Asthma

Question 1

how is asthma dx

Answer 1

measure baseline FEV-1
give albuterol
measure FEV-1
if there is >12% increase in FEV-1 - asthma dx

Question 2

what are the criteria for step 1
what is/are the recommended treatments for this step?

Answer 2

asthma sx <2x/week

PRN low dose ICS - formoterol
or
low dose ICS - SABA

Question 3

what are the criteria for step 2
what is/are the recommended treatments for this step?

Answer 3

asthma sx or need for SABA >2x/week

low dose ICS - formoterol for rescue
or
SABA rescue + ICS-LABA maintenance

Question 4

what dose of ICS is always used in rescue

Answer 4

low dose ICS

Question 5

what are the criteria for step 3
what is/are the recommended treatments for this step?

Answer 5

sx most days or waking at night 1+ x/week

low dose ICS-formoterol rescue and maintenance
or
SABA rescue + low dose ICS - LABA maintenance

Question 6

what are the criteria for step 4
what is/are the recommended treatments for this step?

Answer 6

asthma sx daily or waking 1+ night a week or exacerbation upon initial presentation

low dose ICS-formoterol rescue + medium dose ICS - formoterol maintenance
or
SABA rescue + medium dose ICS-LABA maintenance

Question 7

what are the criteria for step 5
what is/are the recommended treatments for this step?

Answer 7

beyond step 4 management, need referral

low dose ICS-formoterol rescue + high dose ICS - formoterol
or
SABA rescue + high dose ICS-LABA

Question 8

how do we assess asthma control and when to step up therapy?

Answer 8

4 questions
daytime sx >2x/week?
nighttime awakenings?
SABA >2x/week?
activity limited 2/2 asthma?
0 yes’ = well controlled
1-2 yes’ = partly controlled, inc by 1 step
3-4 yes’ = uncontrolled, inc by 1-2 steps

Question 9

what are the three main ICS for asthma

Answer 9

budesonide (Pulmicort)
fluticasone (Flovent, Arnuity)
mometasone (Asmanex)

Question 10

what are the low dose ICS strengths of
budesonide
fluticasone
mometasone

Answer 10

budesonide 200-400mcg
fluticasone 100-250mg (MDI and DPI)
mometasone MDI 200-400mcg
DPI 110-220mcg

Question 11

what are the low doses of ICS usually used for

Answer 11

rescue in combination with formoterol

Question 12

budesonide + formoterol =

Answer 12

Symbicort

Question 13

what are the medium dose ICS strengths of
budesonide
fluticasone
mometasone

Answer 13

budesonide >400-800mcg
fluticasone 250-500 (MDI and DPI)
mometasone MDI 200-400mcg
DPI 220-440mcg

Question 14

what are the high dose ICS strengths of
budesonide
fluticasone
mometasone

Answer 14

budesonide >800mcg
fluticasone >500 (MDI and DPI)
mometasone MDI >400mcg
DPI >440mcg

Question 15

what are the medium/moderate ICS doses usually used for

Answer 15

step 4

Question 16

what are the high ICS doses usually used for

Answer 16

step 5

Question 17

what are the characteristics of an MDI? what inhalers does this include?

Answer 17

HFA, Respimat, Symbicort, Dulera
shake before using
can use spacer
aerosolized liquid
HFA = propellant
slow, deep inhalation
need to be primed and re-primed after some time

Question 18

what are the characteristics of an DPI? what inhalers does this include?

Answer 18

Diskus, Ellipta, Handihaler, Respiclick, Flexhaler
do not shake
fine powder
no propellant
need quick, forceful inhalation
no spacer!!
no priming

Question 19

budesonide =

Answer 19

pulmicort

Question 20

fluticasone =

Answer 20

Flovent, Arnuity

Question 21

mometasone =

Answer 21

Asmanex

Question 22

budesonide + formoterol =

Answer 22

Symbicort

Question 23

fluticasone + salmeterol =

Answer 23

Advair

Question 24

fluticasone + vilanterol =

Answer 24

Breo

Question 25

mometasone + formoterol =

Answer 25

Dulera

Question 26

what ICS has a neb soln dosage form? why does this help?

Answer 26

budesonide good for children

Question 27

counseling points for ICS

Answer 27

rinse and spit after use inc risk fx, growth retardation, imm supp SE: dysphonia, thrush, cough

Question 28

all ICS products are CI as ...

Answer 28

monotherapy for asthma exacerbation

Question 29

albuterol brands dosage forms and dosing SE

Answer 29

Ventolin HFA, Proair Respiclick, Proair HFA, Proventil HFA MDI/DPI: 1-2 inhalations every 4-6h prn nebulizer: 1.25-5mg q4-8h prn SE: tremor, nervousness, palpitaitons, hyperglycemia, hypokalemia

Question 30

Qvar =

Answer 30

beclometasone

Question 31

a LABA must always be used with an

Answer 31

ICS

Question 32

salmeterol =

Answer 32

Serevent

Question 33

Spiriva =

Answer 33

tiotropium

Question 34

what ICS/LABA combinations are FDA approved for asthma?

Answer 34

fluticasone/salmeterol = Advair, Airduo fluticasone/vilanterol = Breo mometasone/formoterol = Dulera budesonide/formoterol = Symbicort

Question 35

are there any LAMA/LABA/ICS products FDA approved for asthma?

Answer 35

yes Trellegy (umeclidinium/vilanterol/fluticasone)

Question 36

montelukast MOA dosing BBW

Answer 36

LTD4 receptor antagonist 1-5 yo = 4mg PO HS 6-14 yo = 6mg PO HS >14 yo = 10mg PO HS BBW: neuropsychiatric events

Question 37

theophylline dosing DDI

Answer 37

5mg/kg IBW LD then 100-600mg MD DDI: major 1A2 substrate

Question 38

signs of theophylline toxicity

Answer 38

persistent vomiting arrhythmias seizures

Question 39

who would not be a good candidate for theophylline

Answer 39

patients with epilepsy, arrhythmias, PUD

Question 40

what are the recommended tx for exercise induced asthma? how should the patient use the inhaler(s)?

Answer 40

SABA or low-dose ICS-formoterol take 5-15 min before activity SABA will last 2-3 hours ICS-formoterol will last 12 hours

Question 41

what therapies are not recommended for asthma in pregnancy?

Answer 41

all are recommended to be continued in pregnancy

Question 42

what order should patients take their inhalers in? do they have to wait between doses

Answer 42

SABA, wait 60 sec then LAMA, LABA, wait 60 sec then ICS

Question 43

what are the benefits of spacers

Answer 43

increase drug delivery to lungs dec risk of thrush good for children or those with low hand-breath coordination

Question 44

what readings on a peak flow meter indicate what to do for asthma management?

Answer 44

>80-100% - continue therapies >50-80% - set up asthma action plan, caution <50% - emergency, go to ED

Question 45

what inhaler needs 2 sprays to be primed and required priming if not used for 7 days

Answer 45

Symbicort

Question 46

what inhalers require 4 sprays to prime and should be re-primed if not used for 7 days

Answer 46

Flovent Dulera

Question 47

what inhalers require 4 sprays to prime and should be re-primed if not used for 14 days

Answer 47

Flovent Proair