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Asthma Flashcards

1
Q

What are classic symptoms of asthma?

A
  1. wheezing
  2. chest tightness
  3. coughing
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2
Q

What are common asthma triggers?

A
  1. pollution
  2. cigarettes
  3. cold air/weather change
  4. pets
  5. dust/pollen/cockroaches
  6. perfumes/cosmetics
  7. aspirin/NSAIDs/non-selective beta-blockers
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3
Q

What comorbid conditions can trigger asthma?

A
  1. infections
  2. allergies
  3. GERD
  4. obesity
  5. obstructive sleep apnea
  6. anxiety/stress/depression
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4
Q

How is asthma diagnosed?

A

Spirometry:
1. measure FEV1 at baseline
2. give albuterol
3. measure post-bronchodilator FEV1
4. FEV1increase > 12% post bronchodilator is consistent with asthma

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5
Q

What guidelines are established for treating asthma

A

Global Initiative for Asthma (GINA)

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6
Q

What is used to assess patient for initial asthma therapy?

A

Clinical Assessment and Treatment Step

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7
Q

What is step 1 symptom severity?

A

Daytime symptoms <2 times per month
No night symptoms

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8
Q

What is step 2 symptom severity?

A

Daytime symptoms >2x/month but less than 4-5 days/week
No night symptoms

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9
Q

What is step 3 symptom severity?

A

Daytime symptoms most days
≥ 1 night awakening/ week

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10
Q

What is step 4 symptom severity?

A

Daytime symptoms every day
≥ 1 night awakening/ week

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11
Q

What is a general treatment approach to asthma?

A

assess Q 2-6 weeks:
1. assess adherence
2. assess technique, including priming and cleaning
3. step-up, maintain or step-down treatment
once control is achieved follow up Q 1-6 months; Q 3 months with step-down therapy

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12
Q

What medication classes are reliever/rescue drugs?

A
  1. inhaled ICS+ formoterol (preferred)
  2. inhaled SABA
  3. systemic steroids
  4. inhaled epinephrine
  5. SAMA
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13
Q

What reliever medication is available OTC?

A

inhaled epinephrine

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14
Q

Why is ICS preferred in all patients for exacerbation and maintenance vs. bronchodilators?

A
  1. most effective antiinflammatory drugs
  2. reduces exacerbations
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15
Q

What drug classes are controller/maintenance?

A
  1. ICS
  2. LABA + ICS
  3. Leukotriene receptor antagonists (LTRA) PO
  4. Theophylline PO/IV
  5. LAMA (Add on)
  6. injectable monoclonal antibodies SC/IV
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16
Q

What monoclonal antibody is for severe allergic asthma?

A

Omalizumab (Xolair)

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17
Q

What monoclonal antibodies are for severe eosinophilic asthma?

A
  1. mepolizumab (Nucala)
  2. reslizumab (Cinqair)
  3. benralizumab (Fasenra)
  4. dupilumab (Dupixent)
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18
Q

What monoclonal antibody is used in severe asthma regardless of eosinophil count/ other markers?

A

Tezepelumab (Tezspire)

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19
Q

What is initial therapy for step 1?

A
  1. prn low-dose ICS+ formoterol
    OR
  2. SABA + low-dose ICS
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20
Q

What is initial therapy for step 2/ needing SABA > 2 times/month?

A
  1. prn low-dose ICS+ formoterol
    OR
  2. prn SABA + low-dose ICS+ low dose ICS scheduled
    OR
  3. prn SABA + low-dose ICS+ LTRA
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21
Q

What is initial therapy for step 3?

A
  1. prn and scheduled low-dose ICS + formoterol
    OR
  2. prn SABA +ICS AND scheduled low dose ICS +formoterol
  3. low-dose ICS + LTRA
  4. Medium-dose ICS
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22
Q

What is initial therapy for step 4/ initial presentation is exacerbation?

