Asthma

Question 1

What are the 2 MOAs of B2 agonists?

Answer 1

1) Bronchodilators
2) Inhibition of release of immediate hypersensitivity mediators from mast cells

Question 2

What is the tolerance of B2 agonists?

Answer 2

Can occur with chronic administration and seems to plateau after about 1 week of regular therapy but response recovers rapidly after only 3 days of nonuse

Question 3

What has a BLACK BOX WARNING that says it’s not to be used as monotherapy for long term control bc of an increased risk of asthma-related death?

Answer 3

Long-acting (LABA) (like Salmeterol (Serevent) and Formoterol (Foradil, Performist))

Question 4

What are the preferred concomitant therapy with ICSs in 12+y/o steps 1-5 and 6-11 years of age steps 3-5?

Answer 4

Controller / reliever LABAs
(Salmeterol (Serevent) and Formoterol (Foradil, Performist))

Question 5

1) Give 3 examples of SABAs
2) Give 2 examples of LABAs

Answer 5

1) Albuterol (Ventolin, ProAir, Proventil) –Rx
Levalbuterol (Xopenex) – Rx
Epinephrine (Primatene Mist) – OTC
2) Salmeterol (Serevent)
Formoterol (Foradil, Performist)

Question 6

Who is continuous B2 agonist nebulization recommended for?

Answer 6

1) Patients having an unsatisfactory response (achieving less than 50% of normal FEV1 or PEF) following the initial three doses (every 20 minutes) of aerosolized β2-agonists 2) Potentially for patients presenting initially with PEF or FEV1 values of less than 30% of predicted normal

Question 7

True or false: An elevated heart rate is not an indication to use lower doses or to avoid using inhaled β2-agonists

Answer 7

True

Question 8

What is the MOA of corticosteroids?

Answer 8

Possible effect on beta receptors:
-May increase the number of receptors
-May improve receptor responsiveness to adrenergic stimulation

Question 9

List 5 examples of ICSs

Answer 9

1) Beclomethasone
2) Budesonide
-also nebulizer
3) Ciclesonide
4) Flunisolide
5) Mometasone
(all of the above are inhalers)

Question 10

How do you dose Budesonide?

Answer 10

1) 90 or 180 mcg/ dose DPI, Flexhaler
(15-30% lung delivery)
2) 200 and 500 mcg ampules, 1mg
(5-8%)

Question 11

What are the DPIs of Budesonide?

Answer 11

1) Low: 180-360/180-540
2) Med: 360-720/540-1080
3) High: >720/ >1080

Question 12

Systemic Corticosteroids:
1) How long are they dosed for?
2) Give examples

Answer 12

1) Adults 5-7 days, kids 3-5 days (until PEF reaches 70%)
2) Dexamethasone (Decadron), methylprednisolone (Medrol Dosepak), prednisolone (Prelone), prednisone (Deltone) or hydrocortisone

Question 13

1) List 3 local effects of corticosteroids
2) List 2 long-term systemic effects of corticosteroids

Answer 13

1) Cough, dysphonia, oropharyngeal candidiasis
2) Adrenal axis suppression; immunosuppression

Question 14

Anticholinergics:
1) What is their MOA?
2) Which one of these can decrease sputum volume long-term?

Answer 14

1) Competitive inhibitors of muscarinic receptors
2) Ipratropium

Question 15

Give 2 examples of short-acting anticholinergics

Answer 15

1) Ipratropium (Atrovent)
2) DuoNeb (albuterol / ipratropium nebulizer solution)

Question 16

Give an example of a long-acting anticholinergic used for asthma

Answer 16

Tiotropium (Spirva Respimat; do not use handihaler for asthma)

Question 17

1) What is the MOA of leukotriene modifiers?
2) What are some side effects?

