids?
First-line for all patients with persistent asthma; the most effective anti-inflammatory drugs
50
What are some notes about inhaled long-acting beta-2 agonists?
- Used in combination with ICS (should never be used alone due to increased risk of serious adverse outcomes)
- Preferred add-on agents to ICS
51
What are some notes about oral leukotriene receptor antagonists?
- Alternative option to LAB in combination with ICS; can also be added to ICS/LABA treatment
- Most commonly used in children
52
What are some notes about theophylline?
Least desirable option for add-on treatment due to significant adverse effects, drug interactions and the need to monitor serum drug concentrations
53
What are some notes about inhaled long-acting muscarinic antagonists?
Can be used as add-on treatment in patients with a history of exacerbations despite ICS/LABA treatment
54
What are some notes about injectable monoclonal antibodies?
- Add-on treatment in persistent severe asthma of a specific type
- Omalizumab: for severe allergic asthma
- Mepolizumab, reslizumab, benralizumab and dupilumab: for severe eosinophilic asthma
55
What is the recommended medications for step 1 of the algorithm?
As needed low-dose ICS formoterol or SABA + low-dose ICS taken with SABA
56
What is the recommended medications for step 2 of the algorithm?
As-needed low-dose ICS-formoterol or SABA + daily low-dose ICS
57
What is the recommended medications for step 3 of the algorithm?
Low-dose ICS-formoterol + low-dose ICS-formoterol or SABA + low-dose ICS-LABA
58
What is the recommended medications for step 4 of the algorithm?
Low-dose ICS-formoterol + medium-dose ICS-formoterol or SABA + medium-dose ICS-LABA
59
What is the recommended medications for step 5 of the algorithm?
Low-dose ICS-formoterol + high-dose ICS-formoterol or SABA + high-dose ICS-LABA
60
What is the recommendation during a follow-up visit if asthma is well-controlled?
Maintain current step (if controlled for at least 3 months, may step down treatment)
61
What is the recommendation during a follow-up visit if asthma is not well-controlled?
Sep up 1 step
62
What is the recommendation during a follow-up visit if asthma is very poorly controlled?
Step up 1-2 steps (consider a short course of oral steroid)
63
What is the MOA of beta-2 agonists?
These medications bind to beta-2 receptors, causing relaxation of bronchial smooth muscle, which leads to bronchodilation
64
When are SABAs used?
SABAs are used as-needed (rescue therapy) for acute asthma symptoms. SABAs can still be considered for use with an ICS for patients with an ICS for patients in Step 1 and as a rescue option in later steps of therapy. They can also be used for other reversibly airway diseases, such as cold, allergies and bronchitis
65
When are LABAs used?
LABAs are used as part of maintenance therapy beginning in Step 3 of treatment and only in combination with an ICS. A LABA should be added to medium-dose ICS before increasing to high-dose ICS, as this leads to more rapid improvement in symptoms, lung function and a reduction in exacerbations
66
What are some examples of SABAs?
Albuterol, Levalbuterol, Racepinephrine, Primatene
67
What are some warnings of SABAs?
Caution in CVD, glaucoma, hyperthyroidism, seizures, diabetes
68
What are some side effects of SABAs?
Nervousness, tremor, tachycardia, palpitations, cough, hyperglycemia, decreased K
69
What are some notes about SABAs?
- MDIs (HFA products): shake well before use
- Levalbuterol contains R-isomer of albuterol
- Epinephrine inhaler: FDA-approved for mild symptoms in intermittent asthma only
- Most albuterol inhalers contain 200 inhalations/canister; the exception is Ventolin HFA which is available as both a 200 inhalation/canister and 60 inhalations/canister
- EIB: use 2 inhalations 5 minutes prior to exercise
70
What is an example of a LABA?
Salmeterol
71
What are the boxed warnings of Salmeterol?
Increased risk of asthma-related deaths; should only be used in asthma patients who are currently receiving but are not adequately controlled on a long-term asthma control medication (an inhaled corticosteroid)
72
What are some notes about Salmeterol?
Maintenance inhaler only; not for acute bronchospasm
73
What is the MOA of corticosteroids?
Corticosteroids inhibit the inflammatory response. They block the late-phase reaction to allergens, reduce airway responsiveness and are potent and effective anti-inflammatory medications
74
How are ICSs helpful in the treatment of asthma?