A
  1. prn low-dose ICS + formoterol AND scheduled medium-dose ICS + formoterol
  2. prn low-dose ICS + formoterol AND scheduled medium-dose ICS + LABA
  3. prn low-dose ICS + SABA AND scheduled medium-dose ICS + formoterol +LRTA/tiotropium
  4. high-dose ICS
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23
Q

What is the initial treatment for step 5?

A
  1. prn low-dose ICS + formoterol AND scheduled high-dose ICS + formoterol
  2. prn low-dose ICS + SABA AND scheduled high-dose ICS + LABA
  3. prn low-dose ICS + SABA AND scheduled high ICS + formoterol +tiotropium/oral steroid/injectable treatments
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24
Q

albuterol

A
  1. ProAir HFA
  2. ProAIr Respiclick (DPI)
  3. Proventil HFA
  4. Ventolin HFA
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25
Salmeterol
Severevent Diskus (DPI)
26
Levalbuterol
Xopenex HFA
27
Beclomethasone
QVAR RediHaler
28
Budesonide
Pulmicort Flexhaler (DPI) Pulmicort Respules (nebulizer)
29
Budesonide+ formoterol
Symbicort (DPI) Breyna (DPI)
30
Fluticasone
Flovent HFA Flovent Diskus (brand D/C) Arnuity Ellipta (DPI) ArmonAir Digihaler (DPI)
31
Fluticasone+salmeterol
Advair Diskus Advair HFA
32
Fluticasone + vilanterol
Breo Ellipta
33
Mometasone + formoterol
Dulera
34
Mometasone
Asmanex HFA Asmanex
35
Ciclesonide
Alvesco
36
What are SEs of beta-2 agonists?
1. nervousness 2. tremor 3. tachycardia 4. palpitations 5. cough 6. hyperglycemia 7. hypokalemia
37
What are warnings with SABAs?
Use caution in: 1. CVD 2. glaucoma 3. hyperthyroidism 4. seizures 5. diabetes
38
What are monitoring parameters for SABAs?
1. # of days of SABA use 2. sx frequency 3. peak flow 4. pulmonary function tests 5. BP 8. HR 9. blood glucose 10. K+
39
What is an important counseling point for MDI (HFA) use?
shake well before use
40
What is the difference between levalbuterol vs. albuterol?
Levalbuterol contains the R-isomer of albuterol
41
What are boxed warnings with LABAs?
1. increased risk of asthma-related deaths; should only be used in asthma patients already receiving but not controlled on inhaled corticosteroids 2. increased risk of asthma-related hospitalization in pediatric and adolescent patients
42
What is the MOA of beta-2 agonists?
beta-2 agonists bind to beta-2 receptors --> relaxation of bronchial smooth muscle--> bronchodialation
43
Epinephrine
Asthmanefrin Refill
44
Why should inhaled epinephrine not be used?
non-selective beta-agonist; FDA-approved for mild asthma symptoms in intermittent asthma only
45
Albuterol+ budesonide
Airsupra
46
What is the MOA of ICS?
inhibit inflammatory response
47
What are warnings with ICS?
1. high doses for extended periods of time can cause adrenal suppression 2. immunosuppression 3. increased risk of fractures 4. growth retardation
48
What are SEs of ICS?
1. dysphonia (difficulty speaking) 2. oral candidiasis (thrush) 3. cough 4. headache 5. hoarseness 6. URTIs 7. hyperglycemia
49
What are the monitoring parameters with ICS?
1. use of SABA/ rescue inhaler 2. sx frequency 3. peak flow 4. growth (children) 5. s/sx of renal insufficiency 6. s/sx thrush 7. bone density
50
What can be done to decrease the risk of thrush?
1. rinse mouth with water and spit out each time ICS used to prevent thrush 2. use a spacer with MDI ICS
51
What is the only ICS available as a nebulizer suspension?
Budesonide (Pulmicort Respules)
52
How is Pulmicort Respules used?