Answer 17

1) Reduction of production or action of leukotrienes in inflammation and allergy; reduces airway edema and smooth muscle contraction
2) HA, GI upset, psychiatric effects
INCREDIBLY Rare: idiosyncratic syndrome similar to the Churg–Strauss syndrome, HF, vasculitis

Question 18

Leukotriene Modifiers: Give 3 examples

Answer 18

1) Montelukast (Singulair)
2) Zafirlukast (Accolate)
3) Zileuton (Zyflo)

Question 19

Give 2 examples of biologics

Answer 19

1) Omalizumab (Xolair)
2) Dupilumab (Dupixent)

Question 20

1) What does Omalizumab (Xolair) have a black box warning for?
2) What is its dosing based on?

Answer 20

1) Anaphylaxis (even up to 12 mo after)
2) Weight and IgE levels

Question 21

What is the MOA of Dupilumab/ Dupixent?

Answer 21

Interluekin-4 antagonist

Question 22

Give examples of Recombinant Interleukin-5 Antagonists

Answer 22

1) Benralizumab
2) Mepolizumab
3) Reslizumab

Question 23

Give an example of a mast cell stabilizer

Answer 23

Cromolyn

Question 24

How long do you need to wait between puffs for SABAs?

Answer 24

15-30 seconds

Question 25

How should pts monitor their PEF?

Answer 25

The green zone is equal to 80% to 100%, the yellow zone is equal to 50% to 79%, and the red zone is less than 50%

Question 26

What are considered the preferred long-term control therapy for persistent asthma in all patients due to their potency and consistent effectiveness?

Answer 26

ICSs

Question 27

Differentiate between glucocorticoids and mineralocorticoids

Answer 27

Glucocorticoids – immune system response Mineralocorticoids – blood pressure response / electrolytes (retain sodium and eliminate potassium)

Question 28

How is acute severe asthma defined?

Answer 28

FEV1 <40% or SPO2 of <90%

Question 29

Define Exercise-induced bronchospasm

Answer 29

Drop in FEV1 of 10% or greater from baseline; return of baseline function within ≈ 30 minutes

Question 30

Experts consider nocturnal symptoms to be a sign of __________________ asthma

Answer 30

inadequately treated persistent

Question 31

For those patients inadequately controlled on low-dose ICSs, what two actions can you choose from?

Answer 31

An increased dose of the ICS or the combination of ICS and LABA

Question 32

True or false: ICS use, even with low doses, causes reductions in growth velocity in children

Answer 32

True

Question 33

Osteoporosis, cataracts, and skin bruising can all be side effects of what?

Answer 33

ICSs

Question 34

What do you need to know about treating asthma in pregnancy?

Answer 34

1) Low-dose ICSs recommended as preferred treatment for mild persistent asthma with the addition of a LABA if not adequately controlled 2) Avoid stepping down therapy during gestation -Budesonide and albuterol are preferred drugs 3) Patients who are well-controlled on a particular ICS should remain on current treatment 4) During delivery, fentanyl, rather than morphine, should be used for pain control -Morphine may induce more histamine release compared to fentanyl

Question 35

Give some risk factors for death bc of asthma

Answer 35

No current use of ICSs; overuse of short-acting inhaled β2-agonist therapy (more than one canister per month); history of psychiatric disease or psychosocial problems; poor medication adherence; lack of a written asthma action plan

Question 36

The primary therapy of acute exacerbations of asthma is pharmacologic, which includes what?

Answer 36

1) Short-acting inhaled β2-agonists 2) Depending on the severity: systemic corticosteroids, inhaled ipratropium, intravenous magnesium sulfate, and O2

Question 37

What therapy, instead of oxygen, reduces resistance to flow and increases ventilation by converting turbulent flow to more efficient laminar flow?

Answer 37

Heliox

Question 38

What will acute asthma lab values look like on corticosteroids?

Answer 38

1) Leukocytosis: No left shift 2) ↑ glucose and lactic acid

Question 39

What will acute asthma lab values look like on B2 agonists?

Answer 39

1) Decreases in potassium, magnesium, and phosphate -Concern for patient with CVD or concomitant diuretics 2) ↑ glucose and lactic acid