ICSs reduce symptoms, increase lung function, improve quality of life and reduce the risk of exacerbations
75
When are inhaled corticosteroids used in the treatment of asthma?
They are used as needed in combination with formoterol or a SABA as a rescue treatment for acute symptoms, and individually or in combination with a LABA for maintenance/controller treatment
76
What are some examples of ICSs?
Beclomethasone (QVAR RediHaler), Budesonide (Pulmicort), Fluticasone (Flovent, Arnuity) + salmeterol (Advair) + vilanterol (Breo Ellipta), Mometasone (Asmanex) + formoterol (Dulera), Ciclesonide (Alvesco)
77
What are some contraindications of ICSs?
Primary treatment of status asthmaticus or acute episodes of asthma
78
What are some warnings of ICSs?
High doses for prolonged periods of time can cause adrenal suppression, increases risk of fractures, growth retardation (in children) and immunosuppression
79
What are some side effects of ICS?
Dysphonia (difficulty speaking), oral candidiasis (thrush), cough, headache, hoarseness, URTIs, hyperglycemia
80
What are some monitoring parameters of ICSs?
Use of SABA/rescue inhaler, symptom frequency, peak flow; growth (children/adolescents), s/sx of hypothalamic-pituitary-adrenal axis suppression/adrenal insufficiency, s/sx of thrush; bone mineral density
81
What is a note about ICSs?
Rinse mouth with water and spit out after each use to prevent thrush; can use a spacer device with an MDI to decrease risk
82
What are some notes about Alvesco?
MDI that does not need to be shaken before use
83
What are some notes about Budesonide?
Only ICS available as a nebulized solution; used commonly in young children
84
What are some notes about Pulmicort Respules?
Only use with a jet nebulizer connected to an air compressor; do not use an ultrasonic nebulizer
85
What are some notes about QVAR RediHaler?
Breath-activated aerosol with characteristics of a DPI and MDI; do not shake or use with a spacer; does not need priming or activation
86
What are some notes about ArmonAir and AirDuo Digihalers?
Contain a built-in electronic module that detects, records and stores data (detects when the inhaler is used and measures inspiratory flow)
87
What is a low daily dose of Beclomethasone?
100-200 mcg
88
What is a medium daily dose of Beclomethasone?
> 200-400 mcg
89
What is a high daily dose of Beclomethasone?
> 400 mcg
90
What is a low daily dose of Budesonide?
200-400 mcg
91
What is a medium daily dose of Budesonide?
> 400-800 mcg
92
What is a high daily dose of Budesonide?
> 800 mcg
93
What is a low daily dose of Ciclesonide?
80-160 mcg
94
What is a medium daily dose of ciclesonide?
> 160-320 mcg
95
What is a high daily dose of Ciclesonide?
> 320 mcg
96
What is a low daily dose of Fluticasone?
- MDI and DPI: 100-250 mcg
97
What is a medium daily dose of Fluticasone?
> 250-500 mcg
98
What is a high daily dose of Fluticasone?
> 500 mcg
99
What is a low daily dose of Mometasone?
- MDI: 200-400 mcg
| - DPI: 200 mcg
100
What is a medium daily dose of Mometasone?
- MDI: 200-400 mcg
| - DPI: 200 mcg
101
What is a high daily dose of Mometasone?
- MDI: > 400 mcg
| - DPI: 400 mcg
102
What combinations of inhalers are preferred for asthma and what combinations are preferred for COPD?
ICS and ICS/LABA combinations are preferred for asthma, whereas LABA, LAMA or LAMA/LABA combinations are preferred for COPD
103
What are some key features of MDIs?
- HFAs, , Respimat or no suffix can be brand name identifiers
- Aerosolized liquid is the dose delivery
- Some use of a propellant
- Administration is a slow, deep inhalation while pressing the canister (hand-breath coordination)
- Spacers can be used and helpful in patients incapable of hand-breath coordination and decreases risk of thrush (with ICS)
- Shaking prior to use is required for all products except QVAR RediHaler, Alvesco and Respimat products
- Priming is required before first use and if not used for a certain period of time
104
What are some key features of DPIs?