only use with a jet nebulizer connected to an air compressor; DO NOT use an ultrasonic nebulizer
53
Why should QVAR RediHaler not be shaken or used with a spacer?
breath-activated aerosol with characteristics of MDi and DPI
54
Which ICS contains built-in electronic module that detects, record, and stores data (detects when inhaler is used and measures inspiratory flow)?
1. ArmonAir Digihaler (fluticasone) 2. AirDuo Digihaler (fluticasone+ salmeterol)
55
What is a low daily dose of Beclomethasone MDI 40 or 80 mcg/inh?
100-200 mcg
56
What is a medium daily dose of Beclomethasone MDI 40 or 80 mcg/inh?
>200-400mcg
57
What is a high daily dose of Beclomethasone MDI 40 or 80 mcg/inh?
>400 mcg
58
What is a low daily dose of Budesonide DPI 90 or 180 mcg/inh?
200-400 mcg
59
What is a medium daily dose of Budesonide DPI 90 or 180 mcg/inh?
>400-800 mcg
60
What is a high daily dose of Budesonide DPI 90 or 180 mcg/inh?
>800 mcg
61
What is a low daily dose of Ciclesonide MDI 80 or 160 mcg/inh?
80-160 mcg
62
What is a medium daily dose of Ciclesonide MDI 80 or 160 mcg/inh?
160-320 mcg
63
What is a high daily dose of Ciclesonide MDI 80 or 160 mcg/inh?
>320 mcg
64
What is a low daily dose of Fluticasone MDI/DPI?
100-250 mcg
65
What is a medium daily dose of Fluticasone MDI/DPI?
>250-500 mcg
66
What is a high daily dose of Fluticasone MDI/DPI?
>500mcg
67
What is a low daily dose of Mometasone MDI 100/200 mcg/inh?
200-400 mcg
68
What is a medium daily dose of Mometasone MDI 100/200 mcg/inh?
200-400 mcg
69
What is a high daily dose of Mometasone MDI 100/200 mcg/inh?
>400 mcg
70
What is a low daily dose of Mometasone DPI 110/220 mcg/inh?
110-220 mcg
71
What is a medium daily dose of Mometasone DPI 110/220 mcg/inh?
>220-440 mcg
72
What is a high daily dose of Mometasone DPI 110/220 mcg/inh?
>440
73
How can MDIs be identified by brand name?
HFA, Respimat, or no suffix (ex. symbicort, dulera)
74
How can DPIs be identified by brand name?
Diskus, Ellipta, Pressair, HandiHaler, RespiClick, Flexhaler
75
Which MDIs can a spacer not be used with?
1. QVAR RediHaler 2. Respimat products
76
Which MDIs do not need to be shaken before use?
1. QVAR RediHaler 2. Alvesco 3. Respimat products 4. Atrovent HFA
77
Which DPI requires priming?
Flexhaler
78
What is the MOA of montelukast?
inhibits leukotriene D4 (LTD4)--> reduce airway edema, constriction, and inflammation
79
What is the MOA of zafirlukast?
inhibits leukotriene D4 and leukotriene E4
80
What is the MOA of Zileuton?
inhibits 5-lipoxygenase--> inhibits leukotriene formation
81
What are boxed warnings with montelukast?
neuropsychiatric events (serious behavior/mood changes including suicidal thoughts and actions)
82
What are indications for montelukast?
1. asthma 2. allergic rhinitis 3. exercise-induced bronchospasm
83
Montelukast
Singular
84
Zafirlukast
Accolate
85
Zileuton
Zyflo
86
What are warnings with all leukotriene modifying agents?
1. neuropsychiatric events: monitor for signs of aggressive behavior, hostility, agitation, hallucinations, depression, suicidal thinking 2. systemic eosinophilia (montelukast, zafirlukast)
87
What are SEs with all leukotriene modifying agents?
1. headache 2. dizziness 3. abdominal pain 4. elevated LFTs 5. URTIs
88
What is dosing for montelukast ages 1-5?
4 mg daily in the evening
89
What is dosing for montelukast ages 6-14?
5mg daily in the evening
90
What is doing for montelukast age 14+?
10 mg daily in the evening
91
What is the dosing of montelukast for exercise-induced bronchospasm?
5 mg (6-14 y/o) or 10 mg (≥15y/o) 2 hours before exercise
92
What dosage forms does montelukast come in?
1. tablet 2. chewable tablet 3. packet (granules)
93
How can Montelukast granules administered?
1. directly in the mouth 2. dissolved in a small amount (~5mL) of breast milk or formula 3. mixed with a spoonful of applesauce, carrots, rice, or ice cream (nothing else) USE WITHIN 15 MINUTES OF OPENING PACKET
94
How must zafirlukast be dispensed?
in original container --> protect from moisture and light
95
What should be monitored when taking zafirlukast/zileuton?
LFTs
96
What should be monitored when taking montelukast?
behavior changes
97
How is montelukast affected by CYP metabolism?
1. minor substrate of CYP3A4, CYP2C8, and CYP2C9 2. weak inhibitor of CYP2C8, and CYP2C9 3. gemfibrozil will increase the concentration of montelukast 4. lumacaftor can decrease levels of montelukast
98
How is zafirlukast affected by CYP metabolism?
1. Major substrate of CYP2C9 2. moderate inhibitor of CYP2C9 and weak inhibitor of CYP2C8 3. can increase levels of theophylline 4. increase levels of CYP2C9 substrates (warfarin)
99
How is zileuton affected by CYP metabolism?
1. minor substrate of CYP1A2 and CYP3A4 2. weak inhibitor of CYP1A2 3. can increase levels of theophylline, propranolol, and warfarin
100
What is the MOA of theophylline?
blocks phosphodiesterase--> increase in cAMP and increased epinephrine from adrenal medulla --> bronchodilation
101
What are the active metabolites of theophylline?
1. caffeine 2. 3-methylxanthine
102
What is a therapeutic level of theophylline and how is it measured?
5-15mcg/mL; measure peak level at steady state (after 3 days of oral dosing)
103
What is dosing for theophylline?
LD: 5 mg/kg (IBW; unless TBW
104
What are warnings with theophylline?
can exacerbate cardiovascular arrhythmias, PUD, and seizure disorders
105
What are SEs with theophylline?
1. N/V 2. headache 3. insomnia 4. increased HR 5. tremor 6. nervousness
106
What are signs of toxicity from theophylline?
1. persistent vomiting 2. arrhythmias 3. seizures
107
What should be monitored when taking theophylline?
1. theophylline levels 2. HR 3. CNS symptoms (insomnia, irritability) 4. use of rescue inhaler
108
How much theophylline is in aminophylline?
2:1 --> theophylline: ethylenediamine
109
How are theophylline and aminophylline interconverted?
aminophylline x 0.8= theophylline theophylline / 0.8= aminophylline ATM (Aminophylline to Theophylline Multiply)
110
Theophylline has first-order kinetics followed by zero-order kinetics, what does this mean for dosing?
in the higher end of the therapeutic range, small dose increases can result in large concentration increases
111
How is theophylline affected by CYP metabolism?
1. Major substrate of CYP1A2 2. Minor substrate of CYP 3A4 and CYP2E1
112
What medications increase theophylline levels?
inhibitors of CYP1A2: 1. ciprofloxacin 2. zileuton 3. fluvoxamine 4. propranolol Other drugs: 5. zafirlukast 6. alcohol 7. allopurinol 8. disulfiram 9. estrogen-containing OCs 10. methotrexate 11. pentoxifylline 12. propafenone 13. verapamil
113
Which CYP3A4 inhibitors can increase levels of theophylline?
1. clarithromycin 2. erythromycin
114
What drugs can decrease theophylline levels?
1. carbamazepine 2. phenytoin 3. fosphenytoin 4. phenobarbital 5. primidone 6. rifampin 7. ritonavir 8. marijuana smoking 9. st.johns wart 10. levothyroxine
115