- Brand name identifiers include Diskus, Ellipta, Prescair, Hanfihaler, Neohaler, Respiclick, Flexhaler
- Dose delivery is fine powder
- No propellant
- Administration is quick, forceful inhalation (breath activated dose delivery; no need to press anything)
- Spacer cannot be used
- Do not shake
- Priming is not needed except for Flexhaler (prior to first use)
105
What is the MOA of leukotriene receptor antagonists (LTRAs)?
Leukotriene receptor antagonists (LTRAs) inhibit leukotriene mediators of airway inflammation which reduces airway edema, constriction and inflammation
106
What is the MOA of the different LTRAs?
Montelukast inhibits leukotriene D4 (LTD4), while zafirlukast inhibits both LTD4 and LTE4. Zileuton, a 5-lipoxygenase inhibitor, inhibits leukotriene formation
107
What are the different examples of leukotriene modifying agents?
Montelukast, Zafirlukast, Zileuton
108
What is a boxed warning of Montelukast?
Neuropsychiatric events (e.g. serious behavior and mood-related changes, including suicidal thoughts or actions)
109
What is a contraindication of Zafirlukast and zileuton?
Hepatic impairment
110
What are some warnings about leukotriene receptor antagonists?
- Neuropsychiatric events; monitor for signs of aggressive behavior, hostility, agitation, hallucinations, depression, suicidal thinking
- Systemic eosinophilia, sometimes presenting with features of vasculitis consistent with Churg-Strauss syndrome (rare)
111
What are some side effects of leukotriene receptor antagonists?
Headache, dizziness, abdominal pain, increased LFTs, URTIs
112
What are some monitoring parameters of leukotriene receptor antagonists?
LFTs (zafirlukast and zileuton), mood or behavior changes (montelukast)
113
What are some notes about Montelukast granules?
Can be administered directly in the mouth; dissolved in a small amount (5 mL) of breast milk or formula or mixed with a spoonful of applesauce, carrots, rice or ice cream (do not mix with anything else); use within 15 minutes of opening the packet
114
What are some notes about Zafirlukast?
Protect from moisture and light; dispense in original container
115
What is a drug interaction of Montelukast?
Montelukast is a minor substrate of CYP3A4 and 2C8/9 and a weak inhibitor of CYP2C8/9
*Gemfibrozil can increase levels of montelukast and lumacaftor can decrease levels of montelukast
116
What are some drug interactions with Zafirlukast?
Zafirlukast is a major substrate of CYP2C9. It inhibits CYP2C9 (moderate) and CYP2C8 (weak)
* Zafirlukast can increase levels of theophylline and CYP2C9 substrates (e.g. warfarin)
* Erythromycin and theophylline decrease zafirlukast levels
117
What is a drug interaction of Zileuton?
Zileuton is a minor substrate of CYP1A2, 2C9 and 3A4 and a weak inhibitor of CYP1A2. It can increase levels of propranolol, theophylline and warfarin
118
What is the MOA of theophylline?
Theophylline blocks phosphodiesterase, causing an increase in cyclic adenosine monophosphate (cAMP) and release of epinephrine from adrenal medulla cells which results in bronchodilation
119
Why is the use of theophylline limited?
Use of theophylline is limited by decrease effectiveness, drug interactions and adverse effects. It can cause diuresis, CNS and cardiac stimulation and gastric acid secretion
120
What are some warnings associated with Theophylline?
Can exacerbate cardiovascular arrhythmias, peptic ulcer disease and seizure disorders
121
What are some side effects associated theophylline?
Nausea, vomiting, headache, insomnia, increased HR, tremor, nervousness
*Toxicity: persistent vomiting, arrhythmias, seizures
122
What are monitoring parameters of Theophylline?
Theophylline levels, HR, CNS effects (insomnia, irritability), use of rescue inhaler
123
What are some notes about Theophylline?
- Aminophylline contains 2:1 theophylline and ethylenediamine
- To convert aminophylline to theophylline, multiply by 0.8*; to convert theophylline to aminophylline, divide by 0.8
124
Give a brief description of Theophylline kinetics?
Theophylline has saturable kinetics (first-order kinetics, followed by zero-order kinetics). In the higher end of the therapeutic range, small increase in dose can result in a large increase in theophylline concentration. Theophylline is a substrate of CYP1A2 (major) and CYP3A4 and 2E1 (minor)
125
What are some examples of CYP1A2 inhibitors that increase theophylline levels?
Cimetidine, Ciprofloxacin, Fluvoxamine, Propranolol and Zileuton
126
What are some examples of CYP3A4 inhibitors that increase theophylline levels?
Clarithromycin and Erythromycin
127
What are some examples of other drugs that increase theophylline levels?
Zafirlukast, alcohol, allopurinol, disulfiram, estrogen-containing oral contraceptives, methotrexate, pentoxifylline, propafenone and verapamil
128
What are some examples of drugs that can decrease theophylline levels?
Carbamazepine, fosphenytoin, phenobarbital, phenytoin, primidone, rifampin, ritonavir, levothyroxine, St. John's Wort and tobacco/marijuana smoking
129
What medications can theophylline cause a decrease of levels?
Lithium and Zafirlukast
130
What are some conditions/foods that increase theophylline levels?
CHF, cirrhosis or liver disease, acute pulmonary edema, cor pulmonale, fever, hypothyroidism, shock and high carb/low protein diet
131
What are some conditions/foods that can decrease theophylline levels?
Low carb/high-protein diet, daily consumption of charbroiled beef, cystic fibrosis and hyperthyroidism
132
What is the MOA of anticholinergics?
Anticholinergics inhibit muscarinic cholinergic receptors and reduce the intrinsic vagal tone of the airway, leading to bronchodilation
*Short-acting anticholinergics are sometimes used in combination with SABAs in hospitalized patients experiencing an acute exacerbation
133
What is a long-acting anticholinergic that is FDA-approved for asthma?
A long-acting anticholinergic, tiotropium is FDA-approved for asthma in patients > 6 years of age with a history of exacerbations despite ICS/LABA therapy
134
What is the MOA of Omalizumab?
Omalizumab is a monoclonal antibody that inhibits IgE binding to the IgE receptor on mast cells and basophils
135
What is Omalizumab indicated for?
It is indicated for moderate to severe persistent, allergic asthma in patients > 6 years of age with a positive skin test to a perennial aeroallergen and inadequate symptom control on inhaled corticosteroids (Step 5 or 6 treatment)
136
What is a boxed warning of Omalizumab?
Anaphylaxis has occurred as early as after the first dose and has occurred beyond 1 year after beginning treatment; closely observe patients after administration and be prepared to manage anaphylaxis that can be life-threatening
137
What are some warnings associated with Omalizumab?
Increased risk of serious cardiovascular and cerebrovascular adverse events; malignancies have been observed in clinical studies (rare)
138
What are some side effects associated with Omalizumab?
Injection site reactions, headache, dizziness, fatigue, arthralgias, pain
139
What are some monitoring parameters of Omalizumab?
Baseline IgE, FEV1, peak flow, s/sx of anaphylaxis and infection
140
What is interleukin?
Interleukin is a cytokine responsible for the growth, differentiation, recruitment, activation and survival of eosinophils (a cell type associated with inflammation and an important component in the cause of some types of asthma)
141
How can monoclonal antibodies be used for treating asthma?
Monoclonal antibodies can be used to inhibit interleukin from binding to receptors
142
What are some examples of monoclonal antibodies used for the treatment of asthma?
Mepolizumab, reslizumab, and benralizumab are IL-5 receptor antagonists. Dupilumab is an IL-4 and IL-3 receptor antagonist. All are indicated for the management of severe asthma with an eosinophilic phenotype. When used, they should be added to maintenance inhaler treatment.
143
Describe the indication, administration and availability of Mepolizumab.
Indicated in patients > 6 years of age and given SC once every four weeks. It is now available in a prefilled syringe and an auto-injector that can be administered at home by the patient or caregiver. Side effects are minor (headache and injection site reactions)
144
Describe the indication, administration and availability of Reslizumab.
Indicated in adults only, and is given IV once every four weeks. Reslizumab has a boxed warning for anaphylaxis that can be life-threatening. After administration, patients should be observed by a healthcare professional who is able to manage anaphylaxis
145
Describe the indication, administration and availability of Benralizumab.
Indicated for patients > 12 years of age and given SC once every four weeks for three doses, then every eight weeks. The Fasenra Pen is an auto-injector that can be administered at home by the patient or caregiver. Side effects are minor
146
Describe the indication, administration and availability of Dupilumab.
Indicated for patients >12 years of age with moderate-severe asthma with an eosinophilic phenotype or corticosteroid-dependent asthma. It is given SC every other week
147
What medications are preferred to prevent most EIB?