What drug can theophylline decrease levels of due to increased renal excretion?
lithium
116
What conditions or food can increase theophylline (by reducing clearance?
1. CHF 2. cirrhosis/ liver disease 3. fever 4. acute pulmonary edema 5. cor pulmonale (pulmonary heart disease) 6. hypothyroidism 7. shock 8. high carb/low protein diet
117
What conditions or food can decrease theophylline (by increasing clearance?
1. low carb/ HIGH PROTEIN diet 2. daily consumption of charbroiled beef 3. cystic fibrosis 4. hyperthyroidism
118
Omalizumab
Xolair
119
Mepolizumab
Nucala
120
Reslizumab
Cinqair
121
Benralizumab
Fasenra Fasenra pen
122
Dupilumab
Dupixent
123
Rezepelumab
Tezspire
124
How is omalizumab administered?
1. initiated in a healthcare setting under medical supervision (≥3 doses) 2. SC every 2 to 4 weeks based on body weight and pretreatment IgE levels 3. must have documented allergic asthma with a positive skin test or in vitro reactivity to an aeroallergen
125
What boxed warnings does omalizumab have?
anaphylaxis( can occur at any time during treatment); must be observed after administration
126
What is the MOA of omalizumab?
IgG monoclonal antibody; inhibitors IgE binding to the receptor on mast cells and basophils
127
What is the MOA of interleukin receptor antagonist?
blocks interleukins (cytokines responsible for growth, differentiation, recruitment, activation, and survival of eosinophils) to reduce inflammation; block IL-5 (except dupilumab)
128
What is the MOA of dupilumab?
blocks interleukins (cytokines responsible for growth, differentiation, recruitment, activation, and survival of eosinophils) to reduce inflammation; block IL-4 and 13
129
Which agents are interleukin receptor antagonists?
1. mepolizumab 2. reslizumab 3. benralizumab 4. dupilumab
130
How is mepolizumab administered?
SC Q 4 weeks
131
How is reslizumab administered?
IV Q 4 weeks
132
How is benralizumab administered?
SC Q 4 weeks x 3 doses then Q 8 weeks
133
How is dupilumab administered?
SC every other week
134
Which monoclonal antibodies can be administered at home by the patient/ caregiver?
1. mepolizumab 2. dupilumab 3. Faserna pen (benralizumab) 4. tezepelumab
135
Which interleukin receptor antagonist has a boxed warning for anaphylaxis?
Reslizumab (IV)
136
How is exercise-induced bronchospasm treated?
SABA or low-dose ICS+ fomoterol 5-15 minutes before exercise
137
How long will effects of a SABA last?
2-3 hours
138
How long will effects of ICS+ formoterol last?
up to 12 hours
139
What agent can be beneficial if a longer duration of exercise is expected with EIB?
salmeterol +ICS
140
How should Salmeterol+ ICS be administered for EIB?
take 30 minutes before exercise
141
How is montelukast used for EIB?
1. can be taken 2 hours before exercise and lasts up to 24 hours 2. DO NOT take additional doses for EIB if already taking for another indication
142
How is asthma treated in pregnancy?
1. keep control, do not escalate 2. ICS prn or daily
143
How long should an albuterol inhaler last with good asthma control?
12 months (3-4 months with Ventolin 60 inhalations/canister)
144
How long should a patient wait if prescribed multiple doses of inhaled medications?
wait 60 seconds between each inhaled dose
145
What order should asthma medications be given in?
1. SABA 2. LABA/LAMA 3. ICS waiting 60 seconds in between each inhalation
146
What are the types of nebulizers?
1. jet 2. ultrasound 3. mesh

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