SABAs or low-dose ICS plus formoterol are preferred to prevent most EIB
148
Describe when to take SABAs or low-dose ICS plus formoterol alone with onset and duration of action.
They are taken 5-15 minutes before exercise. The effects of the SABA will last 2-3 hours, while the duration of the ICS plus formoterol can last up to 12 hours
149
What is an alternative to SABAs or ICS plus formoterol in the prevention of exercise-induced bronchospasm?
Salmeterol (a LABA) can be used as an alternative to a SABA if a longer duration of symptom control is needed and it should be taken 30 minutes before exercise
150
What is an important note if a patient is taking a LABA for the prevention of exercise-induced bronchospasm?
If the patient is using a LABA for asthma maintenance, they should not use additional doses of EIB. LABAs should never be used alone for persistent asthma
151
What is another alternative if LABAs cannot be used for prevention of exercise-induced bronchospasm?
Montelukast is taken two hours prior to exercise and lasts up to 24 hours. It is effective inly 50% of patients. Patients taking montelukast for asthma, or any other indication, should not take an additional dose to prevent EIB
152
What does EIB typically indicate?
EIB is often a marker of inadequate asthma control. It might be necessary to start or increase a controller medication to control the EIB
153
What is the recommendation for asthma control in pregnancy?
Asthma control can worsen during pregnancy. To ensure oxygen supply to the fetus, it is safer to treat asthma with medications than to have poorly controlled asthma. Down-titration of medications is not recommended, and exacerbations should be treated aggressively. An ICS should be continued during pregnancy and is still the preferred controller (either as needed or daily). Budesonide is typically the ICS used
154
What is essential to make sure most patients use their inhaler correctly?
Patient counseling and assessing inhaler technique is essential. Assessing adherence is important when evaluating asthma control
155
How long should a SABA rescue inhaler last?
SABA rescue inhalers can last a varying amount of time depending on use, but for a patient with good asthma control, an albuterol inhaler should last about 12 months (or 3-4 months for the smaller Ventolin HFA inhaler with 60 inhalations/canister)
156
Describe the timing and order of use of inhalers.
If prescribed > 1 inhalation of medication at a time, the patient should wait 60 seconds between each one. If using more than one inhaler, the sequence of inhalers is important. Bronchodilators work faster than ICS. Using bronchodilators first will open the airways quickly, allowing the ICS to travel deeper into the lungs,
157
What is a nebulizer?
A nebulizer is a device that turns liquid medication into a fine mist. The fine mist can be inhaled through a face mask or mouthpiece and into the lungs
158
How do nebulizers work?
Nebulizers use natural breathing, making medication delivery easy for infants, children and elderly
159
What are three types of nebulizers?
Jet, ultrasound and mesh
160
What are the common concentrations of albuterol as a nebulizer solution?
Albuterol comes as a nebulizer solution in both unit dose packaging and a 20 mL vial. The two common concentrations are 0.083% solution, containing 2.5 mg/3 mL and a 0.5% solution, containing 2.5 mg/0.5 mL. The 0.083% solution is a ready-to-use preparation that can be placed directly into the nebulizer (no dilution required). The 0.5% concentrated solution must be diluted with 2.5 mL of normal saline prior to use.
161
What is a spacer?
Spacer is a generic term for different types of open tubes that are placed between the mouthpiece of an MDI and the mouth of the patient to help with medication delivery. Spacers are used for children and in anyone with dexterity issues
162
What are some important notes about spacers?
Spacers reduce the risk of thrust. They should never be used with a DPI. Clean spacers at least once a week (in warm, soapy water)
163
What is a peak flow meter?
Peak flow meters are handheld devices that measure the peak expiratory flow rate (PEFR).
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What is the PEFR?
The PEFR is the maximum flow rate from a forceful exhalation, starting from fully inflated lungs. The patient's best PEFR is called their personal best (PB), which can be measured by spirometry
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What does PEFR depend on?
The measurement takes into account the patient's height, gender and age because the PEFR depends on the muscular strength of the patient
166
How can peak flow meters be beneficial?
Peak flow meters are beneficial in patients with frequent asthma exacerbations, persistent asthma (steps 3-6), poor perception of airflow obstruction and unexplained response to environmental factors. When used correctly, peak flow meters can identify exacerbations early (even before the patient is symptomatic), allowing treatment to begin sooner
167
What is the purpose of an asthma action plan?
An asthma action plan is developed by the healthcare provider so the patient knows how to manage symptoms at home and avoid hospitalizations due to an exacerbation
168
How does a healthcare provider make an asthma action plan?
This is done by taking the patient's PB and outlining "zones" of control (based on the percentage of their PB). Each "zone" is then given a specific action to follow
169
Describe the steps of proper peak flow meter technique.
- Use the peak flow meter every morning upon awakening and before the use of any asthma medications. Proper technique and best effort are essential. Less than the best effort can lead to taking unnecessary medication
- Move the indicator to the bottom of the numbered scale. Stand up straight. Exhale comfortably.
- Inhale as deeply as possible. Place lips firmly around the mouthpiece, creating a tight seal
- Blow out as hard and as fast as possible. Write down the PEFR
- Repeat steps two or more times, with enough rest in between. Record the highest value
- Compare the peak flow value to your personal asthma action plan and follow the steps as instructed
170
Describe the process of peak flow meter care.
- Always use the same brand of peak flow meter
- Clean at least once a week using warm water and mild soap; if you have an infection, clean the meter more frequently. Rinse gently; do not use brushes to clean the inside of the peak flow meter. Do not place peak flow meters in boiling water. Allow the meter to air dry before using again
171
What does the green zone of an asthma action plan indicate?
- >80-100% of personal best
- indicates all clear (good control)
- patients are instructed to follow routine-maintenance plan
172
What does the yellow zone of an asthma action plan indicate?
- 50-80%
- Indicates "caution" (worsening lung function)
- Patient-specific intervention required (action plan) - usually an increase in rescue inhaler use and the addition or increase of other medications
173
What does the red zone of an asthma action plan indicate?
- <50% of personal best
- Indicates "medical alert" - seek medical attention
- Action plan includes using a rescue inhaler, possibly steroids and going to the emergency department
174
Describe the steps to administering metered-dose inhalers.
1) Make sure the canister is fully inserted into the actuator. Always use the actuator that came with the canister. Shake the inhaler well for 5 seconds immediately before each spray (except for Qvar or Alvesco). Remove cap from the mouthpiece and check mouthpiece for foreign objects prior to use
2) Breathe out fully through your mouth expelling as much air from your lungs as possible. Holding the inhaler upright, place the mouthpiece into your mouth and close your lips around it
3) While breathing in slowly and deeply through your mouth, press the top of the canister all the way down with your index finger. Right after the spray comes out, take your finger off the canister. After you have inhaled all the way, take the inhaler out of your mouth and close your mouth. Hold your breath for 10 seconds, then breathe normally. If another inhalation is needed, wait 1 minute and repeat Steps 1-3. Place cap back on the mouthpiece after use
175
How do you prime Ventolin HFA, ProAir HFA?
Spray 4 times (3 or ProAir) away from the face, shaking between sprays. Prime again if > 14 days from last use or if you drop it
176
How do you clean Ventolin HFA, ProAir HFA?
To prevent medication buildup and blockage, remove the metal canister (do not let this get wet) and rinse the mouthpiece only under warm running water for 30 seconds, then turn upside down and rinse under warm water for another 30 seconds. Shake to remove excess water and let air dry. Clean at least weekly.
177
How do you prime Flovent HFA, Dulera?
Spray 4 times away from the face, shaking between sprays. Prime again with just 1 spray if > 7 days from last use (> 5 days for Dulera)
178
How do you clean Flovent HFA?
Use a clean cotton swab dampened with water to clean the small circular opening where the medication sprays out. Gently twist the swab in a circular motion to remove any medication buildup. Do not take the canister out of the plastic actuator. Wipe the inside of the mouthpiece with a damp tissue. Let air dry overnight
179
How do you prime Symbicort?
Spray 2 times away from the face, shaking between sprays. Prime again if > 7 days from last use.
180
How do you clean Symbicort, Dulera?
Wipe the inside and outside of the mouthpiece opening with a clean, dry cloth. Do not put into water
181
What are the steps to use Fluticasone/Salmeterol (Advair Diskus)?
1) Hold the Diskus in your left hand and put the thumb of your right hand in the thumb grip. Push the thumb grip away from you as fas as it will go until the mouthpiece appears and the Diskus snaps into position
2) Hold the Diskus in a level, flat position with the mouthpiece towards you. Slide the lever away from the mouthpiece until it clicks
3) Before using, breathe out fully while holding the Diskus away from your mouth. Do not tilt the Diskus
4) Put the mouthpiece to your lips. Breathe in quickly and deeply through the inhaler. Do not breathe in through your nose. Remove the Diskus from your mouth and hold your breath as long as possible, up to 10 seconds. Then, breathe out slowly.
5) Close the Diskus by putting your thumb in the thumb grip and sliding it as far back towards you as it will go, until the Diskus clicks shut. Rinse your mouth with water and spit out the water to prevent thrush. Do not swallow the water
182
How do you clean Advair Diskus?
Do not wash the Diskus. Store in a dry place
183
What are the steps to using Budesonide (Pulmicort Flexhaler)?
1) Twist off the white cover. Holding the middle of the inhaler with one hand, twist the brown base fully in one direction as far as it will go with the other hand. Twist it fully back again in the other direction as far as it will go. You will hear a "click" during one of the twisting movements. The dose is now loaded. Do not shake the inhaler after it is loaded.
2) Turn your head away from the inhaler and breathe out fully
3) Place the mouthpiece in your mouth and close your lips around the mouthpiece. Breathe in deeply and forcefully through the inhaler. Remove the inhaler from your mouth and breathe out. Replace the white cover on the inhaler and twist shut. Rinse your mouth with water and spit out the water to prevent thrust
184
How do you prime Pulmicort?
Twist off the white cover. Holding the inhaler upright, twist the brown base fully in one direction as far as it will go and then fully back. You will hear a click during one of the twisting motions. Repeat twisting motion again (back and forth). The inhaler is now primed and ready to load your first dose. This inhaler does not need to be primed again (even after long periods of no use)
185
How do you clean Pulmicort?
Wipe the mouthpiece with a dry tissue weekly. Do not use water or immerse it in water
186
What are the steps to using Albuterol (ProAir RespiClick), fluticasone/salmeterol (AirDuo RespiClick)?
1) Make sure the cap is closed before each dose. Hold the inhaler upright as you open the cap fully. Open the cap all the way back until you hear a "click." Your inhaler is now ready to use. Do not open the cap unless you are taking a dose. (Opening and close the cap without inhaling a dose will waste medication and can damage your inhaler)
2) Breathe out through your mouth and push as much air from your lungs as you can. Turn your head away from the inhaler so you do not breathe into the mouthpiece
3) Put the mouthpiece in your mouth and close your lips around it. Breathe in deeply through your mouth, until your lungs feel completely full of air. Do not let your lips or fingers block the vent above the mouthpiece. Hold your breath for as long as possible, up to 10 seconds. Remove the inhaler from your mouth. Check the dose counter on the back of the inhaler to make sure you received the dose. Close the cap over the mouthpiece after each use of the inhaler. Make sure the cap closes firmly into place. For AirDuo RespiClick, rinse your mouth with water and spit out the water to prevent thush. Do not swallow the water
187
How do you prime ProAir RespiClick and AirDuo Respiclick?
None needed
188
How do you clean ProAir RespiClick and AirDuo Respiclick?
Keep your inhaler drug and clean at all times. Do not wash or put any part of your inhaler in water. If the mouthpiece needs cleaning, gently wipe it with a dry cloth or tissue after using
189
What are some counseling points for all patients with asthma?
- Always have your rescue inhaler with you for asthma attacks
- If asthma symptoms get worse, or if you increase the use of your rescue inhaler for asthma attacks, contact your healthcare provider right away
190
What are some counseling points of Montelukast?
- Take in the evening
- Can cause suicidal ideation, behavior and mood changes
- Do not use more than one dose within 24 hours. If using daily for another indication, do not take another dose to prevent exercise-induced asthma
- For the oral granules, administer within 15 minutes of opening the packet and can be mixed with a teaspoonful of baby formula, breast milk, applesauce, mashed carrots, rice or ice cream or given directly in the mouth
191
What are some counseling points of Budesonide?
- Store upright, protected from light, at room temperature
- Ampules should be used within two weeks of opening the aluminum package
- Gently swirl the ampule in a circular motion before use
- Rinse with water and spit it out after each dose. If a face mask was used, wash face after each treatment
